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Telehealth Consent

Telehealth Consent

Last modified 1/14/2024

OUR HEALTHCARE PROVIDERS DO NOT ADDRESS MEDICAL EMERGENCIES. IF YOU BELIEVE YOU ARE HAVING A MEDICAL EMERGENCY, YOU SHOULD DIAL 911 OR GO TO THE NEAREST EMERGENCY ROOM.

INTRODUCTION

Telehealth is a method of delivering healthcare services using communication technologies to facilitate diagnosis, consultation, treatment, education, care management, and self-management of a patient’s health care.

You are reviewing and acknowledging this Telehealth Consent Form because you are seeking healthcare services (the “Services”) from Flexup Wellness PLLC and its affiliated entities utilizing telehealth technologies facilitated through the Flexup Wellness PLLC website, iOS mobile app, web mobile app, or any partner platform, mobile app, or web mobile technologies (collectively, the “Flexup Wellness PLLC Platform”). This Telehealth Consent Form supplements but does not modify or supersede any Terms of Use, Privacy Policy, or Notice of Privacy Practices of Flexup Wellness PLLC or other healthcare providers offering services via the Flexup Wellness PLLC Platform.

By clicking “I consent to telehealth,” you indicate that you have reviewed this Telehealth Consent Form or had it explained to you, that you understand the risks and limitations of using telehealth technologies, that you have been given the opportunity to ask questions and that such questions have been answered to your satisfaction, and that you consent to receiving the Services from licensed healthcare providers employed by or contracted with Flexup Wellness PLLC (“Flexup Providers”) who are located at sites remote from you.

TREATMENT-SPECIFIC CONSENT

By clicking “I consent to telehealth,” you understand and agree to the following:

  1. I understand that Flexup Wellness PLLC offers telehealth visits, which are conducted through videoconferencing, telephonic, health surveys and asynchronous technology, and my Flexup Provider will not be present in the room with me.

  2. I consent to Flexup Wellness PLLC importing and accessing my medical records and medication list, including prescription records.

  3. To protect the confidentiality of my health information, I agree to undertake my telehealth visit in a private location, and I understand that my Flexup Wellness Provider will similarly be in a private location. If any other individuals are present (e.g., for technological or translation assistance), I will be informed of their presence and role and will have the opportunity to consent to their presence.

  4. I understand there are potential risks to the use of telehealth technology, including but not limited to interruptions, delays, unauthorized access, and technical difficulties. I understand that either my Flexup Wellness provider or I can discontinue the telehealth appointment if the technical connections are inadequate for my visit. I agree to hold harmless Flexup Wellness PLLC, its management company, and its employees, contractors, agents, directors, members, managers, shareholders, officers, representatives, assigns, predecessors, and successors for delays in evaluation or for information lost due to such technical failures.

  5. I understand that in some cases, my Flexup Wellness provider might be a nurse practitioner or a physician assistant as an alternative to a physician.

  6. I understand that I could seek an in-office visit instead of obtaining care from a Flexup Wellness provider, and I am choosing to participate in a telehealth visit. I further understand that my Flexup Wellness provider may not have access to a complete copy of my medical records and will not have the ability to perform an in-person examination, which could result in negative health outcomes (e.g., adverse drug interactions or allergic reactions). While telehealth technologies may benefit me, no specific results or outcomes are guaranteed, and my condition may not improve.

  7. I agree that any information I provide as part of a telehealth visit is accurate, true, and complete.

  8. I understand that my Flexup Wellness provider may determine that a telehealth visit is not appropriate for me due to my specific health concerns or other reasons related to my health status. In such a case:

    • I will receive an alert notifying me that I am unable to use the Services for the issue I submitted.

    • My request for a telehealth visit will not be submitted to my Flexup Wellness provider.

    • My Flexup Wellness provider will not receive any of the information I submitted.

    • I will need to seek care through other means.

