Telehealth Informed Consent

Telehealth involves the use of secure electronic communications, information technology, or other means to enable a healthcare provider and a patient at different locations to communicate and share individual patient health information for the purpose of rendering clinical care. This “Telehealth Informed Consent” informs the patient (“patient,” “you,” or “your”) concerning the treatment methods, risks, and limitations of using a telehealth platform.

Services Provided

Telehealth services offered by may include a patient consultation, diagnosis, treatment recommendation, prescription, and/or a referral to in-person care, as determined clinically appropriate (the “Services”).

These telehealth services are provided by medical groups (“Groups”) and the Groups’ engaged providers (our “Providers” or your “Provider”), including 525 Medical Group, P.A., Openloop Healthcare Partners, PC, Openloop Healthcare Partners California, PC, Openloop Healthcare Partners Colorado, PC, Openloop Healthcare Partners New Jersey, PC, Openloop Healthcare Partners Wisconsin SC, Reliant.MD Medical Associates, PLLC, Reliant.MD Medical Associates California, PC, Reliant.MD Medical Associates Colorado, PC, Reliant.MD Medical Associates New Jersey, PC, Reliant.MD Medical Associates Wisconsin, SC, MECNB, Physician Services, PC, MECNB Physician Services California, PC, MECNB Physician, Services Colorado, PC, MECNB Physician Services New Jersey, PC, and MECNB Physician, Services, SC..

Empirical Health Inc. does not provide the Services; it performs administrative, payment, and other supportive activities for Group and our Providers.

Electronic Transmissions:

The types of electronic transmissions that may occur using the telehealth platform include, but are not limited to:

• Appointment scheduling;
• Completion, exchange, and review of medical intake forms and other clinically relevant information (for example: health records; images; output data from medical devices; sound and video files; diagnostic and/or lab test results) between you and your Provider via: asynchronous communications; two-way interactive audio in combination with store-and-forward communications; and/or two-way interactive audio and video interaction;
• Treatment recommendations by your Provider based upon such review and exchange of clinical information;
• Delivery of a consultation report with a diagnosis, treatment and/or prescription recommendations, as deemed clinically relevant;
• Prescription refill reminders (if applicable);
• and/or Other electronic transmissions for the purpose of rendering clinical care to you.

Expected Benefits

• Improved access to care by enabling you to remain in your preferred location while your Provider consults with you. Our telehealth services are available 8 hours a day, 5 days a week.
• Convenient access to follow-up care. If you need to receive non-emergent follow-up care related to your treatment, please contact your Provider by directly sending a message through your user account.
• More efficient care evaluation and management. [Provide a description of uses of and response times for e-mails, electronic messages and other communications transmitted via telehealth technologies (e.g., [X] hours during the week or [X] hours over weekends and holidays)].

Service Limitations

The primary difference between telehealth and direct in-person service delivery is the inability to have direct, physical contact with the patient. Accordingly, some clinical needs may not be appropriate for a telehealth visit and your Provider will make that determination.

Our providers do not address medical emergencies. If you believe you are experiencing a medical emergency, You should dial 9-1-1 and/or go to the nearest emergency room. Please do not attempt to contact Empirical Health Inc., GROUP, or your Provider. After receiving emergency healthcare treatment, you should visit your local primary care PROVIDER.

Our Providers are an addition to, and not a replacement for, your local primary care provider. Responsibility for your overall medical care should remain with your local primary care provider, if you have one, and we strongly encourage you to locate one if you do not. Groups do not have any in-person clinic locations.

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.

I understand that I am responsible for payment of any amounts due and owing resulting from my Telehealth visit.

Security Measures

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. All the Services delivered to the patient through telehealth will be delivered over a secure connection that complies with the requirements of the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”).

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

Possible Risks:

• Delays in evaluation and treatment could occur due to deficiencies or failures of the equipment and technologies, or provider availability.
• In the event of an inability to communicate as a result of a technological or equipment failure, please contact the Group at hello@empirical.health.
• In rare events, your Provider may determine that the transmitted information is of inadequate quality, thus necessitating a rescheduled telehealth consult or an in-person meeting with your local primary care doctor. I understand that either my Telehealth provider or I can discontinue the Telehealth appointment if the technical connections are not adequate for my visit.
• In very rare events, security protocols could fail, causing a breach of privacy of personal medical information.

