Patient Consent To Use Of Tele-health

Beam Healthcare S.C. and its associated medical practices (collectively, “Group”) and their affiliated health care providers (“Providers”) may arrange for you to connect with Providers and/or provide you with professional services using asynchronous and/or synchronous telehealth technologies (“Telehealth Technology”). If you have questions about use of the Telehealth Technology itself and whether it is appropriate for your condition, the risks associated with using the Telehealth Technology, or the Provider’s credentials and professional background, please ask your Provider. In exchange for your use of the Telehealth Technology to receive care, you acknowledge and agree to the following terms and conditions of this informed consent (this “Consent”):

1. Use of Telehealth Technology. You understand and agree that:
  • There are many benefits, but also risks associated with receiving care via Telehealth Technology. Benefits include convenience, increased access, and the ability to receive care in your home. Risks are outlined in Section 2 below.
  • The Provider will decide, in his or her sole discretion, whether it is appropriate to treat your condition using the Telehealth Technology. The Provider may request that you halt receiving care via Telehealth Technology and instead receive in-person care if the Provider deems appropriate.
  • Services provided through Telehealth Technology may involve electronic communication of your personal medical information to Providers that may be located in other areas, including out of state.
  • Your Provider will take measures to protect the privacy and security of any personal medical information transmitted through Telehealth Technology in accordance with federal, state, and other applicable law.
  • You have the right to request copies of your medical records, which may be provided electronically or in hard copy format at reasonable cost of preparation, shipping and delivery.
  • The anticipated response time for electronic communications submitted through the Telehealth Technology varies and you accept any risk associated with the response time, including a delay in obtaining medical care.
  • No warranty or guarantee has been made to you concerning any particular result related to your condition or diagnosis.
2. Risks Associated with Use of Telehealth Technology. You understand that use of the Telehealth Technology has risks associated with it, such as (1) information that you transmit through the Telehealth Technology may be insufficient to allow for appropriate medical decision-making by the Group Provider (e.g., poor resolution of transmitted images); (2) failures of equipment (e.g., servers, devices) or infrastructure (e.g., communications lines, power supply, software failure) may cause interruptions and delays in the provision of care and treatment, or loss of information; and (3) in rare events, security protocols could fail, causing unauthorized access to your medical information. You acknowledge that, although Group and its telehealth technology vendor strive to prevent unauthorized access to information about me through encryption of information transmitted by the Telehealth Technology and other security measures, Group and its vendors cannot guarantee that your use of the Telehealth Technology and the information will be private or secure, and you consent to this risk. You understand and consent to the risks associated with your use of the Telehealth Technology.

3. Accuracy of Information Submitted to the Group Provider. You acknowledge and agree that you are solely responsible for ensuring that the information submitted by you through the Telehealth Technology is accurate, complete and current. You understand that the Group Provider will rely on this information to diagnose and prepare a treatment plan for your medical condition and your failure to provide accurate, complete and current information may lead to a delay in your treatment or a misdiagnosis.

4. Release and Waiver. You acknowledge and agree to limit, disclaim, and release Group from liability in connection with the Telehealth Technology’s use.

5. Expenses. You understand and agree that you or the entity sponsoring your receipt of our telehealth services, as applicable, are responsible for the cost of all professional fees associated with your use of our telehealth services and the Telehealth Technology, which may change from time to time, and the cost of any medications or supplies prescribed by the Group Provider, if applicable, as well as any equipment provided by the Group, including but not limited to peripheral equipment for use in engaging with the Telehealth Technology.

6. Other Legal Terms. This Consent cannot be amended except in writing by mutual agreement of Group and you. If any provision is or becomes unenforceable or invalid, the other provisions will continue with the same effect.

7. Right to Revoke. You understand that you can revoke this Consent by sending written notice using certified mail to Group at: Beam Healthcare S.C. 25 W Main St, FL5, Madison, WI 53703 (“Revocation”). You agree that your Revocation must contain your name and your address. You also understand that your Revocation means that you are not permitted to receive care using Telehealth Technology. Your Revocation will be effective upon Group’s receipt of your written notice, except that your Revocation will not have any effect on any action taken by the Group Provider in reliance on this Consent before it received your written notice of Revocation.

By checking here, you indicate that you have read, understand, and consent to receive care through Telehealth Technologies.


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