I hereby request, consent and authorize United Concierge Medicine, PLLC and its subsidiaries, affiliates and agents (collectively, the “Company”) and their employed or contracted physicians, physician assistants, nurse practitioners or other licensed health care professionals (the “Professionals”), to utilize Telehealth** through the Company’s proprietary systems, methods and protocols to access, diagnose, consult, treat and educate myself and those I am authorized to represent (the “Services”).
I understand that the Professionals will make every attempt to accurately access, diagnose and treat the health care condition for which I or those I am authorized to represent present to the Company or the Professionals.
I understand that the Services are self-pay, even if deemed to be a covered service under any health insurance plan or program that I or those I am authorized to represent are enrolled under at the time the Service is provided. I agree not to bill any private commercial insurer or federal or state health care program (i.e. Medicare, Medicaid, Tri-Care, Veterans Affairs, Federal Employee Health Benefits, etc.) even if deemed to be a covered service under such third-party insurance plan, and acknowledge that neither the Company nor the Professionals will bill any third-party health insurance plan for the Services provided.
I understand that the subscription and service fees due to the Company DO NOT include the costs of any treatment, procedure, service, medicine, drug or product provided by separate independent individuals or entities that may be prescribed*** or recommended by the Company or the Professional. I understand that I and those I am authorized to represent may receive one or more separate bills for such prescription medicines and other treatments, procedures, services or products and I am wholly responsible for payment of such costs, and further understand, that the independent entities and individuals will have their own billing and collection practices.
I understand that once the Professional decides on any prescription medicines or other treatment, procedure, service or product, if any, it is my responsibility to read and understand the risks and the potential side-effect profile and the adverse drug interactions of the medications and any other medications I may be taking concurrently, or consult with my primary care or specialty physician and pharmacist regarding the same, and ultimately to determine if I accept the risks.
I understand that it is my right to contact my primary care or specialty physician before starting any prescription medicines or other treatment, procedure, service or product or change my behavior based on any prescription, diagnosis, recommendation or education by the Company or the Professional in the course of the Service provided, to confirm that my primary care or specialty physician approves of the regimen.
I understand that all health care treatments can have potential adverse side effects and I accept responsibility for such potential adverse outcomes. If adverse effects are noted, I understand that it is my responsibility to stop any prescription medicines or other treatment, procedure, service or productprescribed or recommended by the Company or the Professional, and to report any adverse side-effects to the Company, the Professional, my primary care or specialty physician, or go to the nearest Emergency Room if I have any reason to suspect that I have a medical emergency.
I acknowledge that the Professionals shall exercise reasonable medical judgment in delivery of the Services provided, if any, but the condition for which I or those I am authorized to represent may seek a diagnosis, consultation or treatment may worsen after the Service provided, and both I and those I am authorized to represent are subject to the risks described above, including risks that the condition may worsen. I agree that I will not be entitled to a refund or recompense from Company or the Professionals for any reason, including poor outcomes.
I WILL INFORM THE COMPANY OR THE PROFESSIONAL OF ANY CONDITION THAT WOULD LIMIT MY ABILITY TO RECEIVE THE SERVICES PROVIDED OR THAT WOULD BE RELEVANT TO THE SERVICES THEMSELVES. IN PARTICULAR, I UNDERSTAND THAT IF I AM PLANNING TO BECOME PREGNANT, AM CURRENTLY PREGNANT, BECOME PREGNANT, OR AM BREASTFEEDING, THAT I WILL: (A) ADVISE COMPANY AND THE PROFESSIONALS OF THIS FACT; AND (B) ASK MY OB/GYN OR PEDIATRICIAN IF THE TREATMENTS RECOMMENDED BY THE PROFESSIONALS ARE ACCEPTABLE DURING THIS PERIOD OF TIME.
