Telehealth Consent Form
Section I. Introduction
Driven Care, Inc. refers to a network of medical professional organizations affiliated and their employed and contracted health care providers (the “Providers”).
Section II. Telehealth Definition:
Telehealth involves the delivery of health and wellness services using electronic communications, information technology, or other means between a licensed, certified, or registered healthcare professional at one location and a patient in another location about a clinical matter. Telehealth may be used for diagnosis, treatment, follow-up and/or patient education. These telehealth services may involve various modalities, including asynchronous interactions, real-time video and audio encounters and interactive audio with store and forward. This “Telehealth Informed Consent” informs the patient or guardian (“patient,” “you,” or “your”) concerning the treatment methods, risks, and limitations of utilizing telehealth to meet your health and wellness needs.
Section III. Benefits of Telehealth:
It can be easier and more efficient for you to access health and wellness services. You can obtain 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. If you need follow-up care, please contact us through our website www.drivencare.org.
Section IV. Risks of Telehealth
Information transmitted to your health professional may not be sufficient to allow for appropriate health or wellness services to meet your particular need. Some clinical needs may not be appropriate for a telehealth visit and your Provider will make that determination. The technology necessary to interact with your health professional may fail and delay your services. If a technical failure prevents you from communicating with your Providers, you should call the following phone number: 714-406-1887. As all data exchanged is in a digital format, a data breach enables increased access to your health data. In rare events, a lack of access to complete medical records, and/or the quality of transmitted data could result in adverse drug interactions, allergic reactions, and/or other clinical judgment errors. You may stop or decline any on-going Health Care Services provided by Driven Care, Inc. using telehealth technologies at any time, although you acknowledge that applicable fees may apply if a medical consultation has occurred prior to request to cancel services and Driven Care, Inc. has no obligation for your on-going care or selection of separate health care services in such circumstances.
LABORATORY PRODUCTS AND SERVICES: To facilitate certain Health Care Services provided to you, Providers may require that you complete diagnostic test(s). These diagnostic tests are provided by third-party laboratories, and neither Driven Care, Inc. nor your Provider(s) can guarantee the accuracy or reliability of these tests. These laboratory tests can provide false negative, false positive, or inconclusive results that could impact your Provider(s) ability to correctly diagnose or treat your medical conditions. A failure or defect of these tests could also impact your Provider(s) ability to correctly diagnose or treat your medical conditions.
Section V. Not for Emergencies
I understand that I should never use Driven Care telehealth services in a medical or psychiatric emergency. I understand that in an emergency, I should dial 911 or go to the nearest emergency room.
Section VI. Patient Acknowledgement
By accepting this Telehealth Informed Consent, you acknowledge you understand and consent to the following:
1. I have reviewed this Telehealth Informed Consent carefully, and understand there are risks, limitations, and benefits of utilizing telehealth.
2. I understand that the electronic nature of the telehealth services means that there is a greater risk to the privacy of my health information.
3. In some cases, my Provider may be a nurse practitioner or physician assistant and not a physician.
4. Persons may be present during the telehealth visit other than my Provider in order to operate the telehealth technologies and/or for language translation assistance, if requested. If another person is present during the telehealth visit, I will be informed of the individual’s presence and his/her role.
5. I understand that information I provide as part of any telehealth offering is viewed as accurate, true, and complete. I understand that I may have opportunities to correct any incorrect information.
6. I understand that in certain instances, and in compliance with applicable law, my Provider may determine that it is appropriate to provide my Health Care Services asynchronously via store-and-forward technology. In such instances, my Provider and I will communicate electronically through the Driven Care/Elation Platform and not via telephone or video. I agree that if my provider makes that determination, I would like to receive Health Care Services in this manner.
7. I understand that there is no guarantee that I will be given a prescription and that the decision of whether a prescription is appropriate will be made in the professional judgment of my Provider. I understand that while the use of telehealth may provide benefits to me, no such benefits or specific results can be guaranteed and my condition may not improve.
8. I understand there is a risk of technical failures during the telehealth encounter beyond the control of Driven Care, Inc. and my Provider(s). I agree to hold harmless Driven Care, Inc. and its employees, contractors, agents, directors, members, managers, shareholders, officers, representatives, assigns, predecessors, and successors for delays in evaluation or for information lost due to such technical failures..
9. I understand that certain diagnostic testing services, including laboratory products and services offered through Driven Care, Inc. to support the Health Care Services of Providers, may contain defects, including ones which may limit functionality or produce erroneous results, any or all of which could limit or otherwise impact the quality, accuracy and/or effectiveness of the medical care or other services that I receive from my Provider(s).
