Consent to Treat for Telemedicine
Informed Consent for Treatment, Telemedicine Services, and Financial Agreement / Assignment of Benefits / Release of Information
1. Consent for Diagnosis and Treatment.
By your acceptance below, you hereby request, consent, and authorize medical care given to you or your minor child via telehealth by Mammoth Health, PLLC and its affiliated healthcare providers as set forth below, which may include orders for diagnostic procedures, medications, or treatment the physician(s) or other practitioners involved in your/your child's care consider medically necessary. You understand you have the right to consent or refuse to consent to any proposed procedure or therapeutic course. You acknowledge that no guarantees have been made to you regarding the outcome of any medical, surgical, diagnostic or therapeutic treatment. You understand that some physicians and other practitioners provide their services as independent contractors to the Practice, are not employees or agents of the Practice, and that the Practice is not liable for their acts or omissions. You agree to receive telehealth services as described in further detail below, which means the delivery of health care services, including assessment, treatment, diagnosis, and education, using interactive or asynchronous audio, video, and data communications. You understand that the Practice and its physicians or other practitioners are in a different location than you and that you must accurately report your location during registration.
What is Telemedicine
Telemedicine is the use of electronic communications by a health care provider to deliver health care services to you when you are physically located at a different site than the provider. Telemedicine is not a separate medical specialty. Telemedicine providers who provide Services (as defined below) to you will do so as employees or contractors of one of the following professional entities, depending on the state in which you are located at the time of your visit: Mammoth Health, PLLC, a Florida professional limited liability company, Mordkin Medical, PC, a California professional corporation, Mammoth Medical, PC, a New Jersey professional service corporation, and Ajax Medical, PLLC, a New York professional limited liability company.1 The aforementioned entities will be referred to collectively as the “Practice” for purposes of this Consent. The Practice’s telehealth platform may include clinicians with whom you exchange information during a telemedicine visit for diagnosis, treatment, follow-up, coordination of care, and/or educational health care needs (the “Services”). For example, information exchanged during your telehealth encounter may include:
Your medical history
Laboratory test results
Information about treatment options
When using the Services, you will be treated by and will enter into a clinician-patient relationship with a clinician that is employed by or partnered with the Practice and who is licensed in the state in which Services are offered (“Clinician”). For the purposes of this consent, Clinicians are defined as credentialed healthcare providers, and they may include physicians, nurse practitioners, physician assistants, registered nurses, and other types of healthcare providers.
Your telehealth encounter may take place using one or more telehealth modalities, each of which is designed to provide your Clinician with information needed in order to provide you with appropriate diagnosis and treatment. Depending on your particular condition and other factors, the Services may not be delivered via all of these modalities. Specifically, the Services may be delivered using one or more of the following modalities:
A questionnaire to verify your eligibility to receive a laboratory test;
An asynchronous store-and-forward encounter that exchanges medical information, including laboratory test results, diagnoses, and treatment options;
A live, interactive, audio-only conversation to discuss laboratory test results, diagnoses, and treatment options; and
A live, interactive, audio-visual encounter to discuss laboratory test results, diagnoses, and treatment options.
Electronic systems used to deliver the Services will incorporate network and software security protocols to protect the confidentiality of patient identification and laboratory results and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption. You agree to hold the Practice and the Clinician harmless against any information or data that is compromised due to such technical failures or other causes.
Expected Benefits and Possible Risks of Telemedicine Services
By your acceptance below, you acknowledge that you understand that some potential benefits of telehealth, results of which are not guaranteed or assured, include: remote access to medical care; medical evaluation and management; and reduced exposure to patients, medical staff, and other individuals at the Practice. You also understand that the potential risks of telehealth include limited or no availability for diagnostic laboratory testing and imaging to assist your provider in diagnosis and treatment; your provider's inability to conduct a hands-on physical examination; and delays in evaluation and treatment due to technical difficulties or interruptions resulting from electronic transmission issues or loss of information due to technical failures. You agree that you will not hold the Practice responsible for lost information due to technological failures. You understand that your provider's recommendation and/or advice and your diagnoses and/or treatment may be based on factors not within his/her control, including incomplete or inaccurate data provided by you. You understand that your provider relies on information provided by me before and during the telehealth encounter and that you must provide accurate and complete information about your medical history, condition(s), and current or previous medical care that is complete and accurate to the best of your ability. In case of a medical emergency, you will dial 911 or go directly to the nearest hospital emergency room.