I understand that it is my sole responsibility to communicate and provide the Company and the Professionals with detailed, accurate and complete information concerning medical, medication and other history, allergies to medications and procedures, physical, mental and other relevant symptoms and conditions, and any other information or records requested or pertinent to the diagnosis and treatment of myself or those I am authorized to represent. I understand that, as with any service, to the extent that information is not provided or, if provided, is not detailed, accurate and complete, the services provided by the Company and the Professionals may be materially affected. I assume all risks, and assume full responsibility and waive all claims against the Company and the Professionals for personal injury, death or damages of any kind and agrees to the extent permitted by applicable law to defend, indemnify and hold harmless the Company and the Professionals from and against any and all claims of any nature including all costs, expenses and attorneys’ fees, which in any manner result from the failure to provide pertinent information and/or the failure to provide accurate and/or complete information as required.
Limited Nature of Relationship
TO THE EXTENT ALLOWABLE BY LAW, THE SERVICES PROVIDED, IF ANY, ARE NOT INTENDED TO CREATE, NOR DO THEY CREATE, ANY PRACTITIONER-PATIENT RELATIONSHIP WITH THE COMPANY OR THE PROFESSIONALS, EXCEPT WITH THE PROFESSIONALS, FOR THE LIMITED PURPOSES OF PROVIDING THE SERVICES.
I understand that the PRACTITIONER -patient relationship, if created, is explicitly limited in nature to the Services, provided and nothing else. I understand that I will not receive any Services from the Company or the Professionals outside of the limited scope of the Services. I AGREE THAT NEITHER THE COMPANY NOR THE PROFESSIONALS HAVE AN OBLIGATION TO ACCESS, DIAGNOSE, CONSULT, TREAT OR EDUCATE ME REGARDING ANY CONDITIONS BEYOND WHAT MAY BE DISCLOSED, DISCOVERED, EVALUATED OR DISCUSSED DURING THE SERVICES PROVIDED.
I understand that I have the option to withhold or withdraw my consent to receive the Services via Telehealth at any time, but that doing so will cause the Company and the Professionals to discontinue providing subsequent Services, it being acknowledged that the Company and the Professionals will only be delivering Services via Telehealth. In such case, I understand that I will need to seek treatment and care elsewhere.
I acknowledge and accept that the physical examination portion of the Service, if any, will be delivered via Telehealth in reliance upon either video, images, telephone consultation, questionnaire, medical records or otherwise. I accept this, with full knowledge of all potential benefits and consequences, and deem this method of physical examination appropriate and complete.
I understand that due to a specific medical condition or technical problems, a face-to-face consultation may be necessary after the Services provided, if any, and/or the Professional may not be able to accurately diagnose the condition due to limitations inherent in using Telehealth.
I understand that federal and state laws concerning the confidentiality of person health information apply to services delivered and information acquired via Telehealth, including patient access and amendments to medical records. I understand that in rare circumstances, security safeguards and protocols could fail causing a breach of patient privacy.
I have read and understand the written information provided above. I agree that the information provided above adequately explains the Services, along with the risks and benefits of said Services. I have had the opportunity to ask questions about this information – if I had any questions, all of my questions have been answered in full by the Company. By electronically signing this form, I acknowledge and agree to all of the above, and certify that I have no questions and/or have had my questions answered in full.
By electronically signing this Informed Consent, I am agreeing to conduct transactions electronically, and intend for my electronic signature to be a binding electronic signature/contractual obligation on myself and those I am authorized to represent. Further, I understand and acknowledge that I am digitally receiving a copy of this Agreement concurrently upon execution to print and/or retain a copy of this Agreement.
**“Telehealth” means the use of electronic information and communication technologies as a mode of delivering health care services and public health to facilitate the assessment, diagnosis, consultation, treatment, education, care management and self-management of a patient’s health care while the patient is at the originating site and the health care provider is at a distant site. Telehealth facilitates patient self-management and caregiver support for patients and includes synchronous interactions and asynchronous store and forward transfers.
***Online prescriptions will only be issued when indicated and approved by a physician, and as permitted by law in your state.
Revised: February 11, 2015