10. I understand Driven Care, Inc. makes available a specific set of services and I may need to seek other resources for my other health needs. There is no guarantee that I will be treated by a Provider. My Provider reserves the right to deny care for any reason if, in the professional judgment of my Provider, the provision of the services, including when provided via telehealth is not medically or ethically appropriate. I understand that the Providers, and not Driven Care, Inc., are responsible for the quality and appropriateness of the care they render to me and make all decisions regarding clinical care in their independent discretion without the influence of Driven Care, Inc. I agree to only seek relief against the Provider for any liabilities pertaining to medical or clinical issues arising as a direct result of medical or clinical services accessed through Driven Care, Inc.
11. I understand that by using the Driven Care Platform I am not always speaking or messaging with my Provider in real-time, and there may be a delay before my messages or information is reviewed. I understand that I must check the Driven Care Platform for messages because this is the way that my Provider will communicate important information to me. I understand that if I do not check the Driven Care Platform regularly, then my services may be delayed.
12. I understand that I have the opportunity to discuss the use of telehealth, including the Health Care Services, with my Provider(s), including the benefits and risks of such use and the alternatives to the use of telehealth. I have the right to withdraw my consent to the use of telehealth in the course of my care, without prejudice to any future care or treatment and without risking the loss or withdrawal of any health benefits to which I am entitled, but I understand that the Providers who provide Health Care Services via the Driven Care Platform do not offer in-person treatment.
13. I understand that I have access to my medical record pertaining to the Health Care Services of Providers utilizing the Driven Care Platform in accordance with applicable laws and regulations and that my primary care provider, or another treating provider, may obtain copies of my health and wellness information with my consent.
14. I understand that while the Driven Care Platform may make available access to pharmacy or diagnostic lab services that are coordinated with the Health Care Services, I am able to request any pharmacy or lab of my preference.
15. I agree that Driven Care, Inc is a third-party beneficiary of the Telehealth Patient Consent and has the right to enforce it against you.
BIRTH CONTROL PILLS / PATCHES / RINGS
By signing below, I acknowledge that I am voluntarily receiving hormonal contraceptives including the combination birth control pill/patches/rings.
If used according to the instructions, the combination Pill, Patch or Ring is 99.5% effective in preventing pregnancy. I have been informed that the Pill, Patch, or Ring do not protect against sexually transmitted diseases, including HIV/AIDS.
I understand that I may experience the following benefits from using the Pill/Patch/Ring:
√ Decreased menstrual cramps √ Less risk of pelvic inflammatory disease
√ Decreased menstrual bleeding √ Improvement in acne (if any did exist)
√ Increased regularity of periods √ Less risk of cancer of the uterus or ovaries
√ Decreased mid-menstrual cycle pain √ Less risk of benign breast tumors and ovarian cysts
I understand that adverse events from using the Pill/patch/ring include but are not limited to stroke, heart attack, and death.
I understand that I can request a prescription for many different types of birth control and that different types have different risks of adverse events and different side effects.
I understand that, in general, combination birth control pills/patches/vaginal rings have a higher risk of serious side effects and adverse events, including blood clots, stroke, permanent disability, and death, than progestin-only pills. Combination pills/ patches/ vaginal rings contain 2 hormones, estrogen and progestin.
I understand that hormonal birth control prescribed by Driven Care providers that contain estrogen – namely combination birth control pills, the birth control patch, and the birth control ring – have a higher risk of serious side effects and adverse events, including blood clots, stroke, permanent disability, and death, than birth control that does not contain estrogen. Progestin-only pills do not contain estrogen and therefore present a lower risk of serious side effects. There are also birth control methods that do not contain hormones, such as barrier methods.
I understand that if I request a prescription for a combination pill/patch/vaginal ring, then it is important that I provide a recent and accurate blood pressure measurement because it is not appropriate to take combination pills if I have a history of elevated blood pressure or currently have high blood pressure.
I understand that if I take a combination pill/patch/vaginal ring without knowing my blood pressure, I have a significant risk of blood clots, stroke, permanent disability, or death.
I have been told to watch for the following danger signals:
A Abdominal pain (severe)
C Chest pain (severe), shortness of breath
H Headache (severe), dizziness, weakness, or numbness
E Eye problems (vision loss or blurring), speech problems
S Severe leg pain (calf or thigh)
I have been informed on the proper use of the Pill/Patch/Ring and understand that in order for the contraceptive method to be effective, I must use it consistently and correctly. I have been told that I should use another method of birth control until I have had at least one regular period before attempting to become pregnant. I have also been informed that my periods will most likely return to their previous status when I stop using the Pill/Patch/Ring.
I understand that if I request a prescription for a specific birth control pill/patch/vaginal ring, then I accept any increased risk of adverse events and serious side effects associated with that particular medicine. Also, if I choose an option not covered by my insurance, such as insisting on a name-brand when the insurance only covers generic, then there will be added costs that I must pay, or I will not receive the medication.