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Telehealth Consent

Last updated: August, 2024

LOOKMEDS, LLC (“LOOKMEDS”) TELEHEALTH CONSENT FORM

THE HEALTHCARE PROVIDERS PROVIDING TELEHEALTH SERVICES THROUGH THE LOOKMEDS PLATFORM 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 mode of delivering health care services via 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”) utilizing telehealth technologies by OpenLoop Healthcare Partners, PC and its affiliated entities (the “Provider Network”) facilitated through the LookMeds website, mobile or web apps, or other web technology (the “LookMeds Platform”). This Telehealth Consent Form supplements but does not modify or supersede any Terms of Use, Privacy Policy, or Notice of Privacy Practices of LookMeds or the Provider Network, or other healthcare providers offering services via the LookMeds 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 health care providers employed by or contracted with the Provider Network (“Providers”) who are located at sites remote from you.

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

  1. I understand that the Provider Network offers telehealth visits, which are conducted through videoconferencing, telephonic, and/or asynchronous technology and my Provider will not be present in the room with me.  
  2. To protect the confidentiality of my health information, I agree to undertake my telehealth visit in a private location, and I understand that my Provider will similarly be in a private location. If any other individuals are present (i.e., for technological or translation assistance), I will be informed of the individual’s presence and such individual’s role, and I will be given the opportunity to consent to such individual’s presence.
  3. 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 Provider or I can discontinue the telehealth appointment if the technical connections are not adequate for my visit. I AGREE TO HOLD HARMLESS LOOKMEDS AND THE PROVIDER NETWORK AND THEIR AFFILIATES, TOGETHER WITH THEIR 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.
  4. I understand that I have the opportunity to discuss the use of telehealth, including the benefits and risks, with my Provider, I understand I could seek an in-office visit rather than obtain care from a Provider, and I am choosing to participate in a telehealth visit with a Provider. I further understand that my 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 from the recommended treatment (e.g., adverse drug interactions or allergic reactions). I further understand that while using telehealth technologies may benefit me, no such benefits or specific results are guaranteed and my condition may not improve.
  5. I understand that in some cases, my Provider might be a nurse practitioner or a physician assistant and not a physician.
  6. I agree that any information I provide as part of any telehealth visit is accurate, true, and complete.
  7. I understand that my Provider may determine that a telehealth visit is not appropriate for me due to my particular health concern or for other reasons related to my health status. In such a case: (i) I will receive an alert notifying me that I will be unable to use the Services for the particular issue I submitted; (ii) my request for a telehealth visit will not be submitted to my Provider; (iii) my Provider will not receive any of the information that I submitted; and (iv) I will need to seek any needed care in another way.
  8. I understand the LookMeds Platform makes available a specific set of services and I may need to seek other resources for my other health needs. There is no guarantee that I will be approved for treatment by a Provider. My Provider reserves the right to deny care for any reason if, in the professional judgment of my Provider, the provision of the services, including when provided via telehealth is not medically or ethically appropriate. I understand that the Providers, and not LookMeds or the Provider Network, are responsible for the quality and appropriateness of the care they render to me and make all decisions regarding clinical care in their independent discretion without the influence of LookMeds or the Provider Network. I agree to only seek relief against the Provider for any liabilities pertaining to medical or clinical issues arising as a direct result of medical or clinical services accessed through the LookMeds Platform.
  9. I understand that participating in a telehealth visit is not a guarantee that I will be given a prescription, and that the decision as to whether a prescription is appropriate for my condition will be made in the professional judgment of my Provider.
  10. I understand that while the LookMeds Platform may make available access to certain pharmacy or diagnostic lab services, I may request to use any pharmacy or lab of my preference.
  11. I understand that certain diagnostic testing services, including laboratory products and services facilitated through the LookMeds Platform, to support the services of Providers, may contain defects, including ones which may limit functionality or produce erroneous results, any or all of which could limit or otherwise impact the quality, accuracy and/or effectiveness of the medical care or other services that I receive from my Provider(s).
  12. I understand that by using the LookMeds Platform I am not always speaking or messaging with my Provider in real-time, and there may be a delay before my messages or information is reviewed. I understand that I must check the LookMeds Platform for messages because this is the way that my Provider will communicate important information to me. I understand that if I do not check the LookMeds Platform regularly, then my services may be delayed.
  13. I understand that I am responsible for payment of any amounts due and owing resulting from my telehealth visit.
  14. I understand that Providers do not address medical emergencies via the LookMeds Platform. I understand that the responsibility of my Provider may be to direct me to emergency medical services, such as an emergency room.
  15. I agree that LookMeds is a third-party beneficiary of the Telehealth Consent Form and has the right to enforce it against me.

