Telehealth Consent Terms

PAGRRX.COM INFORMED CONSENT FOR TELEHEALTH

 

This Informed Consent for Telehealth contains important information focusing on providing healthcare services using the phone or the Internet. Please read this carefully and let us know if you have any questions. We will not be able to treat you until we have this signed agreement with you. By clicking the I Agree and Consent button, you are entering an agreement with us.

 

Benefits and Risks of Telehealth

Telehealth refers to providing Healthcare and Medication services remotely using telecommunications technologies, such as video conferencing or telephone. One of the benefits of telehealth is that the patient and clinician can engage in services without being in the same physical location. This can be helpful particularly during the Coronavirus (COVID-19) pandemic in ensuring continuity of care as the patient and clinician likely are in different locations or are otherwise unable to continue to meet in person. ?It is also more convenient and takes less time. Telehealth, however, requires technical competence on both our parts to be helpful. Although there are benefits of telehealth, there are some differences between in-person treatment and telehealth, as well as some risks. For example:

 

Possible Benefits:

  • Improved access to care by enabling you to remain in your home while the provider consults and obtains test results at distant/other sites.
  • More efficient care evaluation and management.
  • Obtaining expertise of a specialist as appropriate

Possible Risks:

  • Risks to confidentiality. As telehealth sessions take place outside of your physician’s office, there is potential for other people to overhear sessions if you are not in a private place during the session. On my end, I will take reasonable steps to ensure your privacy. It is important; however, for you to make sure you find a private place for our session where you will not be interrupted. It is also important for you to protect the privacy of our session on your cell phone or other device. You should participate in therapy only while in a room or area where other people are not present and cannot overhear the conversation.

 

  • Issues related to technology. There are many ways that technology issues might impact telehealth. For example, technology may stop working during a session, other people might be able to get access to our private conversation, or stored data could be accessed by unauthorized people or companies.

 

Informed Telehealth Consent Agreement

Pagrrx.com and EirSystems, Inc., the owner of the domain, 129 Walnut St, Chattanooga, TN 37402.

  1. I understand that my Primary Care Provider recommends engaging in telehealth services with me to provide treatment.

 

  1. I understand this is out of necessity and an abundance of caution and has originated due to the Coronavirus (Covid-19) pandemic. This will continue until such time that we are able to meet in person, or could continue, depending on the particular circumstance.

 

  1. I understand that telehealth treatment has potential benefits including, but not limited to, easier access to care.

 

  1. I understand that telehealth has been found to be effective in treating a wide range of disorders, and there are potential benefits including, but not limited to easier access to care. I understand; however, there is no guarantee that all treatment of all patients will be effective.

 

  1. I understand that it is my obligation to notify my Primary Care Coordinator of my location at the beginning of each treatment session. If for some reason, I change locations during the session, it is my obligation to notify my Primary Care Coordinator of the change in location.

 

  1. I understand that it is my obligation to notify my Primary Care Coordinator of any other persons in the location, either on or off camera and who can hear or see the session. I understand that I am responsible to ensure privacy at my location. ?I will notify my Primary Care Coordinator at the outset of each session and am aware that confidential information may be discussed.

 

  1. I understand that it is my obligation to ensure that any virtual assistant artificial intelligence devices, including but not limited to Alexa or Echo, will be disabled or will not be in the location where information can be heard.

 

  1. I agree that I will not record either through audio or video any of the session, unless I notify my Primary Care Coordinator, and this is agreed upon.

 

  1. I understand there are potential risks to using telehealth technology, including but not limited to, interruptions, unauthorized access, and technical difficulties. I understand some of these technological challenges include issues with software, hardware, and internet connection which may result in interruption.

 

  1. I understand that my Telehealth Coordinator is not responsible for any technological problems of which my Telehealth Coordinator has no control over. I further understand that my Telehealth Coordinator does not guarantee that technology will be available or work as expected.

 

  1. I understand that I am responsible for information security on my device, including but not limited to, computer, tablet, or phone, and in my own location.

 

  1. I understand that my Primary Care Coordinator or I (or, if applicable, my guardian or conservator), can discontinue the telehealth consult/visit if it is determined by either me or my Primary Care Coordinator that the videoconferencing connections or protections are not adequate for the situation.

 

  1. I have had a conversation with my Primary Care Coordinator, during which time I have had the opportunity to ask questions concerning services via telehealth. My questions have been answered, and the risks, benefits, and any practical alternatives have been discussed with me.

 

  1. com is the technology service we will use to conduct telehealth videoconferencing appointments. My Primary Care Coordinator has discussed the use of this platform.? Prior to each session, I will receive an email link to enter the ?waiting room? until the session begins.? There are no passwords or log in required.

By clicking the ?I Agree and Consent? button, I acknowledge:

  1. com is NOT an emergency service. In the event of an emergency, I will use a phone to call 9-1-1 and/or another appropriate emergency contact.

 

  1. I recognize my Primary Care Coordinator may need to notify emergency personnel in the event he/she feels there is a safety concern, including but not limited to, a risk to self/others or my Primary Care Coordinator is concerned that immediate medical attention is needed.

