Telehealth Consent

Last Updated April 1, 2020

BY CLICKING “I AGREE,” CHECKING A RELATED BOX TO SIGNIFY YOUR ACCEPTANCE, USING ANY OTHER ACCEPTANCE PROTOCOL PRESENTED THROUGH THE SERVICE OR OTHERWISE AFFIRMATIVELY ACCEPTING THIS CONSENT, YOU ACKNOWLEDGE THAT YOU HAVE READ, ACCEPTED, AND AGREED TO BE BOUND BY THIS CONSENT. IF YOU DO NOT AGREE TO THIS CONSENT, DO NOT CREATE AN ACCOUNT OR USE THE SERVICE. YOU HEREBY GRANT AGENCY AUTHORITY TO ANY PARTY WHO CLICKS ON THE “I AGREE” BUTTON OR OTHERWISE INDICATES ACCEPTANCE TO THIS CONSENT ON YOUR BEHALF.

The purpose of this consent form (“Consent”) is to provide you with information about telehealth and to obtain your informed consent to the use of telehealth in the delivery of healthcare services to you by health providers (“Providers”) using the online platform owned and operated by ClearMD Solutions, Inc. (the “Service”). The Service is provided by ClearMD Solutions, Inc. herein also referred to as ClearMD.

Before you give your consent, make sure you understand how using the Service to obtain medical care differs from visiting a more traditional doctor’s office. ClearMD does not provide any medical services. ClearMD can store a request for medical services and forward that request to a licensed medical provider in your state.

NOT FOR EMERGENCIES

I understand that I should never use the Service in an emergency. I understand that in an emergency, I should dial 911 or go to an emergency department.

USE OF TELEHEALTH

I understand that telehealth involves the delivery of healthcare services using electronic communications, information technology or other means between a healthcare provider and a patient who are not in the same physical location.
I understand that telehealth may be used for diagnosis, treatment, follow-up and/or patient education, and may include, but is not limited to, one or more of the following: electronic transmission of medical records, photo images, personal health information or other data between a patient and a healthcare provider; interactions between a patient and healthcare provider via audio, video and/or data communications (such as secure messaging); use of output data from medical devices, sound and video files.
I understand that alternative methods of care are available to me, such as in-person services, and I may choose an alternative at any time. I can always discuss alternative options with my Providers. I understand that I am free to obtain a medical examination from another healthcare provider that is not associated with the Service.
I understand that I have the right to withdraw my consent to the use of telehealth without prejudicing my ability to receive any future care or treatment and without risking the loss or withdrawal of any health benefits to which I am entitled.
I understand that my withdrawal of consent will be effective upon receipt of written notice to my Providers, except that such withdrawal will not have any effect on any action taken by ClearMD or my Providers in reliance on this Consent before it received my written notice of withdrawal.
I understand that my withdrawal of consent will not affect any other provision of this Consent, and I will continue to be bound by this Consent.
I understand a licensed Provider 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.
I understand I can choose to fill my prescription at a pharmacy of my choice.

DOCTOR-PATIENT RELATIONSHIP

I understand that my Providers have the right to refuse to take responsibility for my care if my Providers make a professional judgment that I am not a good candidate for this service. I understand that making a request for treatment (by completing a visit and making payment) or sending a message through the Service does not in and of itself create a duty of care or create a doctor-patient relationship.
I understand that my Providers will take responsibility for my care only after my Providers have reviewed my request for treatment, reviewed all my information, and then subsequently determined that I am a good candidate for the telehealth services.
I understand that there may be a delay before my Providers review my request for treatment and any messages I send, although Providers strive for responses within 2 business days.

LIMITED SERVICE SCOPE

I understand that by using the Service I will receive care for a limited scope of services only.
I understand that by using the Service I won’t receive any other medical services that go beyond the services offered by ClearMD. I need to seek other sources for my other medical needs. I understand that there are limitations in the provision of medical care and treatment via telehealth and technology, including the Service, and I may not be able to receive diagnosis and/or treatment through telehealth for every condition for which I seek diagnosis and/or treatment.
I understand that by using the Service for a telemedical consultation, I won’t have an in-person consultation and physical exam that might identify a medical condition that needs further investigation or immediate treatment.

