Curex Inc., Curex Medical Services P.A., Curex Medical of California P.C., Curex Medical of New Jersey P.C. (“Curex”), its affiliated health care providers, or other members of your care team (each, a “Provider”), may arrange for you to connect with Providers and/or provide you with professional services using asynchronous and/or synchronous telehealth technologies (“Telehealth Technology”). If you have questions about use of the Telehealth Technology itself and whether it is appropriate for your condition, the risks associated with using the Telehealth Technology, or the Provider’s credentials and professional background, please ask your Provider. In exchange for your use of the Telehealth Technology to receive care, you acknowledge and agree to the following terms and conditions of this informed consent (this "Consent"):
1. Use of Telehealth Technology. You understand and agree that:
● There are many benefits, but also risks associated with receiving care via Telehealth Technology. Benefits include convenience, increased access, and the ability to receive care in your home. Risks are outlined in Section 2 below.
● The Provider will decide, in his or her sole discretion, whether it is appropriate to treat your condition using the Telehealth Technology. The Provider may request that you halt receiving care via Telehealth Technology and instead receive in-person care if the Provider deems appropriate.
● Services provided through Telehealth Technology may include behavioral health services, including tele-psychiatry, and you expressly agree to receive such services through Telehealth Technology.
● If you are a parent or legal guardian of a minor that is seeking to receive mental health treatment through Telehealth Technology, you agree that (1) you are providing this Consent on behalf of your minor child, and (2) you will verify your identity before any services are delivered to your minor child.
● Services provided through Telehealth Technology may involve electronic communication of your personal medical information to Providers that may be located in other areas, including out of state.
● Your Provider will take measures to protect the privacy and security of any personal medical information transmitted through Telehealth Technology in accordance with federal, state, and other applicable law.
● You have the right to request copies of your medical records, which may be provided electronically or in hard copy format at reasonable cost of preparation, shipping and delivery.
● The anticipated response time for electronic communications submitted through the Telehealth Technology varies and you accept any risk associated with the response time, including a delay in obtaining medical care.
● No warranty or guarantee has been made to you concerning any particular result related to your condition or diagnosis.
2. Risks Associated with Use of Telehealth Technology. You understand that use of the Telehealth Technology has risks associated with it, such as (1) information that you transmit through the Telehealth Technology may be insufficient to allow for appropriate decision-making by the Provider; (2) failures of equipment (e.g., servers, devices) or infrastructure (e.g., communications lines, power supply, software failures) may cause interruptions and delays in the provision of care and treatment, or loss of information; and (3) in rare events, security protocols could fail, causing unauthorized access to your health information. You acknowledge that, although Curex and its telehealth technology vendors strive to prevent unauthorized access to information about you through encryption of information transmitted by the Telehealth Technology and other security measures, Curex and its vendors cannot guarantee that your use of the Telehealth Technology and the information will be private or secure, and you consent to this risk. You understand and consent to the risks associated with your use of the Telehealth Technology.
3. Accuracy of Information Submitted to the Provider. You acknowledge and agree that you are solely responsible for ensuring that the information submitted by you through the Telehealth Technology is accurate, complete and current at all times when you use the Telehealth Technology. You understand that the Provider will rely on this information to provide services to you.
4. Release and Waiver. You acknowledge and agree to limit, disclaim, and release Curex from liability in connection with the use of Telehealth Technology.
5. Expenses. You understand and agree that you may be responsible for the cost of certain professional fees associated with your use of the Telehealth Technology and the cost of any medications or supplies prescribed by the Provider, if applicable.
6. Other Legal Terms. This Consent cannot be amended by Curex except in writing and with your consent. If any provision is or becomes unenforceable or invalid, the other provisions will continue with the same effect.
7. Right to Revoke. You have the right to withhold or withdraw your consent to the use of Telehealth Technologies in the course of your care at any time, without affecting your right to future care or treatment. You may suspend or terminate access to the services at any time for any reason or for no reason in accordance with this Section 7. You understand that you can revoke this Consent by sending written notice using electronic mail to Curex at: firstname.lastname@example.org (“Revocation”). You agree that your Revocation must contain your name and your address. You also understand that your Revocation means that you are not permitted to receive care using Telehealth Technology. Your Revocation will be effective upon Curex’s receipt of your written notice, except that your Revocation will not have any effect on any action taken by the Provider in reliance on this Consent before Curex received your written notice of Revocation. Further by providing this Telehealth Consent you agree to the following: I understand that Telehealth is a mode of delivering health care services via communication technologies (e.g., internet or cellphone) to facilitate diagnosis, consultation, treatment, education, care management, and self-management of a patient’s health care. By acknowledging my consent below, I understand and agree to the following:
1. I understand that Curex offers Telehealth consultations, which are conducted through\ videoconferencing, telephonic, and asynchronous technology and my Telehealth provider will not be present in the room with me.
2. I understand there are potential risks to the use of Telehealth technology, including but not limited to, interruptions, delays, unauthorized access, and or other technical difficulties. I understand that either my Telehealth provider or I can discontinue the Telehealth appointment if the technical connections are not adequate for my visit.
3. I understand that I could seek an in-office visit rather than obtain care from a Telehealth provider, and I am choosing to participate in a Telehealth consultation with Curex.
4. To protect the confidentiality of my health information, I agree to undertake my Telehealth consultation in a private location, and I understand that my Telehealth provider will similarly be in a private location.
5. I understand that I am responsible for payment of any amounts due and owing resulting from my Telehealth visit.
6. In an emergent situation, I understand that the responsibility of my Telehealth provider may be to direct me to emergency medical services, such as an emergency room.
By acknowledging below, I certify:
● that I have read this form and/or had it explained to me
● that I understand the risks and benefits of a Telehealth appointment
● That I have been given the opportunity to ask questions and that such questions have been answered to my satisfaction.
AUTHORIZATION TO BILL INSURANCE AND ASSIGNMENT OF BENEFITS
The above information is true to the best of my knowledge. I authorize Curex to directly bill my insurance company and I further authorize any third-party payer through which I have benefits to make payment directly to Curex. I understand that I am financially responsible for any balance. I also authorize Curex or insurance company to use and disclose of any healthcare information for the purpose of obtaining payment for services and determining insurance benefits. Services provided by outside companies (i.e. lab, pathology, radiology) are billed separately by those companies.
CONSENT TO TEXT OR EMAIL USAGE FOR APPOINTMENT REMINDERS AND OTHER HEALTHCARE REMINDERS
By proceeding, I consent to receive text messages from the practice at my phone number or email to receive appointment reminders and general health reminders\ of information. I understand that this request is to receive emails and/or text messages will apply to all future appointment reminders/feedback/health information unless I request a change in writing. I also acknowledge this means of communication is not considered secure for the transmission of private information.