3. Automated Appointment Reminders.
By supplying your home phone number/mobile phone number/email address, you acknowledge that the Practice or a third-party automated outreach and messaging system may notify you of a pending appointment, missed appointment, lab results, or deliver any other health care message by call, email, or text message. To service your account or collect any amounts you may owe, you consent for Practice or a third party acting on its behalf to call or text you at any phone number associated with your account, including through pre-recorded/automated voice and text messages. You understand that your cell phone carrier may charge you for these text messages and that you will be offered an easy way to opt out of these automated calls or text messages.
4. Use and Release of Medical Information.
As an alternative to a telemedicine consultation, you can make an in-person appointment with your primary care physician or specialty provider.
By selecting “AGREE,” you acknowledge that in addition to the information above, you understand and agree to the following:
You must be physically located in your state of residence (as identified in your new patient registration) during your scheduled telemedicine consultation. If you are no longer located in the state used at the time of registration, you are obligated to notify the Clinician immediately and no later than at the beginning of your telemedicine consultation.
You have had the alternatives to a telemedicine consultation explained to you, and it is your voluntary choice to participate in this telemedicine consultation.
You understand there is no guarantee you will be treated by a Clinician. The Clinicians reserve the right to deny care for potential misuse of Services or for any other reason if, in the professional judgment of the Clinician, the provision of Services is not medically or ethically appropriate.
You understand there is no guarantee that you will be given a prescription by the Clinician.
You understand that you cannot use the Services to get prescriptions for non-therapeutic drugs and certain other drugs which may be harmful because of their potential for abuse or that otherwise cannot be appropriately prescribed using the Services.
You understand that you can choose to refuse or end the telemedicine service at any time without affecting your right to future care and treatment.
You understand that you may request that your Clinician forward a copy of your medical records to your primary care provider, and in such cases, you expressly consent to the sharing of such medical records with your primary care provider.
You understand that you may request that your Clinician assist you with identifying options for non-emergency follow-up care needs, to the extent that you want or need in-person health care services.
You understand that you may register any complaints regarding the Services or your Clinician through Customer Support via the “Contact Us” section of our website at LetsGetChecked.com or with the applicable state professional licensing board.
You understand that you or your Clinician can discontinue the telemedicine visit at any time if the videoconferencing connections or other telehealth modalities are inadequate to exchange medical information, transmit diagnoses, or review treatment options.
You understand that you will not physically be in the same room as your Clinician.
You understand there are potential risks to using telemedicine technology, which, while unlikely, may include loss of confidentiality, integrity, and availability of information, and/or other technical difficulties with Services.
You understand that your healthcare information may be shared with other individuals for scheduling, treatment, and/or billing purposes. Under no circumstances will your identifiable patient information from the telehealth encounter, including images, be shared with researchers or other entities without your written consent.
You have the right to object to the videotaping or other recording of a telemedicine visit. You also agree not to record a telemedicine visit without your Clinician’s permission.
You understand that you have the right to request a copy of the medical record that is created as a result of using the Services.
In an emergency situation, you understand that you should immediately contact emergency services.
You understand that you will be responsible for any copayments, coinsurances, deductibles, and/or non-covered services that apply to your telemedicine visit (if applicable).
You understand that it is your duty to inform your Clinician of any relevant interactions regarding your care that you may have with other healthcare providers.
You understand this Informed Consent and consent, on your own behalf to receive Services.