  9. I understand that participating in a telehealth visit does not guarantee that I will be given a prescription. The decision to prescribe medication will be made based on the professional judgment of my Flexup Wellness provider.

  10. I understand that while the Flexup Wellness PLLC Platform may facilitate access to certain pharmacy or diagnostic lab services, I may request to use any pharmacy or lab of my preference.

  11. I understand that I am responsible for any payments resulting from my telehealth visit.

  12. I understand that Flexup Wellness providers do not address medical emergencies via the Flexup Wellness PLLC Platform. I understand that the responsibility of my Flexup Wellness provider may be to direct me to emergency medical services, such as an emergency room.

  13. I, as the parent or legal guardian of a minor, authorize and consent to any medical order, laboratory order, medical diagnosis, or treatment, and confirm that I have the legal authority to consent to such treatment or order.

  14. I agree that Flexup Wellness PLLC is a third-party beneficiary of this Telehealth Consent Form and has the right to enforce its terms against me.

  15. I understand and agree that I give permission to Flexup Providers to use and disclose my protected health information, including my entire medical record. This information is used or disclosed for the purpose of telehealth treatment. This authorization expires when I contact contact@flexupwellness.com.

  16. I understand that if the entity receiving my information is not covered by HIPAA, the disclosed information may no longer be protected by HIPAA.

  17. I may refuse to agree to this authorization. Refusal will not affect my payment, ability to obtain treatment, or eligibility for health plan benefits unless this authorization is required for research related to treatment, enrollment in a health plan, or providing healthcare solely for third-party use, such as legal proceedings.

  18. I may inspect or copy the protected health information to be used or disclosed under this authorization, except for information created as part of a clinical trial, where access is suspended until the trial is completed.

  19. I may revoke this authorization in writing at any time by sending a written notification to 571 Boston Turnpike STE 3 #1104, Shresbury, Ma 01545. Revocation will not apply to actions taken by Flexup Wellness providers prior to receipt of the notice.

ADDITIONAL TREATMENT-SPECIFIC CONSENT (Teletherapy)

The following consent applies to patients accessing the Services for telehealth consultations related to mental or behavioral health:

  1. I acknowledge that I may receive a telehealth consultation related to mental or behavioral health as part of the Services (“Teletherapy”). Teletherapy involves the communication of my mental health information to my Flexup Wellness provider. While Teletherapy has the same purpose as in-person therapy sessions, the experience may differ due to the nature of the technology used.

  2. I understand that I have the right to withhold or withdraw consent for treatment at any time without affecting my right to future care or treatment.

  3. The confidentiality of my medical information is protected by law, including during Teletherapy sessions, unless exceptions to confidentiality apply (e.g., mandatory reporting of child or elder abuse, danger to self or others, or legal proceedings involving emotional or mental health).

  4. I understand that Teletherapy services may not be as complete as in-person services. If my Flexup Provider believes I would benefit from another form of therapy, I will be referred to a professional who can provide such services.

  5. I understand that while Teletherapy may benefit me, no specific results or outcomes are guaranteed. Counseling may not improve my condition and, in some cases, could lead to worsening symptoms.

  6. I accept that Teletherapy is not suitable for emergency situations. If I am experiencing suicidal thoughts or planning to harm myself, I can contact the National Suicide Prevention Lifeline at 1-800-273-TALK (8255) for free, 24-hour support. If I am actively at risk of harm, my Flexup Provider will recommend more appropriate services.

  7. I understand that any dissemination of personally identifiable images or information from Teletherapy sessions requires my written consent.

  8. I am aware if experiencing signs and symptoms including chest pain or discomfort (angina), shortness of breath at baseline, shortness of breath on exertion, fatigue, dizziness, nausea, sweating, palpitations; it crucial to be evaluated by a primary care provider before starting any treatment plan recommended by FlexUp Wellness PLLC to ensure proper diagnosis and tailored care.

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