CONSENT TO TEXT OR EMAIL USAGE FOR APPOINTMENT AND OTHER HEALTHCARE REMINDERS AND GENERAL INFORMATION

By clicking “I accept”, I further authorize the Provider Network to contact me by phone or SMS/ text message at the telephone number I have provided, or to send emails at the email address I have provided, with appointment reminders and general health information. I understand that this request to receive emails and/or text messages will apply to all future appointment reminders/feedback/health information unless I request a change in writing. I also acknowledge this means of communication is not considered secure for the transmission of private information.

ADDITIONAL STATE-SPECIFIC DISCLOSURES

The following consents apply to patients accessing the Services for the purposes of participating in a telehealth visit within the states listed below, as required by state law:

Alaska: I understand that my primary care provider may obtain a copy of my records of my telehealth encounter.

California Patients: The Open Payments database is a federal tool used to search payments made by drug and device companies to physician and teaching hospitals. It can be found at https://openpaymentsdata.cms.gov.

For informational purposes only, a link to the federal Centers for Medicare and Medicaid Services (CMS) Open Payments web page is provided above. The federal Physician Payments Sunshine Act requires that detailed information about payment and other payments of value worth over ten dollars ($10) from manufacturers of drugs, medical devices, and biologics to physicians and teaching hospitals be made available to the public.

Treatment Records: I understand that If I live in one of the following states, my primary care provider or other treating physician may obtain a copy of my telehealth treatment records with my consent, and the Provider Network may securely send a copy of my telehealth treatment records to my primary care provider or other treating physician. If I need help sending my telehealth treatment records to my primary care provider I can contact 1-855-597-1248. If I would like the Provider Network to do so, I can call 1-855-597-1248 and provide information necessary for the Provider Network to securely send my records.

Connecticut: I understand that my primary care provider may obtain a copy of my records of my telehealth encounter.

Kansas: I understand that if I have a primary care provider or other treating physician, the person providing telemedicine services must send a report to such primary care or other treating physician of the treatment and services rendered to me during the telemedicine encounter within three days of me providing consent to the person providing telemedicine services to send such report.

New Hampshire: I understand that my primary care provider or treating provider may obtain a copy of my records of my telehealth encounter.

New Jersey: I understand I have the right to request a copy of my medical information, and I understand my medical information may be forwarded directly to my primary care provider or health care provider of record, or upon my request, to other health care providers.

Ohio: I understand that my primary care provider may obtain a copy of my records of my telehealth encounter.

South Carolina: I understand that my medical records may be distributed only with my consent and in accordance with applicable laws and regulations to other treating health care practitioners.

Texas: I understand that with my consent my medical records may be sent to my primary care physician within 72 hours after receiving Services.

Formal Complaints:

California: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website here, or the physician assistant board’s website here.

Georgia: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here.

Idaho: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here.

Indiana: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here.

Iowa: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here.

Kentucky: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here.

Maine: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here.

New York: I have been informed that to get information regarding your rights and how to report professional misconduct, I should visit here.

Oklahoma: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here; or, the Oklahoma Board of Osteopathic Examiners’ website, here.

Oregon: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here.

Rhode Island: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here.

Texas:

NOTICE CONCERNING COMPLAINTS - Complaints about physicians, as well as other licensees and registrants of the Texas Medical Board, including physician assistants, acupuncturists, and surgical assistants may be reported for investigation at the following address: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018, Assistance in filing a complaint is available by calling the following telephone number: 1-800-201-9353, For more information, please visit our website at www.tmb.state.tx.us.

AVISO SOBRE LAS QUEJAS - Las quejas sobre médicos, asi como sobre otros profesionales acreditados e inscritos del Consejo Médico de Tejas, incluyendo asistentes de médicos, practicantes de acupuntura y asistentes de cirugia, se pueden presentar en la siguiente dirección para ser investigadas: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018, Si necesita ayuda para presentar una queja, llame al: 1-800-201-9353, Para obtener más información, visite nuestro sitio web en www.tmb.state.tx.us.

Vermont: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here; or, the Vermont Board of Osteopathic Examiners’ website, here.

Wyoming: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here.

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