Consent to Telehealth

 

Agreement between User and www.getsuboxone.com and www.hipaa.jotform.com 

We provide websites and applications through which you can obtain an online visit with an independent, licensed healthcare professional (a “Provider“) and mail order pharmacy services for any medications prescribed to you (collectively, the “Services“). The Services constitute a form of telehealth, which involves the delivery of health care services using electronic communications between a health care provider and a patient who are in different physical locations. We believe that telehealth has the potential to provide a number of benefits, including convenient, discreet, and affordable care. Telehealth may be used for diagnosis, treatment, follow-up and/or patient education. Telehealth may include, but is not limited to:

•Electronic transmission of medical records, photo images, personal health information or other data between a patient and a Provider;

•Interactions between a patient and a Provider via audio, video and/or asynchronous data communications, such as secure messaging and email; and

•Use of data from remote monitoring devices, medical devices, and sound or video files.

The websites, applications, and information systems used in the Services incorporate network and software security protocols to protect the privacy, security, and integrity of your health information.

Possible Benefits of Telemedicine

•Telehealth can make accessing medical care easier, more efficient, and less expensive.

•You can obtain medical care and treatment at times that are convenient for you.

•You can interact with providers without the necessity of an in-office appointment.

Possible Limitations of Telehealth

•Information transmitted to your Provider may not be sufficient to allow for appropriate medical decision making or your Provider may not be able to provide medical treatment for your condition via telehealth, and you may be required to seek alternative care.

•The inability of your Provider to conduct certain tests or assess vital signs in person may in some cases prevent the Provider from diagnosing or treating you or identifying that you need urgent medical care.

•Your medical care could be delayed due to technological failures that interrupt the Services.

•Data security protocols or safeguards could fail and cause a breach of your identified health information.

•Due to the nature of the Services and regulatory requirements in certain jurisdictions, your treatment options, especially pertaining to certain prescriptions, may be limited.

By accepting this Consent to Telehealth, you acknowledge your understanding and agreement to the following:

•I have read this Consent to Telehealth carefully, and understand the risks and benefits of the use of telehealth in my medical care and treatment.

•I give my informed consent to receive medical care and treatment by telehealth from Providers affiliated with Healthcare Intermediaries.

•I understand that the delivery of health care services via telehealth is an evolving field and that the use of telehealth in my medical care and treatment may include uses of technology not specifically described in this consent.

•I understand that while the use of telehealth may provide potential benefits to me, as with any medical care service no such benefits or specific results can be guaranteed. My condition may not be cured or improved, and in some cases, may get worse.

•I understand that 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, treatments, or medications.

•I understand that 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.

•I understand that my Provider may determine in his or her sole discretion that my condition is not suitable for treatment using telehealth, and that I may need to seek medical care and treatment in-person or from an alternative source.

•I understand that the Services enable coordination and communication with a Provider and do not replace my relationship with any existing health care provider.

•I understand that I cannot obtain emergency care through the Services, and I should call 9-1-1 and seek immediate medical treatment if I am experiencing a medical emergency.

•I understand that my information, including my identified health information, will be collected, used, shared, and protected as described in the Privacy Policy.

•I understand that I have access to all of my health and wellness information pertaining to my telehealth consultation with my Provider in accordance with applicable laws and regulations.

•I understand that Healthcare Intermediaries and my Provider will share my telehealth record with my other health care providers only with my consent and at my request. I understand that I can have my telehealth record sent to my other health care providers by emailing Healthcare Intermediaries at help@getsuboxone.com and providing my consent along with my health care provider’s name, address, and phone number.

•I understand that a technical failure affecting the Services may result in the loss of my information and/or interrupt my online visit. In addition to any disclaimers that I agreed to by accepting the Terms of Use, I agree to hold Healthcare Intermediaries harmless for any loss of information or delay in care resulting from a technical failure.

•I understand that I can withhold or withdraw this consent at any time by emailing Healthcare Intermediaries at help@getsuboxone.com with such instruction. Otherwise, this consent will be considered renewed upon each new telehealth consultation with a Provider.

•I agree and authorize Healthcare Intermediaries and my Providers to collect, use, and share my information, including my identified health information and other information regarding the telehealth exam, as described in Healthcare Intermediaries’ Privacy Policy and for any other purposes permitted by law, including for treatment, payment, and health care operations purposes.

 

All capitalized terms used in this Consent to Telehealth but not defined herein have the meanings assigned to them in the Terms of Use. For avoidance of any doubt, the terms “Healthcare Intermediaries”, “we”, “us”, “Healthcare Intermediaries’”, or “our“ refer to Healthcare Intermediaries LLC and the terms “you“ and “yours“ refer to the person using the Services.