Parent/Guardian Informed Consent to Treatment via Telehealth

Last Updated: April 1, 2021

Telehealth involves the use of electronic communications to enable healthcare providers at different locations to share individual patient medical information for the purpose of improving patient care. Telehealth services offered via Curex affiliates, including Curex Medical Services, P.A, Curex Medical of California, P.C. and Curex Medical of New Jersey, P.C. (Collectively, “Curex Medical Group”) may also include chart review, remote prescribing, lab referrals, appointment scheduling, health information sharing, and non-clinical services, such as patient education. The information you or the patient for whom you are the legal guardian ("Patient") provide may be used for diagnosis, therapy, follow-up and/or patient education, and may include any combination of the following: (1) health records and test results; (2) images and asynchronous communications; (3) live two-way audio and video; (4) interactive audio with store and forward; and (5) output data from medical devices and sound and video files.

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.

Curex Medical Group providers (our "providers") are an addition to, and not a replacement for, a primary care provider. Responsibility for overall medical care should remain with a local primary care provider, if the Patient has one, and we strongly encourage you to locate one if the Patient does not.

Expected Benefits:

Service Limitations:

Possible Risks:

You and the Patient may contact the Patient’s Provider for follow-up questions by directly sending a message to the Patient’s Provider via our member portal.  The Patient’s Provider will be familiar with and have access to available medical resources, including emergency resources near your or the Patient’s location, in order to make an appropriate referral where medically indicated.  The Patient’s Provider will typically respond within thirty-six hours.  However, if the Patient is experiencing a medical emergency, you or the Patient should dial 9-1-1, go to the nearest urgent care center or emergency room, or contact local emergency assistance services immediately.

By checking the box associated with Parent/Guardian Informed Consent (upon creation of the Child’s profile), you, the Patient’s parent or guardian, acknowledge that you understand and agree with the following:

  1. I hereby consent to the Patient’s receiving Curex Medical Group’s services via telehealth technologies. I understand that Curex Medical Group and its providers offer telehealth-based medical services, but that these services do not replace the relationship between the Patient and a primary care doctor. I also understand it is up to the Curex Medical Group provider to determine whether or not the Patient’s specific clinical needs are appropriate for a telehealth encounter.
  2. I understand a licensed provider from Curex Medical Group will be assigned to me prior to the consult, however, I can request a different licensed provider at any time. I can review the credentials of my assigned provider.
  3. I understand that federal and state law requires health care providers to protect the privacy and the security of health information. 
  4. I understand that Curex Medical Group will take steps to make sure that the Patient’s health information is not seen by anyone who should not see it. 
  5. I understand that telehealth may involve electronic communication of the Patient’s personal medical information to other health practitioners who may be located in other areas, including out of state.
  6. I understand there is a risk of technical failures during the telehealth encounter beyond the control of Curex Medical Group. I AGREE TO HOLD HARMLESS CUREX MEDICAL GROUP AND ITS EMPLOYEES, CONTRACTORS, AGENTS, DIRECTORS, MEMBERS, MANAGERS, SHAREHOLDERS, OFFICERS, REPRESENTATIVES, ASSIGNS, PARENTS, PREDECESSORS, AND SUCCESSORS FOR DELAYS IN EVALUATION OR FOR INFORMATION LOST DUE TO SUCH TECHNICAL FAILURES.
  7. I understand that I have the right to withhold or withdraw my consent to the use of telehealth in the course of the Patient’s care at any time, without affecting the Patient’s right to future care or treatment. I understand that I may suspend or terminate use of the telehealth services at any time for any reason or for no reason. 
  8. I understand that if Patient is experiencing a medical emergency, that I and the Patient will be directed to dial 9-1-1 immediately and that the Curex Medical Group providers are not able to connect me or Patient directly to any local emergency services.
  9. I understand that alternatives to telehealth consultation, such as in-person services are available to me and the Patient, and in choosing to participate in a telehealth consultation, I understand that some parts of the services involving tests may be conducted by individuals at Patient’s location, or at a testing facility, at the direction of the Curex Medical Group provider (e.g., labs or bloodwork).
  10. I understand that I may expect the anticipated benefits from the use of telehealth in Patient’s care, but that no results can be guaranteed or assured.
  11. I understand that Patient’s healthcare information may be shared with other individuals for scheduling and billing purposes. Persons may be present during the consultation other than the Curex Medical Group provider in order to operate the telehealth technologies. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history/examination that are personally sensitive to me; (2) ask non-medical personnel to leave the telehealth examination; and/or (3) terminate the consultation at any time.
  12. I understand that Patient will not be prescribed any narcotics for pain, nor is there any guarantee that Patient will be given a prescription at all.
  13. I understand I can choose to fill my prescription at a pharmacy of my choice though certain compounded medications are not widely available. 
  14. I understand that if I or the Patient participate in a consultation, that I have the right to request a copy of Patient’s medical records which will be provided to me at reasonable cost of preparation, shipping and delivery.

Additional State-Specific Consents: The following consents apply to users accessing the Curex Medical Group website for the purposes of participating in a telehealth consultation as required by the states listed below (and where necessary they should be interpreted as referring to Patient and not the parent or legal guardian):

Patient Consent: I have read this document carefully, and understand the risks and benefits of the telehealth consultation and have had my questions regarding the procedure explained and I hereby give my informed consent for Patient to participate in a telehealth consultation under the terms described herein.