Last Updated November 24, 2023
TELEHEALTH AUTHORIZATION AND CONSENT
Please only use our services after you have read this information and subsequently made an informed decision that our services are right for you. If you have any questions, please send us a message through our website or email us at support@drtelx.com
BACKGROUND ON OUR SERVICES: Dr Telx LLC, a Washington State based Limited Liability Company doing business as “Dr Telx” is a medical group that delivers healthcare services and information through a telehealth technology platform (the “Platform”).
NOT FOR EMERGENCIES: Company does not provide medical care on an emergency basis anywhere at any time and is not a substitute for your physician (primary care or specialist). Please do not delay seeking care in a medical emergency because of your communication with Company. In an emergency, dial 911 or go to a hospital emergency department.
NO DUTY OF CARE: Please note that Company does not take responsibility for your health or ongoing care. Instead, we provide highly focused perspective and approach.
RIGHT TO DECLINE CLIENT: Please understand that Company reserves right to refuse to provide services if, in our professional judgment, you are not a good candidate for our services. Visiting Company’s website and making payment, starting a visit, or sending a message to us does not create a duty of care or a provider-patient relationship.
AGREEMENT TO REVIEW ALL CONTENT: You understand that you must read and understand this Telehealth Authorization, the Terms of Use, Privacy Policy, Service Agreement, and all other information provided about specific services before you begin interacting and using our platform. You understand that to read important information, you may need to both click on links and various titles to expand the information that is visible below, and that, without clicking on links and titles, you will not be able to read important information that enables you to give informed consent to treatment.
AGREEMENT TO ANSWER TRUTHFULLY AND USE OUR PLATFORM HONESTLY: You understand that by, using our Platform, you accept the responsibility to provide full and truthful answers to all questions and, when requested, to provide all other data in the most accurate form possible. Company relies exclusively upon information that you provide to decide whether or not treatment is safe and appropriate, and, if you provide incorrect information, then you will be at greater risk of adverse events from any treatment that the provider recommends and you receive that isn’t necessary, appropriate, or safe. It is important that you do not create more than one account. Creating more than one account makes it impossible for Company to see the full history of services that you have received from us. This increases the chances that Company will not have access to important information in your medical record that could influence the provider’s clinical decision.
BENEFITS AND RISKS OF USING OUR SERVICE: We offer resources, information, and recommendations from a different perspective and approach than that of a traditional medical group. In using our Platform, you accept a greater responsibility to read and understand information throughout the Platform about the limitations of telemedicine, the risks of seeking health care information this way, and the risks and benefits of a proposed treatment plan. Specifically, you agree to the following risks:
NEED TO SEEK OTHER SOURCES OF CARE FOR OTHER MEDICAL NEEDS: You need to seek other sources of care for your medical needs.
DELAY: There may be a delay until the next business day before a provider reviews any request for treatment and reads any messages sent. You must check the Platform for messages because this is the way that the provider will communicate important information. Failure to check the Platform regularly may delay the services we provide.
NO IN-PERSON EXAM: By using our telemedicine platform, you will not have an in-person consultation and physical exam with a doctor that might identify a medical condition that needs further investigation or immediate treatment.
RISKS TO ELECTRONIC HEALTH INFORMATION: You understand that although we implement a wide range of administrative, physical, and technical safeguards to protect health information and comply with HIPAA, we cannot guarantee the privacy and confidentiality of all health information. For more details about how we protect and use your health information and complies with HIPAA, see our Privacy Policy.
CONSENT TO COMMUNICATE VIA UNENCRYPTED EMAIL: Our experience is that the overwhelming majority of clients wish to communicate with us via email, even if unencrypted email does not meet HIPAA standards. In signing this consent, you give us permission to use or disclose your medical information to you via the regular email address you provide to us. You acknowledge that we are communicating in this manner irrespective of HIPAA requirements solely at your direction. You may revoke that permission in writing at any time, in which event we will stop any further use or disclosure of your medical information by email, except to the extent we have already acted in reliance on your permission. You understand that we are unable to take back any disclosure we have already made with your permission and that we are required to retain our records of the communications prior to any revocation of authorization to utilize email in communicating with you.
IMPORTANCE OF READING ALL THE INFORMATION WE PROVIDE: You understand that we provide detailed information in the Platform to help you make an informed decision about whether to accept a proposed recommendation from Company on this platform. You understand the importance of reading the information Company provides about adverse events, as this will help you make informed decisions about your care.
RISKS OF ACCEPTING TREATMENT RECOMMENDATIONS:
You understand that adverse events can be caused by a number of things, including an allergic reaction, side effects, or interactions between a medicine, supplement or course of treatment that Company recommends and any medical conditions you may have, other medical conditions, prescription medicines or other things (e.g., supplements, herbs, over-the-counter medicines, or recreational drugs) you are taking, and lifestyle choices such as smoking tobacco products or drinking alcohol.
If you do not understand anything in this Consent or have any other questions, be sure to ask us and your outside doctor. If you go forward with treatment, we will assume that you understood and were able to discuss your questions and concerns with your healthcare provider to your satisfaction.
Telehealth Consent Form
I understand that Telehealth is a mode of delivering health care services via communication technologies (e.g., internet or cellphone) to facilitate diagnosis, consultation, treatment, education, care management, and self-management of a patient’s health care.
By acknowledging my consent below, I understand and agree to the following:
I understand that Vital and affiliate Openloop Healthcare Partners, PC offer Telehealth consultations, which are conducted through videoconferencing, telephonic, and asynchronous technology and my Telehealth provider will not be present in the room with me.
I understand there are potential risks to the use of Telehealth technology, including but not limited to, interruptions, delays, unauthorized access, and or other technical difficulties. I understand that either my Telehealth provider or I can discontinue the Telehealth appointment if the technical connections are not adequate for my visit. 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 with Vital, an affiliate of Openloop Healthcare Partners, PC, 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.
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.
I understand that I am responsible for payment of any amounts due and owing resulting from my Telehealth visit.
In an emergent situation, I understand that the responsibility of my Telehealth provider may be to direct me to emergency medical services, such as an emergency room.
By acknowledging below, 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.
