By clicking the “AGREE” button you acknowledge that you are consenting to receiving care via the Service. The scope of care will be at the sole discretion of the healthcare provider who is treating you, with no guarantee of diagnosis, treatment, or prescription. The healthcare provider will determine whether or not the condition being diagnosed and/or treated is appropriate for a telehealth encounter via the Service. The Service respects and upholds patient confidentiality with respect to protected health information as outlined by the Health Insurance Portability and Accountability Act (“HIPAA”), and, subject to HIPAA regulations, will obtain express patient consent prior to sharing any patient-identifiable information to a third party for purposes other than treatment, payment or health care operations. In addition, by clicking the “AGREE” button you are authorizing Inhealth Medical Services, Inc to release your contact information to American Well solely in order for American Well to provide you with marketing materials promoting the Service. You may opt out of receiving such marketing materials by contacting us at firstname.lastname@example.org. Finally, when using the Service you may be asked if you would like to share certain PHI collected by Apple’s HealthKit with American Well. By clicking on “SYNC” you are authorizing American Well to collect and Inhealth Medical Services, Inc providers to utilize such PHI.
INFORMED CONSENT FOR SERVICES PERFORMED BY Inhealth Medical Services, Inc
We are providing this information on behalf of Inhealth Medical Services, Inc:
Telemedicine involves the use of electronic communications to enable health care providers at sites remote from patients to provide consultative services. Providers may include, but is not limited to primary care practitioners, specialists, subspecialists, registered dieticians, nutritionists, and health educators. The information may be used for diagnosis, therapy, follow-up and/or education, and may include live two-way audio and video and other materials (e.g. medical records, data from medical devices).
The communications systems used will incorporate network and software security protocols to protect the confidentiality of patient information and will include reasonable measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.
An encounter summary will be provided to the patient at the end of each encounter which may be kept for the patient’s records and may be shared with the patient’s local primary care or other provider, as appropriate.
Anticipated Benefits of Telemedicine:
- Improved access to medical care by enabling a patient to remain at his or her home or office while consulting a clinician.
- More efficient medical evaluation and management.
Possible Risks of Telemedicine:
As with any medical procedure, there are potential risks associated with the use of telemedicine. Inhealth Medical Services, Inc believes that the likelihood of these risks materializing is very low. These risks may include, without limitation, the following:
- Delays in medical evaluation and consultation or treatment may occur due to deficiencies or failures of the equipment.
- Security protocols could fail, causing a breach of privacy of personal medical information.
- Lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other negative outcomes.
- I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine; I have received the Inhealth Medical Services, Inc Notice of Privacy Practices which explains these issues in greater detail.
- I understand that telemedicine may involve electronic communication of my personal medical information to medical practitioners who may be located in other areas, including out of state.
- I understand that, for the purposes of diagnosis, therapy, follow-up and/or education that Inhealth Medical Services, Inc affiliated providers utilize the same American Well system.
- I understand that information gathered by Inhealth Medical Services, Inc affiliated providers is not shared with other Inhealth Medical Services, Inc affiliated providers unless that provider is assigned and has agreed to be part of the provider team assigned to treat a patient.
- I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured.
- I understand that my healthcare information may be shared with other individuals for treatment, payment and healthcare operations purposes as it relates to weight management, chronic care management, diabetes prevention programs, sport nutrition or any other services Inhealth Medical Services, Inc may provide. Psychotherapy notes are maintained by clinicians but are not shared with others, while billing codes and encounter summaries are shared with others and with me. If I obtain psychotherapy from Inhealth Medical Services, Inc, I understand that my therapist has the right to limit the information provided to me if in my therapist’s professional judgment sharing the information with me would be harmful to me.
- I further understand that my healthcare information may be shared in the following circumstances:
- a) When a valid court order is issued for medical records.
- b) Reporting suspected abuse, neglect, or domestic violence.
- c) Preventing or reducing a serious threat to anyone’s health or safety.
Patient Consent to the Use of Telemedicine
I understand that this authorization to bill my credit card or debit card (including any other American Well accepted payment mechanism) will remain in effect until I cancel it in writing, and I agree to notify American Well in writing of any changes in my account information. In the case of an ACH Transaction being rejected for Non-Sufficient Funds (NSF), I understand that American Well may at its discretion attempt to process the charge again at any time within 30 days. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I certify that I am an authorized user of this credit card/bank account and will not dispute these scheduled transactions with my bank or credit card company; so long as the transactions correspond to the co-payment required by my health plan.