Consent to Telemedicine
I understand that the telemedicine uses electronic communications to enable and allow health care providers at different locations to share individual patient medical information for the purpose of providing and improving patient care and treatment. OLA MD’s providers may include primary care physicians, specialists, nurse practitioners and/or subspecialists.
IF YOU HAVE A MEDICAL EMERGENCY, SEEK IN-PERSON EMERGENCY CARE IMMEDIATELY OR DIAL 911
I hereby authorize OLA MD, LLC (“OLAMD.COM”), and OLA MD staff and associates (collectively the “OLA MD Personnel”) to examine and evaluate my medical condition and, based on the findings of that examination and evaluation, to provide medical therapies and treatments to me that may be deemed medically necessary for my disease or condition including prescriptions, including use of generic medications and over the counter medications.
I understand that as part of my examination, evaluation and ongoing treatment, I may be expected to give blood and possibly other bodily specimen for testing by a licensed clinical laboratory; and understand that OLA MD Personnel will refer me to a licensed clinical laboratory to collect those specimen from me, to submit them for testing, and to obtain and send the results to OLA MD.
I understand that the therapies and treatments provided, performed, or prescribed by OLA MD Personnel are not covered or reimbursed by Medicare or other insurance, and I agree to pay for all services myself. I understand that I will not be reimbursed by Medicare or my insurance company and OLA MD LLC. will not submit for reimbursement from Medicare or any insurance company on my behalf. I understand that payment is due when services are rendered, and if I should incur a balance for services rendered, I shall promptly pay the balance in full by cash, check, or credit / debit card.
- I understand that my health care provider wishes me to engage in a telemedicine consultation.
- My health care provider has explained to me how the video conferencing technology will be used to affect such a consultation will not be the same as a direct patient/health care provider visit due to the fact that I will not be in the same room as my health care provider.
- I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my health care provider or I can discontinue the telemedicine consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.
- I understand that there may be a delay of a number of days before a doctor reviews my request for treatment or a lab test and any messages I send.
- I understand that the doctor has the right to refuse to take responsibility for my care if the doctor makes a professional judgment that I am not a good candidate for this service. I understand that making a request for treatment (by completing a visit in the App or Website and making payment or by starting a video visit) or requesting a lab test or sending a message through the app does not in and of itself create a duty of care or create a doctor-patient relationship.
- I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. Others may also be present during the consultation other than my health care provider and consulting health care provider in order to operate the video equipment. The above-mentioned people will all maintain confidentiality of the information obtained. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history/physical examination that are personally sensitive to me; (2) ask non‐medical personnel to leave the telemedicine examination room: and or (3) terminate the consultation at any time.
- I understand that the doctor is unable independently to verify the information and photos I provide and that the doctor will make a professional judgment based on the information and photos I provide.
- I have had the alternatives to a telemedicine consultation explained to me, and in choosing to participate in a telemedicine consultation. I understand that some parts of the exam involving physical tests may be conducted by individuals at my location at the direction of the consulting health care provider.
- In an emergent consultation, I understand that the responsibility of the telemedicine consulting specialist is to advise my local practitioner and that the specialist’s responsibility will conclude upon the termination of the video conference connection.
- I understand that I should never use in a medical or psychiatric emergency. I understand that in an emergency, I should dial 911 or go to an emergency department.
- I have had a direct conversation with my doctor, during which I had the opportunity to ask questions in regard to this procedure. My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in I have had a direct conversation with my doctor, during which I had the opportunity to ask questions in a language in which I understand
- I fully understand that there is no guarantee with respect to the benefits that I may or may not realize from the therapies and treatments referred to above and recommended by OLA MD Personnel.
- I understand that although OLA MD implements a wide range of administrative, physical, and technical safeguards to protect my health information OLA MD cannot guarantee the privacy and confidentiality of my health and other information.