Acknowledgements

I further acknowledge and understand the following:

• Prior to the telehealth visit, I have been given an opportunity to select a provider as appropriate, including a review of the provider’s credentials, or I have elected to visit with the next available provider from Group, and have been given my Provider’s credentials.
• I understand that I may be asked to provide my identification and confirm my physical location prior to or during the telehealth visit.
• If I am experiencing a medical emergency, I will be directed to dial 9-1-1 immediately and my Provider is not able to connect me directly to any local emergency services.
• I may elect to seek services from a medical group with in-person clinics as an alternative to receiving telehealth services from Group.
• I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time without affecting my right to future care or treatment.
• Federal and state law requires health care providers to protect the privacy and the security of health information. I am entitled to all confidentiality protections under applicable federal and state laws. I understand all medical reports resulting from the telehealth visit are part of my medical record.
• Group will take steps to make sure that my health information is not seen by anyone who should not see it. Telehealth may involve electronic communication of my personal health information to other health practitioners who may be located in other areas, including out of state. I consent to Group using and disclosing my health information for purposes of my treatment (e.g., prescription information) and care coordination, to receive reimbursement for the services provided to me, and for Group’s health care operations.
• Dissemination of any patient-identifiable images or information from the telehealth visit to researchers or other educational entities will not occur without my consent unless authorized by state or federal law.
• There is a risk of technical failures during the telehealth visit beyond the control of Group.
• In choosing to participate in a telehealth visit, I understand that some parts of the Services involving tests (e.g., labs or bloodwork) may be conducted at another location such as a testing facility, at the direction of my Provider.
• Persons may be present during the telehealth visit other than my Provider who will be participating in, observing, or listening to my consultation with my Provider (e.g., in order to operate the telehealth technologies). If another person is present during the telehealth visit, I will be informed of the individual’s presence and his/her role.
• My Provider will explain my diagnosis and its evidentiary basis, and the risks and benefits of various treatment options.
  I understand that by creating a treatment plan for me, my Provider has reviewed my medical history and clinical information and, in my Provider’s professional assessment, has made the determination that the provider is able to meet the same standard of care as if the health care services were provided in-person when using the selected telehealth technologies, including but not limited to, asynchronous store-and-forward technology.
• I have the right to request a copy of my medical records. I can request to obtain or send a copy of my medical records to my primary care or other designated health care provider by contacting Group through the app-based chat, or by emailing hello@empirical.health. A copy will be provided to me at reasonable cost of preparation, shipping and delivery.
• It is necessary to provide my Provider a complete, accurate, and current medical history. I understand that I can log into my “Portal” within any Empirical mobile apps at any time to access, amend, or review my health information.
• There is no guarantee that I will be issued a prescription and that the decision of whether a prescription is appropriate will be made in the professional judgement of my Provider. If my Provider issues a prescription, I have the right to select the pharmacy of my choice.
• There is no guarantee that I will be treated by a Group provider. My Provider reserves the right to deny care for potential misuse of the Services or for any other reason if, in the professional judgment of my Provider, the provision of the Services is not medically or ethically appropriate.

Additional State-Specific Consents

The following consents apply to patients accessing Group’s website for the purposes of participating in a telehealth consultation as required by the states listed below:

• Alaska: 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.
• 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.
• 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; Or, the Maine Board of Osteopathic Licensure’s website, here.
• 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.
• Oregon: 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.
• Rhode Island: 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.
• Texas: 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.
  AVISO SOBRE LAS QUEJAS - Las quejas sobre médicos, así como sobre otros profesionales acreditados e inscritos del Consejo Médico de Tejas, incluyendo asistentes de médicos, practicantes de acupuntura y asistentes de cirugía, se pueden presentar en la siguiente dirección para ser investigadas: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018. Si necesita ayuda para presentar una queja, llame al: 1-800-201-9353. Para obtener más información, visite nuestro sitio web en www.tmb.state.tx.us.
• Vermont: 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 Vermont Board of Osteopathic Examiners’ website, here.
• California fictitious name permit can be located here.

By acknowledging this informed consent, 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