INFORMED CONSENT REGARDING USE OF TELEHEALTH SERVICES
By selecting “I AGREE,” checking a relevant box to indicate your acceptance, using any other presented acceptance method within the service, or confirming your acceptance in any other affirmative manner, you are confirming that you have read, accepted, and agreed to abide by the terms of this agreement. If you do not agree to the terms of this agreement, please refrain from creating an account or using the service. Furthermore, by clicking the “I AGREE” button or otherwise expressing acceptance on your behalf, you hereby grant agency authority to the responsible party to indicate acceptance to this consent on your behalf.
If you find yourself in a life-threatening situation, such as having thoughts of suicide, please immediately dial 911 or contact the 988 Suicide & Crisis Lifeline at 988.
The objective of this consent form (“Consent”) is to furnish you with information concerning telehealth services and to obtain your informed consent for the utilization of telehealth in the provision of healthcare by physicians, physician assistants (PAs) and/or nurse practitioners (NPs) (“Providers”) through the online platforms owned and operated by NiceRx, its partners, and/or its affiliated companies (the “Service”). In this Consent, the terms “you” and “yours” pertain to the individual employing the Service. In the event that the Service is used by, or on behalf of, a minor between the ages of thirteen (13) and eighteen (18) or the age of majority as specified by applicable state law, “you” and “yours” also encompass (i) the parent or legal guardian granting consent for the minor’s use of the Service or using the Service on the minor’s behalf, and (ii) the minor for whom consent is granted or on whose behalf the Service is employed.
USE OF TELEHEALTH
Telehealth encompasses the provision of healthcare utilizing electronic communications, information technology, or other means to connect a healthcare provider with a patient, even when they are not physically located in the same place. Telehealth can be used for purposes like diagnosis, treatment, follow-up, and patient education, and it may encompass, but is not confined to, activities such as electronically transmitting medical records, personal health information, photo images, or other data between a patient and a provider, engaging in interactions between a patient and provider through video, audio, and/or data communication (including electronic messaging or email exchanges), and utilizing output data from medical devices, video, and sound files. You have the option to explore alternative methods of care, such as in-person services, and you can make that choice at any time. It is advisable to consult with your Provider about alternative options.
Utilizing telehealth services may offer the following potential advantages: enhancing the accessibility and efficiency of accessing medical care or related services and treatments for the conditions managed by your Provider(s); affording you the opportunity to receive medical care or other services and treatments from Provider(s) at times that align with your convenience; and facilitating interactions with Provider(s) without requiring in-person office visits.
While utilizing telehealth for healthcare delivery can offer potential benefits, it’s essential to acknowledge that there are accompanying potential risks associated with telehealth and other technology. These risks include, but are not confined to the following: limitations in the quality, accuracy, or effectiveness of services provided by your Provider; the presence of technological issues, including within the Service, such as bugs or errors that may restrict functionality, generate incorrect results, render all or part of the technology, including the Service, unusable, create inaccurate records, transmissions, data, or content, or lead to the corruption or loss of records, transmissions, data, or content; technology failures may also impact your Provider(s)’ ability to diagnose or treat your condition correctly; certain tests or in-person vital sign assessments may not be possible through telehealth, potentially preventing a diagnosis or necessitating emergency care; your Provider(s) may not be able to treat your specific condition, requiring you to seek alternative healthcare or emergency services; delays in medical assessment or treatment may arise due to Provider(s) unavailability or technology and electronic equipment deficiencies or failures; electronic systems or security protocols may fail, potentially breaching the privacy of your medical or other information; electronically stored and transmitted data, such as through email communications, may be more susceptible to unintentional disclosure of protected health information to third parties; regulatory requirements in specific jurisdictions may limit your Provider(s)’ diagnosis and treatment options, particularly regarding certain prescriptions; limited access to your complete medical records may lead to adverse drug interactions, allergic reactions, or other judgment errors.
In the event of a life-threatening or other emergency situation, such as having thoughts of suicide, please immediately contact 911 or reach out to the 988 Suicide and Crisis Lifeline at 988 for assistance.
In case of an emergency, please dial 911. It’s important to note that telehealth may not be suitable for all situations. If you require immediate or urgent care, you must seek treatment at an emergency room facility or from a healthcare provider capable of providing urgent or emergent care. Providers may not be able to respond promptly to communications submitted through the Service.
If you are not facing an emergency or do not require immediate or urgent care, you have the option to communicate with Providers through the secure message service within the Service. In the event of a technical failure preventing communication through the Service, please contact the following number:
Phone: 1-866-407-0777 (Monday to Friday, 9 AM – 5 PM EST) or Email [email protected]
DATA PRIVACY AND PROTECTION
The electronic systems employed within the Service will incorporate network and software security protocols to uphold the privacy and security of your information, along with measures to prevent both intentional and unintentional data corruption. Your personal information, including identifiers and protected health information, will not be disclosed to any third party without your consent, except as legally authorized for purposes such as consultation, treatment, payment/billing, administrative needs, or as mandated by law to divulge specific information acquired during the provision of health services, or as otherwise detailed in your Provider’s Notice of Privacy Practices. Using the Service may involve email correspondence to and from you, which may contain your protected health information. It is important to understand that NiceRx cannot guarantee the absolute security or privacy of the communication services you employ, including, for instance, your email service provider.
