1. Introduction
Telehealth involves the use of secure electronic communications to enable healthcare providers and patients to share individual patient health information for the purpose of rendering clinical care. This “Telehealth Informed Consent” informs you (“patient,” “you,” or “your”) about the treatment methods, risks, and limitations of using a telehealth platform.
2. Services Provided
Telehealth services offered by Caresful, Inc. (“Caresful”) and its affiliated healthcare providers (“Providers”) may include patient consultations, diagnoses, education, treatment recommendations, prescriptions, and/or referrals to in-person care, as determined clinically appropriate (the “Services”).
3. Electronic Transmissions
The types of electronic transmissions that may occur using the telehealth platform include, but are not limited to:
- Appointment scheduling.
- Completion, exchange, and review of medical intake forms and other clinically relevant information (e.g., health records, images, diagnostic and/or lab test results) between you and your Provider via:
- Asynchronous communications.
- Two-way interactive audio in combination with store-and-forward communications.
- Two-way interactive audio and video interaction.
- Treatment recommendations by your Provider based upon such review and exchange of clinical information.
- Delivery of a consultation report with a diagnosis, treatment, and/or prescription recommendations, as deemed clinically relevant.
- Prescription refill reminders (if applicable).
- Fees assessed for Services and how payments will be rendered.
- Other electronic transmissions that may include forwarding patient-identifiable information to a third party for the purpose of rendering clinical care and treatment to you.
4. Expected Benefits
- Improved access to healthcare by enabling you to remain in your location while consulting with Providers.
- More efficient healthcare evaluation and management.
- Obtaining health and wellness services at times that are convenient for you without the necessity of an in-office appointment, including follow-up care related to your treatment.
5. Service Limitations
- The primary difference between telehealth and direct in-person service delivery is the inability to have direct, physical contact with the patient. Accordingly, some clinical needs may not be appropriate for a telehealth visit, and your Provider will make that determination.
- Our Providers do not address medical emergencies. If you believe you are experiencing a medical emergency, you should dial 9-1-1 and/or go to the nearest emergency room. If you are contemplating suicide, dial 9-1-1 or call/text the National Suicide Prevention Line at 988. Please do not attempt to contact Caresful or your Provider. After receiving emergency healthcare treatment, you should visit your local primary care provider.
- Our Providers are an addition to, and not a replacement for, your local primary care provider. Responsibility for your overall medical care should remain with your local primary care provider, if you have one, and we strongly encourage you to locate one if you do not. Certain Services may be available in-person, and you should speak with your Provider to determine the need for in-person Services.
6. Security Measures
The electronic communication systems we use will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption. All the Services delivered to the patient through telehealth will be delivered over a secure connection that complies with the requirements of the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”).
7. Possible Risks
- Delays in evaluation and treatment could occur due to deficiencies or failures of the equipment and technologies, or provider availability. In the event of an inability to communicate as a result of a technological or equipment failure, please contact Caresful at support@caresful.com.
- In rare events, your Provider may determine that the transmitted information is of inadequate quality, thus necessitating a rescheduled telehealth consultation or a recommendation for in-person care.
- In very rare events, security protocols could fail, causing a breach of privacy of personal medical information.
8. Patient Responsibilities
- I understand that I must provide accurate and complete information about my medical history and current condition to my Provider.
- I understand that I may be asked to provide additional information, including images or lab results, to assist in my treatment.
- I understand that I must inform my Provider of any changes in my condition.
- I understand that I should seek emergency help or follow-up care when recommended by my Provider or when otherwise needed.
9. Financial Responsibility
- I understand that I am responsible for any payments associated with my telehealth consultation, including any applicable co-pays or deductibles.
- I understand that if my insurance does not cover telehealth consultations, I am responsible for the full payment.
10. Consent to Use of Telehealth Services
By clicking “I Agree” or signing this form, I acknowledge that I have read this Telehealth Informed Consent, understand the risks and benefits of the telehealth Services, and by using the Services, I hereby give my informed consent to participate in a telehealth consultation under the terms described herein.
I have read this Telehealth Informed Consent and understand the risks and benefits of the telehealth Services and have had my questions regarding the Services explained and I hereby give my informed consent to participate in a telehealth consultation under the terms described herein.
ARBITRATION NOTICE: UNLESS YOU TIMELY OPT-OUT OF ARBITRATION IN ACCORDANCE WITH THESE TERMS AND CONDITIONS, YOU AGREE THAT DISPUTES BETWEEN YOU AND US OR YOU AND THE MEDICAL GROUPS OR PROVIDERS ARISING OUT OF OR RELATED TO THESE TERMS AND CONDITIONS OR THE SERVICE WILL BE RESOLVED BY BINDING, INDIVIDUAL ARBITRATION AND YOU WAIVE YOUR RIGHTS TO A JURY TRIAL AND TO PARTICIPATE IN A CLASS ACTION LAWSUIT OR CLASS-WIDE ARBITRATION, AS FURTHER SET FORTH BELOW. WE EXPLAIN SOME EXCEPTIONS AND HOW YOU CAN OPT OUT OF ARBITRATION BELOW.
IF YOU HAVE A MEDICAL EMERGENCY, SEEK IN-PERSON EMERGENCY CARE IMMEDIATELY OR DIAL 911. THE SERVICE IS NOT APPROPRIATE FOR ALL MEDICAL CONDITIONS OR CONCERNS. THIS AGREEMENT IS SUBJECT TO CHANGE AS PROVIDED HEREIN.
Caresful Inc. and/or its subsidiaries (collectively, “Caresful”, “we”, or “us”) owns and operates the websites located at www.caresful.com and www.freehivtest.com and may have previously, now or in the future own and/or operate a “Caresful” and/or “FreeHIVTest.com” mobile application (collectively, the “Platform”). Your access and use of the Platform, any part thereof, or anything associated therewith, including its content (“Content”), any products or services provided through the Platform or otherwise by Caresful, and any affiliated website, software or application owned or operated by Caresful (collectively, including the Platform and the Content, the “Service”) are governed by these Terms and Conditions (“Terms and Conditions” or “Agreement”).