 

  1. Though my Primary Care Coordinator and I may be in virtual contact through telehealth services, neither pagrrx.com or my Primary Care Coordinator provides any medical or emergency or urgent healthcare services or advice. I understand should medical services be required; I will contact my physician.? If emergency services are needed, I understand I should call 9-1-1.

 

  1. The pagrrx.com website facilitates videoconferencing and this technology platform is not, itself, a source of healthcare, medical advice, or care.
  1. I understand that the same fee rates apply for telehealth as apply for in-person treatment.? Some insurers are waiving co-pays during this time.? It is my obligation to contact my insurer before engaging in telehealth to determine if there are applicable co-pays or fees which I am responsible for.? Insurance or other managed care providers may not cover telehealth sessions.? I understand that if my insurance, HMO, third-party payor, or other managed care provider do not cover the telehealth sessions, I will be solely responsible for the entire fee of the session.

 

  1. During these times of the impact of Coronavirus (Covid-19) my Primary Care Coordinator may not have access to all of my medical/treatment records. My Primary Care Coordinator has made reasonable efforts to obtain records, but I understand and agree this may not be reasonably possible.

 

  1. To maintain confidentiality, I will not share my telehealth appointment link or information with anyone not authorized to attend the session.

 

  1. I understand that either I or my Primary Care Coordinator can discontinue the telehealth services if those services do not appear to benefit me therapeutically or for other reasons which will be explained to me. I understand there may be no other treatment alternative available.

I have read and understand the information provided above regarding telehealth, and I hereby give informed consent to the use of telehealth by clicking the ?I Agree and Consent? button.

 

Emergency Situations

If there is an emergency situation telemedicine is not an appropriate method of care.

IN CASE OF AN EMERGENCY, YOU SHOULD SEEK IMMEDIATE MEDICAL ATTENTION OR EMERGENCY CARE BY CALLING 911.

Indemnification

YOU AGREE TO INDEMNIFY AND HOLD HARMLESS THE PROVIDER, ITS EMPLOYEES, AGENTS, DIRECTORS, MEMBERS, MANAGERS, SHAREHOLDERS, OFFICERS, REPRESENTATIVES, ASSIGNS, PARENTS, PREDECESSORS, AND SUCCESSORS FROM AND AGAINST ANY AND ALL LOSS OR DAMAGE, INCLUDING ANY AND ALL INDIRECT, INCIDENTAL, SPECIAL, CONSEQUENTIAL OR EXEMPLARY DAMAGES, EXPENSES, LIABILITIES, CLAIMS, OR DEMANDS WHATSOEVER ARISING OUT OF OR RELATED TO ANY FAILURE OF TECHNOLOGY OR EQUIPMENT IN CONNECTION WITH THE PROVISION OF TELEMEDICINE, WHETHER OR NOT ANY SUCH LOSS, DAMAGE, EXPENSE, LIABILITY, CLAIM, OR DEMAND ARISES FROM OR RELATES TO THE PROVIDER’S NEGLIGENCE.

 

Electronic Communications

You may have to have certain computer or cell phone systems to use telepsychology services. ?You are solely responsible for any cost to you to obtain any necessary equipment, accessories, or software to take part in telehealth.

Confidentiality

I have a legal and ethical responsibility to make my best efforts to protect all communications that are a part of telehealth services.? The nature of electronic communications technologies, however, is such that I cannot guarantee that our communications will be kept confidential or that other people may not gain access to our communications. ?I will try to use updated encryption methods, firewalls, and back-up systems to help keep your information private, but there is a risk that our electronic communications may be compromised, unsecured, or accessed by others.? You should also take reasonable steps to ensure the security of our communications (for example, only using secure networks for telehealth sessions and having passwords to protect the device you use for telehealth).

 

The extent of confidentiality and the exceptions to confidentiality that I outlined in my PAGRRX.COM INFORMED CONSENT FOR TELEHEALTH still apply in telehealth.? Please let me know if you have any questions about exceptions to confidentiality.

 

Fees

The same fee rates will apply for telehealth as apply for in-person therapy. ?Some insurers are waiving co-pays during this time.? It is important that you contact your insurer to determine if there are applicable co-pays or fees which you are responsible for.? Insurance or other managed care providers may not cover sessions that are conducted via telecommunication. ?If your insurance, HMO, third-party payor, or other managed care provider does not cover electronic therapy sessions, you will be solely responsible for the entire fee of the session.? Please contact your insurance company prior to our engaging in telehealth sessions in order to determine whether these sessions will be covered.

 

If there is a technological failure and we are unable to resume the connection, you will only be charged the prorated amount of actual session time.

 

Records

The telehealth sessions shall not be recorded in any way unless agreed to in writing by mutual consent? I will maintain a record of our session in the same way I maintain records of in-person sessions in accordance with my policies.

 

Informed Consent

This agreement is intended as a supplement to the general informed consent that we agreed to at the outset of our treatment together and does not amend any of the terms of that agreement.

 

I have read and understand the information provided above regarding telehealth, and I hereby give informed consent to the use of telehealth by clicking the ?I Agree and Consent? button when filling out a form and when using www.PagrRx.com.?