Telehealth Informed Consent

As part of your PreventiveMD program membership, you are provided telehealth services through one or more participating medical groups or provider networks engaged by PreventiveMD (each, a “Medical Group”). The Medical Group utilizes a third-party telehealth platform (the “Platform”), through which independent licensed healthcare providers (“Providers”) will furnish you telehealth services related to your treatment (“Services ”). The Platform is accessible through a third-party virtual care suite (the “Solution”).

By accepting this consent below, you hereby consent to receive the Services. This means that you authorize information related to your health care to be securely electronically transmitted in the form of images and data through an interactive video or telephonic connection between you and the Provider, who may be located in a different location than you.

By accepting this consent below, you acknowledge your understanding and agreement to the following:

• There are possible benefits of telehealth, including, without limitation, increased accessibility and efficiency of medical care, the ability to obtain medical care and treatment at times that are convenient to me, and the ability to interact with Providers without the necessity of an in-office visit.
• There are possible limitations of telehealth, including, without limitation, disruption of transmission by technology failures, breaches of confidentiality by unauthorized persons, and limited ability to respond to emergencies.
• I have a duty to answer questions about my health and medical history honestly and accurately and to keep all of my health care providers, including my Provider, up to date on any changes in my health, symptoms, treatment, or medications.
• Withholding or providing inaccurate information about my health and medical history in order to obtain treatment may result in harm to me, including, in some cases, death.
• The Services enable coordination and communication with a Provider and do not replace my relationship with any existing health care provider.
• I cannot obtain emergency treatment through the Services and should call 9-1-1 and seek immediate medical treatment if I am experiencing a medical emergency.
• If I have questions relating to my care that are not urgent, I can message my Provider through the Solution. I understand that my Provider may not review and respond to my messages until the next business day, depending on when the message was sent.
• My Provider may determine in his or her sole discretion that my condition is not suitable for treatment using the Services and that I may need to seek medical care and treatment in person or from an alternative source.
• I have the right to withhold or withdraw my consent for the Services at any time during the course of my care. Otherwise, this consent will be considered renewed upon each new telehealth consultation with my Provider.
• There will be no video or audio recording of the Services by either party.
• All of my information, including my health information, collected by the Medical Group and my Providers through the Services will be securely stored in an electronic medical record. All federal and state laws protecting the privacy and confidentiality of health information also apply to telehealth, and information disclosed during the Services and written records pertaining to those Services are confidential and may not be disclosed without my written consent unless a disclosure is permitted or required by law.
• The Medical Group, my Providers, and the vendor providing the Platform (the “Platform Vendor”) may collect, store, use, and share my information, including health information and other information regarding the Services, including with the vendor providing the Solution (the “Solution Vendor”), as described in PreventiveMD’s, the Medical Group’s, and the Platform Vendor’s privacy policies, and for any other purposes permitted by law.
• The Medical Group and the Platform Vendor have agreements in place with the Solution Vendor to ensure the confidentiality of the health information to which it has access by virtue of providing its services. By accepting this consent below, I knowingly and voluntarily consent to the disclosure of my health information to, and processing of (including de-identifying and aggregating) such information by, the Solution Vendor to provide the Solution, to improve and develop its technology, as described in the Solution Vendor’s privacy policy, and for any other purposes permitted by law.
• A technical failure affecting the Services may result in the loss of my information or the interruption of my telehealth session. In addition to any disclaimers I have agreed to by accepting the Terms of Use, I agree to hold PreventiveMD, the Medical Group, the Platform Vendor, and the Solution Vendor harmless for any loss of information or delay in care resulting from a technical failure.
• PreventiveMD may, from time to time and in its discretion, change the Medical Group, the Platform Vendor, or the Solution Vendor providing the Services. My continued use of the Services following any such change constitutes my acceptance of the substituted provider or vendor on the same terms set forth in this consent.

I have read the information provided above, I understand its contents, and all my questions have been answered to my satisfaction.

Acknowledgment and Electronic Acceptance

By clicking “I Agree” (or by checking the box and submitting this form, as applicable), I acknowledge that I have read and understood this Telehealth Informed Consent and that I agree to receive the Services on the terms described above. I understand that my electronic acceptance will be recorded together with my account identifier, the date and time of my acceptance, my IP address, and other information sufficient to associate my acceptance with my identity. I agree that my electronic acceptance constitutes my legally binding signature and consent for all purposes, including under the federal Electronic Signatures in Global and National Commerce Act (E-SIGN) and the Uniform Electronic Transactions Act (UETA), and is the equivalent of my handwritten signature.