Authorization and Consent to Participate in a Telemedicine Consultation

The purpose of this form is to obtain your consent to participate in a telemedicine consultation with one of the Medical Alternative Clinics providers.

Telemedicine involves the real-time medical consultation or evaluation of a patient using advanced telecommunications technology, which may include the use of interactive audio, video, or other electronic media. As such, telemedicine allows the provider to see and communicate with the patient in real-time.

I voluntarily request Medical Alternative Clinics, LLC physician providers and such associates, residents, technical assistants, and other health care providers as they may deem necessary (“Medical Alternative Clinics Providers”) to participate in my medical care through the use of telemedicine.

I understand that Medical Alternative Clinics Providers (i) may practice in a different location than where I present for medical care, (ii) may not have the opportunity to perform in-person aspects of a physical examination, and (iii) rely on information provided by me.

I acknowledge that Medical Alternative Clinics, LLC Providers’ advice, recommendations, and/or decision may be based on factors not within their control, such as incomplete or inaccurate data provided by me or distortions of diagnostic images or specimens that may result from electronic transmissions.

I understand that it is my sole responsibility to communicate and provide Medical Alternative Clinics Providers and associates with detailed, accurate and complete information concerning medical, medication and other histories, 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 Medical Alternative Clinics Providers and associates may be materially affected.

I assume all risks, and assume full responsibility and waive all claims against Medical Alternative Clinics Providers and associates for personal injury, death or damages of any kind and agrees to the extent permitted by applicable law to defend, indemnify and hold harmless Medical Alternative Clinics Telemedicine Providers 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. I also understand that the practice of medicine is not an exact science and that no warranties or guarantees are made to me as to result or cure.

I understand that if Medical Alternative Clinics, LLC Providers determine that the telemedicine services do not adequately address my medical needs, they may require an in-person medical evaluation. In the event the telemedicine session is interrupted due to a technological problem or equipment failure, I acknowledge alternative means of communication may be implemented or an in-person medical evaluation may be necessary. If I experience an urgent matter, such as a bad reaction to any treatment after a telemedicine session, I should alert my treating physician and, in the case of emergencies, dial 911, or go to the nearest hospital emergency department.

I will inform the Medical Alternative Clinics Providers 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) inform the Medical Alternative Clinics Providers of this fact, and (b) ask my ob/gyn or pediatrician if the treatments recommended by the Medical Alternative Clinics Providers are acceptable during this period of time.

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 for the telemedicine visit..

I understand Medical Alternative Clinics, LLC visits 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 Medical Alternative Clinics or its associates will bill any third-party health insurance plan for the services provided.

I understand that once the physician 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 Medical Alternative Clinics Providers in the course of the service provided, to confirm that my primary care or specialty physician approves of the regimen.

All existing laws regarding your access to medical information and copies of your medical records apply to this telemedicine consultation. Additionally, dissemination of any patient identifiable images or information from this telemedicine interaction to other clinicians or other healthcare entities shall not occur without your consent, unless authorized under existing confidentiality laws. To facilitate the provision of care and/or treatment through telemedicine, I voluntarily request and authorize the disclosure of all and any part of my medical record (including oral information) to Medical Alternative Clinics, LLC Providers. I understand and agree that the information I am authorizing to be released may include: 1) AIDS/HIV test results, diagnosis, treatment, and related information: 2) drug screen results and information about drug and alcohol use and treatment; 3) mental health information, and 4) genetic information. I understand that the disclosure of my medical information to Medical Alternative Clinics, LLC Providers, including the audio and/or video, will be by electronic transmission. Although precautions are taken to protect the confidentiality of this information by preventing unauthorized review, I understand that electronic transmission of data, video images, and audio is new and developing technology and that confidentiality may be compromised by failures of security safeguards or illegal and improper tampering.

I understand that I may revoke my  consent to the telemedicine consultation at any time without affecting my right of future care or treatment, or risking the loss or withdrawal of any program benefits to which I would otherwise be entitled.

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 Medical Alternative Clinics Providers, except with the Medical Alternative Clinics Providers, 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 Medical Alternative Clinics Providers outside of the limited scope of the services. I agree that Medical Alternative Clinics Providers 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 have been advised of all the potential risks, consequences and benefits of telemedicine. My health care practitioner has discussed with me the information provided above. I have had an opportunity to ask questions about this information and all of my questions have been answered. I understand the written information provided above.