Telehealth

Informed Consent for Telehealth Services

Effective: 15^th of June, 2021.

By typing my name and checking “I agree to Terms of Use” on the MEDPRO Urgent Care Center telehealth page (this form), (i) I understand and agree that I am signing this Consent electronically and that (ii) I have reviewed, understand and accept the risks and benefits of telehealth services as described below and wish to receive such services, and (iii) I agree to the remaining terms of this Consent, including the terms of the MEDPRO Urgent Care Center Privacy Policy.

If I am signing on behalf of a minor, incapacitated or otherwise legally dependent patient, I certify that I am a person with legal authority to act on behalf of the patient, including the authority to consent to medical services, and I accept financial responsibility for services rendered.

1. Telehealth involves the use of electronic communications to enable health care providers at different locations to share individual patient medical information for the purpose of improving patient care. The information may be used for diagnosis, therapy, follow-up and/or education, and may include any of the following: Patient medical records, Medical images, Live two-way audio and video, Output data from medical devices and sound and video files.

2. Electronic systems used 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.

3. Potential benefits of telehealth (which are not guaranteed or assured) include: (a) improved access to medical care by enabling a patient to initiate a visit and consult a healthcare practitioner at a distant/other sites; (b) more efficient medical evaluation and management; (c) obtaining expertise of a distant specialist.

4. As with any medical procedure, there are potential risks associated with the use of telehealth. These risks include, but may not be limited to:

4.1. In rare cases, information transmitted may not be sufficient to allow for appropriate medical decision making by the physician and consultant(s);

4.2. Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment, distortion of diagnostic images or specimens resulting from electronic transmission issues, unauthorized access to my information, or loss of information due to technical failures. I will not hold MEDPRO Urgent Care Center responsible for lost information due to technological failures;

4.3. Limited or no availability of diagnostic laboratory, x-ray, EKG, and other testing, and some prescriptions, to assist my medical provider in diagnosis and treatment;

4.4. My provider’s inability to conduct a hands-on physical examination of me and my condition;

4.5. In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information;

4.6. In rare cases, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors.

5. I understand and agree that:

5.1. I will not be in the same location or room as my medical provider;

5.2. MEDPRO Urgent Care Center is licensed in the state of Florida which is the same state in which I am receiving services. I will report my location accurately during registration.

5.3. I may discuss the aforementioned risks and benefits with MEDPRO Urgent Care Center and will be given an opportunity to ask questions about telehealth services. I have the right to withdraw this consent to telehealth services or end the telehealth session at any time without affecting my right to future treatment by MEDPRO Urgent Care Center.

5.4. I understand that the level of care provided by MEDPRO Urgent Care Center telehealth has to be the same level of care that is available to me through an in-person medical visit. However, if MEDPRO Urgent Care Center's practitioner believes that I would be better served by face-to-face services or another form of care, I will be advised to go to an in-person medical visit or will be referred to the nearest hospital emergency department or other appropriate health care provider.

5.5. In case of an emergency, I will dial 911 or go directly to the nearest hospital emergency room.

5.6. I further understand that MEDPRO Urgent Care Center’s advice, recommendations, and/or decisions may be based on factors not within his/her control, including incomplete or inaccurate data provided by me. I understand that MEDPRO Urgent Care Center relies on information provided by me before and during our
telehealth encounter and that I must provide information about my medical history, condition(s), and current or previous medical care that is complete and accurate to the best of my ability.

6. I consent to, understand and agree that:

6.1. I understand that the laws that protect privacy and the confidentiality of medical information also apply to telehealth, and that no information obtained in the use of telehealth, which identifies me, will be disclosed to researchers or other entities without my consent.

6.2. I understand that I have the right to inspect all information obtained and recorded in the course of a telehealth interaction, and may receive copies of this information for a reasonable fee.

6.3. I understand that a variety of alternative methods of medical care may be available to me, and that I may choose one or more of these at any time. My provider has explained the alternatives to my satisfaction.

6.4. I understand that it is my duty to inform my provider of electronic interactions regarding my care that I may have with other healthcare providers.

6.5. I understand that I may expect the anticipated benefits from the use of telehealth in my care, but that no results can be guaranteed or assured.

6.6. MEDPRO Urgent Care Center will protect the privacy of my health information and will not use or disclose it except as permitted by law. MEDPRO Urgent Care Center’s privacy policies are fully described in the Privacy Policy page, which is available for review and download here: https://www.medprourgentcarecenter/privacy-policy. By signing this Consent, I acknowledge receipt of the Privacy Notice and consent to MEDPRO Urgent Care Center’s use and disclosure of my health information in accordance with its terms. I understand that all existing confidentiality protections that apply to in-person treatment apply to telehealth services.

7. I acknowledge, understand and agree that:

7.1. It is my responsibility to determine whether MEDPRO Urgent Care Center’s telehealth services are covered by my insurer. I will pay the cost of any service that is not covered by my health plan for any reason or are covered but applied to a deductible.

7.2. I will pay at time of service any required co-payments, co-insurance and deductibles, as well as charges for services not covered by insurance, outstanding balances and delinquent accounts.

7.3. I assign to MEDPRO Urgent Care Center all health care benefits to which I am entitled under any insurance policy or benefit plan and authorize payment of benefits directly to MEDPRO Urgent Care Center.

7.4. If I have health care benefits, MEDPRO Urgent Care Center will submit a claim to my insurer and allow 60 days for a response. If my insurer does not respond within 60 days, MEDPRO Urgent Care Center will assume that the visit is not covered and will, to the extent permitted by law, bill me for the visit charges.

7.5. By providing my credit card information and receiving telehealth services, I (i) authorize MEDPRO Urgent Care Center to charge my credit card for any and all unpaid amounts that MEDPRO Urgent Care Center or my insurer determines are my responsibility, and (ii) agree to pay all amounts charged pursuant to this consent and authorization in accordance with the issuing bank cardholder agreement. I agree that MEDPRO Urgent Care Center may charge my credit card for such amounts at the end of my telehealth visit or at a later date.

7.6. I will be billed for all unpaid balances deemed by MEDPRO Urgent Care Center or my insurer to be my responsibility and agree to pay such amounts in full. MEDPRO Urgent Care Center will charge late fees of 1.5% per month on unpaid balances starting 30 days after the first statement, as well as a $30 fee for returned checks. Delinquent accounts may be turned over to a collection agency at which time I am responsible for a $40 collections charge and all associated legal fees in addition to the amount owed.

7.7. MEDPRO Urgent Care Center reserves the right to deny non-emergency services if my account is delinquent.

Electronic Signature

Your name

Your email

I have read and understand the information provided above regarding telehealth, have discussed it with my physician or such assistants as may be designated, and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of telehealth in my medical care.

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