LABORATORY PRODUCTS AND SERVICES
Certain healthcare services provided to you through the Service may necessitate your completion of an at-home diagnostic test. These diagnostic tests are furnished by third-party laboratories, and neither NiceRx and its subsidiaries (referred to collectively as “NiceRx”) nor your Provider(s) can guarantee the accuracy or reliability of these tests. These laboratory tests have the potential to yield false negative, false positive, or inconclusive results, which could potentially affect your Provider(s)’ capacity to make an accurate diagnosis or administer appropriate treatment for your medical conditions. Additionally, a malfunction or deficiency in these tests could also impact your Provider(s)’ ability to correctly diagnose or treat your medical conditions.
OPEN PAYMENTS NOTICE
Exclusively for informational purposes, a hyperlink to the federal Centers for Medicare and Medicaid Services Open Payments web page is offered herein. It is important to note that the federal Physician Payments Sunshine Act mandates the disclosure of comprehensive information regarding payments and other forms of compensation exceeding ten dollars ($10) provided by manufacturers of drugs, medical devices, and biologics to physicians and teaching hospitals. This information is accessible to the public. The Open Payments database, which serves as a federal resource for searching payments made by pharmaceutical and medical device companies to physicians and teaching hospitals, is accessible at https://openpaymentsdata.cms.gov.
By selecting “I Agree,” checking an associated box to indicate your acceptance, utilizing any other acceptance method presented within the Service, or otherwise expressing your affirmative consent, you are hereby confirming your agreement and granting your consent concerning the following:
Healthcare provided to you through the Service will primarily utilize telehealth. In certain situations, your treating Provider may be a nurse practitioner or physician assistant, rather than a physician, and you consent to receiving care from non-physician providers, if applicable, by utilizing the Service. It’s important to note that some of the technology, including the Service, may still be in a beta testing and development phase, and it may not represent a final and finished product. This technology might contain bugs or errors that could potentially limit functionality, produce erroneous results, render parts or the entirety of such technology unavailable or inoperable, generate incorrect records, transmissions, data, or content, or result in the corruption or loss of records, transmissions, data, or content. Any of these issues could have an impact on the quality, accuracy, and effectiveness of the medical care or services you receive from your Provider(s). Moreover, certain diagnostic testing services, including laboratory products and services offered through the Service, may have defects that limit functionality or produce inaccurate results. Such issues may also affect the quality, accuracy, and effectiveness of the medical care or services provided by your Provider(s). The use of telehealth and technology in healthcare services is an evolving field, and it may involve technologies not specifically described in this Consent. While there are potential benefits to using telehealth and technology, no specific results can be guaranteed, including laboratory testing results, diagnosis, or treatment by your Provider(s). Your medical condition may not necessarily improve, and in some cases, it may worsen. Telehealth and technology, including the Service, have limitations, and not every condition may be suitable for diagnosis or treatment through these means. Risks associated with the use of telehealth and technology are outlined in this Consent. You have the opportunity to discuss the use of telehealth, including the Service, with your Provider(s), including the benefits, risks, and alternatives. Note that there will be may be recording of online treatment sessions by your Provider(s) or you. Your Provider(s) will assess your medical condition and, at their discretion, may determine that it is medically appropriate to diagnose and/or treat your condition via telehealth technology, including the Service. By continuing to use the Service, you agree with your Provider’s medical assessment and consent to receiving a diagnosis and/or treatment via telehealth technology. You have the right to withdraw your consent to the use of telehealth without affecting future care or treatment or the loss of any health benefits you’re entitled to. However, Providers using the Service do not offer in-person treatment. Any withdrawal of consent will be effective upon written notice to your Providers, without affecting actions taken by NiceRx or your Provider(s) based on this Consent before receiving your written notice of withdrawal. Other provisions of this Consent will remain in effect, and you will continue to be bound by it. You understand that using the Service involves electronic communication of your personal medical information, including email correspondence. It is your responsibility to provide NiceRx and your Provider(s) with truthful, accurate, and complete information, including details about care you may have received or are receiving from other healthcare providers, along with emergency contact information for your local healthcare providers. Each of your Provider(s) will assess your medical condition and may, at their sole discretion, decide that diagnosing and/or treating your condition using telehealth technology, including the Service, is medically appropriate. By continuing to use the Service, you consent to your Provider’s medical assessment and agree to receive diagnosis and/or treatment via telehealth technology. Each of your Provider(s) may also determine, at their sole discretion, that your condition is not suitable for diagnosis and/or treatment using telehealth technology, including the Service, and may recommend seeking care and treatment from a specialist or other healthcare provider outside of telehealth technology.
NiceRx has commercial relationships with Nice Telehealth Inc. NiceRx also has a financial relationship with the entity that employs or contracts with your Provider. You have the freedom to obtain medical examinations from healthcare providers not affiliated with NiceRx. NiceRx will utilize its pharmacy partners to deliver your order directly to your door, but you are free to obtain your prescription from any pharmacy of your choice. Prescriptions may be filled by and transferred between any pharmacy partners on your behalf. It is your responsibility to cover the full costs associated with using the Service, including any prescriptions you may receive, and you must not attempt to submit a claim to Medicare, any other federal payor, or any state or private insurer.
If you have concerns about a medical professional, you have the option to contact the Medical Board in your respective state to address those concerns. For the appropriate contact information, please refer to the list available here. For clients in California, please take note: Physicians and midwives are subject to licensing and regulation by the Medical Board of California. To verify a license or file a complaint, you can visit www.mbc.ca.gov or call (800) 633-2322.