Agreement to use of Telemedicine

Consent to Participate in Telehealth Consultation & Services

I, the person whose name is indicated below, am executing this Consent to Participate in Telehealth Consultation & Services (“Telehealth Consent”) with Coxaroc, LLC (the “Practice”), and to verify and confirm my discussion with any licensed Health Care Provider acting on behalf of the Practice (collectively referred to as the “Provider”) regarding the risks, benefits, and alternatives to the Telehealth consultation services.

By signing this Telehealth Consent I acknowledge:

• that I sought the Practice for a Telehealth consultation;
• that I am seeking the Practice’s Telehealth consultation services for my own purposes and not on behalf of any third party;
• that I understand that I am a participant in the decision-making process, and I am free to decline services or treatments at any time;
• that I retain the option to withhold or withdraw consent at any time without affecting my right to future care or treatment nor risking the loss or withdrawal of any program benefits to which I would otherwise be entitled;
• that the Provider may, in his or her sole discretion, determine whether the nature of my consultation is inappropriate for Telehealth, and may require me to be seen in-person by a local provider;
• that I will bring it to the attention of the Practice, if, at any time, I have any lack of understanding of the risks, benefits and alternatives to Telehealth, and inquire of my Provider for a further explanation until I have a full understanding before giving consent to any treatment or services.

Definitions.

• “Telehealth” means the practice of medicine using electronic communications, information technology or other means between a licensee in one location, and a patient in another location with or without an intervening healthcare provider. Generally, Telehealth is not an audio-only, telephone conversation, e-mail, text-message, and instant messaging conversation. It typically involves the application of secure videoconferencing or store and forward technology to provide or support healthcare delivery by replicating the interaction of a traditional, encounter in person between a provider and a patient.
• “Telehealth Technologies” means technologies and devices enabling secure electronic communications and information exchange between a licensee in one location and a patient in another location with or without an intervening healthcare provider.
• Purpose. The purpose of this form is to obtain your consent for Practice and its Providers to provide you with Telehealth services using Telehealth technologies. The purpose of the use of Telehealth services is to assist in the care and services provided by Practice.
• Nature of Telehealth Services. Telehealth involves the use of audio, video or other electronic communications to interact with you, consult with your healthcare provider and/or review your medical information for the purpose of diagnosis, therapy, follow-up and/or educational purposes. During your Telehealth consultation, details of your medical history and personal history information may be discussed with other health professionals through the use of interactive video, audio and telecommunications technology. Additionally, a physical examination of you may take place and video, audio, and/or photo recordings may be taken.
• Risks, Benefits and Alternatives. The benefits of Telehealth include having access to medical specialists and additional medical information and education without having to travel outside of your local health care community. Additional benefits are that patients may be diagnosed and treated earlier which can contribute to improved outcomes and less costly treatments. Potential risks of Telehealth include that because of your specific medical condition, or due to technical problems, a face-to-face consultation still may be necessary after the Telehealth appointment.
• The Practice has taken the following steps to ensure the privacy of the Telehealth consultation: We use only HIPAA compliant software through our Electronic Medical Record (EMR) software, teleconferencing software, and other electronic service providers.
• In rare instances, technology failure may lead to the loss of information provided through Telehealth consultations. Additionally, in rare instances, security protocols could fail causing a breach of patient privacy. In rare cases, a lack of access to complete and/or accurate medical records or information may result in adverse drug reactions, allergic reactions, or other judgment errors. You agree to hold Provider and the Practice harmless from any such information loss, and any resulting judgments or decisions, due to technological failures outside of their agency or control. The quality of transmitted data may also affect the quality of the services provided via the Telehealth consultation. The alternative to Telehealth consultation is a face-to-face visit with a provider.
• Medical Information and Records. All laws concerning patient access to medical records and copies of medical records apply to Telehealth. Dissemination of any patient identifiable images or information from the Telehealth consultation shall not occur without your consent.
• Confidentiality. All existing confidentiality protections under federal and state law apply to information used or disclosed during your Telehealth consultation. However, there are both mandatory and permissive exceptions to confidentiality, which may allow or require disclosure of information used or disclosed during the Telehealth consultation. You will be informed of any parties who will be present from the Practice during your telehealth consultation and will have the opportunity to exclude anyone from attending the consultation.
• Rights. You may withhold or withdraw your consent to a Telehealth consultation at any time before and/or during the consultation without affecting your right to future care or treatment or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled. You have the right to be informed of and object to videotaping or other recording of the telehealth consultation.
• Licensure. All Health Care Providers are subject to state licensure of the state of residence of the patient being treated.
• Disclaimer & Restrictions on Treatment. Every Health Care Provider who treats or prescribes through Telehealth is licensed and must comply with the licensure requirements in each jurisdiction where the patient is receiving care. Our Health Care Providers are licensed in all fifty (50) states. Please check our website regularly for notifications of states in which we are providing Telehealth services.

By signing below, you acknowledge and certify that:

• You understand that you may expect anticipated benefits from the use of Telehealth in your care, but that no results can be guaranteed or assured;
• You have had opportunities to ask questions and have had them answered to your satisfaction;
• You have completely read and fully understand the foregoing Telehealth Consent, and you have all of the knowledge you require before signing this Consent;
• You agree and accept all of the terms above; and
• You are legally competent and have sufficient knowledge to give voluntary and informed consent.