You understand that you are unconditionally financially responsible to the Practice as the patient, parent, guardian, conservator, or insured for all charges not covered by your insurance plan. You acknowledge that you are responsible for verifying the extent to which your insurance plan covers the telemedicine services offered by the Practice. You promise to pay the Practice for all services rendered by a Clinician, whether or not such services are covered under the terms of your insurance coverage, including but not limited to, co-payments, co-insurance, deductibles, and non-covered services. If you do not have insurance coverage, you understand that the charges for medical services are your personal responsibility and agree to make payment for any such amounts. If the Practice does not receive payment within thirty (30) days from the date such balance is due, the bill may be turned over to an attorney or collection agency. If so, you agree to pay all reasonable collections costs including attorney’s fees and/or collection fees in addition to the amounts owed for services.
Assignment of Benefits
Further, if you are entitled to receive healthcare benefits under any insurance policy from any person or organization, you hereby assign to the Practice all of your rights, title and interest in those benefits for payment of your bills. You understand that you are responsible for knowing the terms and conditions of any applicable insurance coverage, and certify that the information given regarding your insurance is accurate and current to the best of your knowledge. You agree not to attempt to cash or negotiate insurance checks sent directly to you or to the insured and further agree to promptly endorse and deliver to the Practice any insurance checks, upon receipt. You hereby authorize the Practice to act on your behalf in regard to filing any appeals for insurance. To the extent applicable, you certify that any information you provide in applying for Medicare or Medicaid is correct. You hereby request payment of authorized benefits to be made on your behalf to the Practice by the Medicare or Medicaid program.
Release of Information
Additionally, you authorize the Practice to process claims for payment by your insurance carrier on your behalf for covered services provided to you during this telemedicine consultation. You authorize the Practice to release your medical information to (A) any third-party payor or insurance company responsible for paying your medical bill; (B) any third parties retained by the Practice for the purposes of obtaining payment of your bill; (C) any health care facility or physician to which you are transferred or referred to permit continuity of care; (D) any governmental agency or government entity as may be required by law; or (E) to facilitate applications for financial assistance or other determination of your eligibility for Medicare, Medicaid, and other benefits to which you may be entitled. As permitted or required by applicable state and federal laws, the information in your medical record that may be released to the entities listed above includes, but is not limited to: (1) information about your medical condition and your treatment; (2) information about serious communicable diseases and infections, including information about sexually transmitted diseases, tuberculosis, hepatitis, human immunodeficiency virus (HIV), acquired immunodeficiency syndrome (AIDS) and any other disease or medical condition; (3) any vaccination or immunization administration history; (4) results of toxicology screening and information regarding treatment for substance abuse; (5) information regarding sexual assault or evidence thereof; (6) developmental disability, mental health, psychological and social information, including communications made to or from you by a psychiatrist, licensed psychologist, nurse practitioner, physician's assistant, therapist, social worker, and/or other behavioral health clinician; (7) information regarding genetic and genomic testing, including the tests you received and your results; (8) information related to your insurance plan, policy number and insurance coverage available to you; and (9) personal information about you, such as your address, telephone number and Social Security number. You understand that, if this information is disclosed to a third party, the information may no longer be protected by state or federal privacy regulations and may be re-disclosed by the person or entity that receives the information, in accordance with applicable law.
You understand and agree that this Informed Consent, Financial Agreement, Assignment of Benefits, and Release of Information will remain in effect unless you revoke your authorization in writing, except to the extent that the Practice has already taken action in reliance upon it. Written revocations must be sent via email to DPO@LetsGetChecked.com or sent via physical mail certified and delivered to the Practice at 330 W. 38th St., 405, New York, New York, 10018. Such revocation will be effective upon receipt, but you agree to remain personally liable for all financial commitments incurred prior to such revocation. Any prior Informed Consent, Financial Agreement, Assignment of Benefits, and Release of Information forms that may have been executed, will be replaced by this legal document. You further agree that this form, as executed, is controlling in any disputes related to the above stated terms.