To support our mission of providing high quality care and maximize your outcomes and satisfaction, LocumTele, LLC (“LocumTele”) utilizes a third-party telehealth platform (the “Platform”), through which independent licensed healthcare providers (“Providers”) will provide you telehealth services related to your weight loss treatment (“Services”). The Platform is accessible through a third-party virtual care suite (the “Solution”).
By signing below, you hereby consent to receive the Services. This means that you authorize information related to your health care to be securely electronically transmitted in the form of images and data through an interactive video or telephonic connection between you and the Provider, who are located in two different locations.
By signing below, you acknowledge your understanding and agreement to the following:
1. There are possible benefits of telehealth, including, without limitation, increased accessibility and efficiency to medical care, the ability to obtain medical care and treatment at times that are convenient to me, and the ability to interact with providers without the necessity of an in-office visit.
2. There are possible limitations of telehealth, including, without limitation, disruption of transmission by technology failures, breaches of confidentiality by unauthorized persons, and/or limited ability to respond to emergencies.
3. I have a duty to answer questions about my health and medical history honestly and accurately and to keep all of my health care providers, including my Provider, up-to-date on any changes in my health, symptoms, treatment or medications.
4. Withholding or providing inaccurate information about my health and medical history in order to obtain treatment may result in harm to me, including, in some cases, death.
5. The Services enable coordination and communication with a Provider and do not replace my relationship with any existing health care provider.
6. I cannot obtain emergency treatment through the Services and should call 9-1-1 and seek immediate medical treatment if I am experiencing a medical emergency.
7. If I have questions relating to my care that are not urgent, I can message my Provider through the Solution. I understand that my Provider may not review and respond to my messages until the next business day, depending on when the message was sent.
8. My Provider may determine in his/her sole discretion that my condition is not suitable for treatment using the Services and that I may need to seek medical care and treatment in-person or from an alternative source.
9. I have the right to withhold or withdraw my consent for the Services at any time during the course of my care. Otherwise, this consent will be considered renewed upon each new telehealth consultation with my Provider.
10. There will be no video or audio recording of the Services by either party.
11. All my information, including my health information, collected by LocumTele and my Providers through the Services will be securely stored in an electronic medical record. All federal and state laws protecting the privacy and confidentiality of health information also apply to telehealth and that information disclosed during the Services and written records pertaining to those Services are confidential and may not be disclosed without my written consent, unless a disclosure is permitted and/or required by law.
12. LocumTele, my Providers and the vendor providing the Platform (“Platform Vendor”) may collect, store, use and share my information, including health information and other information regarding the Services, including with the vendor providing the Solution (the “Solution Vendor”), as described in LocumTele’s and Platform Vendor’s Privacy Policies, and for any other purposes permitted by law.
13. LocumTele and Platform Vendor have agreements in place with Solution Vendor to ensure the confidentiality of my health information that it has access to by virtue of providing its services. By signing below, I knowingly and voluntarily consent to the disclosure of my health information to, and processing of (including de-identifying and aggregating) such information by, Solution Vendor to provide the Solution, improve and develop its technology, as described in Solution Vendor’s Privacy Policy, and for any other purposes permitted by law.
A technical failure affecting the Services may result in the loss of my information and/or interrupt my telehealth session. In addition to any disclaimers that I agreed to by accepting the Terms of Use, I agree to hold LocumTele, Platform Vendor and Solution Vendor harmless for any loss of information or delay in care resulting from a technical failure.