GREATER RELIANCE ON INFORMATION YOU PROVIDE

I understand that by using the Service I seek to enter into a relationship where my Providers rely exclusively upon information that I provide to decide whether or not the requested service is safe.
I understand that my Providers have no way of verifying the information I provide and that the doctor will consider the information I provide to be accurate, true, and complete.

ANTICIPATED BENEFITS

I understand that the use of telehealth may make it easier and more efficient for me to access medical care and treatment for the conditions treated by my Providers, including being able to obtain medical care and treatment by my Providers at times that are convenient to me, and enabling me to interact with my Providers without the necessity of an in-office appointment.

ADVERSE EVENTS

I understand that if I provide information that isn’t true and complete, then I’ll be at greater risk of adverse events from taking the prescribed treatment.
I understand that all the information I provide when requesting a prescription is important in my Providers’ determination as to whether I’m a good candidate for a particular treatments and for the service in general.
I understand that adverse events can be caused by a number of things, including an allergic reaction, side effects, or interactions between medications, smoking, or other things (e.g., supplements or recreational drugs) I’m taking.
I understand that technology used to deliver care, including the Service, may contain bugs or other errors, including ones which may limit functionality, produce erroneous results, or incorrect records, transmissions, data or content. I understand this could even extend to lost or corrupted records, transmissions, data or content, 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).
I understand that my condition may not be cured or improved, and in some cases, may get worse.

NO COMMUNICATION WITH A DOCTOR IN REAL TIME

I understand that by using the Service I won’t speak or message with my Providers in real time.
I understand that I must check the Service for messages because this is the way that ClearMD will communicate important information to me. I understand that if I don’t check the Service regularly, then my care may be delayed.
I understand that if I have any questions relating to my care that aren’t urgent, I can message ClearMD.

RISK TO ELECTRONIC HEALTH INFORMATION

I understand that the electronic nature of the Service means that there’s a greater risk to the privacy of my health information compared to visiting a traditional doctor’s office.
I understand that although ClearMD implements a wide range of administrative, physical, and technical safeguards to protect my health information, ClearMD cannot guarantee the privacy and confidentiality of my health information.
I understand that the electronic systems used in the Service will incorporate network and software security protocols to protect the privacy and security of my information, and will include measures to safeguard data against intentional or unintentional corruption.
For more details about how ClearMD protects your health information, see the Privacy Policy.

ADDITIONAL STATE-SPECIFIC CONSENTS

‍The following consents apply to users accessing the ClearMD website for the purposes of participating in a telehealth consultation as required by the states listed below:

Alaska: I understand my primary care provider may obtain a copy of my records of my telehealth encounter. (Alaska Stat. § 08.64.364).
Arizona: I understand I am entitled to all existing confidentiality protections pursuant to A.R.S. § 12-2292. I also understand all medical reports resulting from the telemedicine consultation are part of my medical record as defined in A.R.S. § 12-2291. I also understand dissemination of any images or information identifiable to me for research or educational purposes shall not occur without my consent, unless authorized by state or federal law. (Ariz. Rev. Stat. Ann. § 36-3602).
Connecticut: I understand that my primary care provider may obtain a copy of my records of my telehealth encounter. (Conn. Gen. Stat. Ann. § 19a-906).
District of Columbia: I have been informed of alternate forms of communication between me and a provider or other treating physician for urgent matters. (D.C. Mun. Regs. tit. 17, § 4618.10).
Georgia: I have been given clear, appropriate, accurate instructions on follow-up in the event of needed emergent care related to the treatment. (Ga. Comp. R. & Regs. 360-3-.07(7)).
Iowa: I have been informed that if I want to register a formal complaint about a Provider, I should visit the medical board’s website, here.
Idaho: I have been informed that if I want to register a formal complaint about a Provider, I should visit the medical board’s website, here.
Indiana: I have been informed that if I want to register a formal complaint about a Provider, I should visit the medical board’s website, here.
Kentucky: I have been informed that if I want to register a formal complaint about a Provider, I should visit the medical board’s website, here.
Louisiana: I understand the role of other health care providers that may be present during the consultation other than my assigned Provider. (46 La. Admin. Code Pt XLV, § 7511).
Maine: I have been informed that if I want to register a formal complaint about a Provider, I should visit the medical board’s website, here.
Nebraska: I retain the option to refuse the telehealth consultation at any time without affecting my right to future care or treatment and without risking the loss or withdrawal of any program benefits to which the patient would otherwise be entitled. All existing confidentiality protections shall apply to the telehealth consultation. I shall have access to all medical information resulting from the telehealth consultation as provided by law for access to my medical records. Dissemination of any patient identifiable images or information from the telehealth consultation to researchers or other entities shall not occur without my written consent. (Neb. Rev. Stat. Ann. § 71-8505;).
New Hampshire: I understand that my Provider may forward my medical records to my primary care or treating provider. (N.H. Rev. Stat. § 329:1-d).
New Jersey: I understand I have the right to request a copy of my medical information and I understand my medical information may be forwarded directly to my primary care provider or health care provider of record, or upon my request, to other health care providers. (N.J. Rev. Stat. Ann. § 45:1-62).
Oklahoma: I have been informed that if I want to register a formal complaint about a Provider, I should visit the medical board’s website, here; Or, the Oklahoma Board of Osteopathic Examiners’ website, here.
Rhode Island: If I use e-mail or text-based technology to communicate with my Provider, then I understand the types of transmissions that will be permitted and the circumstances when alternate forms of communication or office visits should be utilized. I have also discussed security measures, such as encryption of data, password protected screen savers and data files, or utilization of other reliable authentication techniques, as well as potential risks to privacy. I acknowledge that my failure to comply with this agreement may result in the Provider terminating the e-mail relationship. (Rhode Island Medical Board Guidelines).
South Carolina: I understand my medical records may be distributed in accordance with applicable law and regulation to other treating health care practitioners. (S.C. Code Ann. § 40-47-37).
Texas: I understand that my medical records may be sent to my primary care provider. (Tex. Occ. Code Ann. § 111.005). I have been informed of the following notice: NOTICE CONCERNING COMPLAINTS - Complaints about physicians, as well as other licensees and registrants of the Texas Medical Board, including physician assistants, acupuncturists, and surgical assistants may be reported for investigation at the following address: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018, Assistance in filing a complaint is available by calling the following telephone number: 1-800-201-9353, For more information, please visit our website at www.tmb.state.tx.us.
Utah: I understand (i) any additional fees charged for telehealth services, if any, and how payment is to be made for those additional fees, if the fees are charged separately from any fees for face-to-face services provided in combination with the telehealth services; (ii) to whom my health information may be disclosed and for what purpose, and have received information on any consent governing release of my patient-identifiable information to a third-party; (iii) my rights with respect to patient health information; (iv) appropriate uses and limitations of the site, including emergency health situations. I understand that the telehealth services the Providers provide meets industry security and privacy standards, and comply with all laws referenced in Subsection 26-60-102(9)(b)(ii), if applicable. I was warned of: potential risks to privacy notwithstanding the security measures and that information may be lost due to technical failures, and agree to hold the Provider harmless for such loss. I have been provided with the location of my Provider’s ClearMD website and contact information. I was able to select my Provider of choice, to the extent possible. I was able to select my pharmacy of choice. I am able to a (i) access, supplement, and amend my patient-provided personal health information; (ii) contact my Provider for subsequent care; (iii) obtain upon request an electronic or hard copy of my medical record documenting the telemedicine services, including the informed consent provided; and (iv) request a transfer to another Provider of my medical record documenting the telemedicine services. (Utah Admin. Code r. 156-1-602).
Virginia: I acknowledge that I have received details on security measures taken with the use of telemedicine services, such as encrypting date of service, password protected screen savers, encrypting data files, or utilizing other reliable authentication techniques, as well as potential risks to privacy notwithstanding such measures; I agree to hold harmless ClearMD and my Provider for information lost due to technical failures; and I provide my express consent to forward patient-identifiable information to a third party. (Virginia Board of Medicine Guidance Document 85-12).
Vermont: I understand that I have the right to receive a consult with a distant-site provider and will receive one upon request immediately or within a reasonable time after the results of the initial consult. I understand that receiving tele-dermatology or tele-ophthalmology services via ClearMD does not preclude me from receiving real-time telemedicine or face-to-face services with the distant provider at a future date. (Vt. Stat. Ann. § 9361(e)).