Telemedicine involves the delivery of healthcare services using electronic communications, information technology or other means between a healthcare provider and a member who are not in the same physical location. Telemedicine may be used for diagnosis, treatment, follow-up and/or member education, and may include, but is not limited to:
- Electronic transmission of medical records, photo images, personal health information or other data between a member and a healthcare provider;
- Interactions between a member and healthcare provider via audio, video and/or data communications; and
- Use of output data from medical devices, sound and video files.
The electronic systems used in the GoalsRx Service will incorporate network and software security protocols to protect the privacy and security of health information and imaging data, and will include measures to safeguard the data to ensure its integrity against intentional or unintentional corruption.
Prior to receiving and/or taking any supplements, treatments, vitamins, or medications in connection with GoalsRx, GoalsRx service members must become familiar with the GoalsRx Internet-based platform so as to become familiar with how to navigate the Program. In particular, make sure you understand any and all risks associated with taking any supplements, treatments, vitamins, or medications.
If you have any non-urgent questions or concerns, please send us a message at firstname.lastname@example.org
DO NOT USE GOALSRX IN AN EMERGENCY.
If you are or may be experiencing an emergency, dial 911 or go to an emergency department.
By signing and initialing this Consent to Telehealth, you acknowledge your understanding and agreement to the following:
Receipt and Understanding
- I have read this special Consent to Telehealth carefully, and understand the risks and benefits of the use of telemedicine in the medical care and treatment provided to me through GoalsRx’s platform by “Providers”.
- I agree to submit a color photograph of Personal Identification Information that can confirm my identity. I understand that it is a crime, and in many states a felony, to willfully, fraudulently, or inappropriately present myself as another person, impersonate another, or present the Personal Identification Information of another person with or without the other’s consent. I understand that using or attempting to use the Personal Identification Information of another for purposes of satisfying GoalsRx’s requirements will automatically result in the discharge of the individual as a patient and/or user of GoalsRx, and will be reported to the relevant authorities.
- I have become familiar with how to use the GoalsRx platform, and I understand how the GoalsRx platform differs from visiting a traditional medical care provider in person.
- I give my informed consent to the use of telemedicine by providers affiliated with GoalsRx.
- I understand that the delivery of healthcare services via telemedicine is an evolving field and that the use of telemedicine in my medical care and treatment may include uses of technology not specifically described in this consent.
- I understand my Providers will not necessarily be in the same physical location as I am at the time of service.
- I understand that I may not always be communicating with a Provider in real time.
- I understand that if I have any questions regarding my care that are not urgent, I can email email@example.com. I understand that this email address is only for non-urgent messages, and may not be reviewed or responded to immediately.
- I understand that I should review all health warnings and guidance for a treatment prior to taking it, participating in it, consuming it, or starting it.
- I understand that if I have any underlying conditions and/or if I am being seen by any healthcare providers or treaters not affiliated with GoalsRx, I should discuss any new supplements, vitamins, or medications with my healthcare providers not affiliated with GoalsRx prior to starting treatment.
Not for Emergencies
- I understand and agree that I will never and should never use GoalsRx in an emergency.
- I understand that in an emergency, I must dial 911 or go to an emergency department.
Understanding Risks & Limitations
- I understand my Providers may be unable to conduct certain tests or assess vital signs in person due to the care being between a Provider and a patient who are not in the same physical location. I understand that in some cases, this may prevent the Provider(s) from providing a diagnosis, providing a treatment, or identifying the need for emergency medical care or treatment.
- I understand the information transmitted to my Provider(s) may not be sufficient to allow for appropriate medical decision making by the Provider(s).
- I understand my Provider may not able to provide medical treatment for my particular condition via telemedicine, and I may be required to seek alternative care.
- I understand there may be delays in medical evaluation and/or treatment due to the remote nature of treatment, the use of technology, and the lack of in-person interaction.
- I understand that given regulatory requirements in certain jurisdictions, my Provider(s) treatment options, especially pertaining to certain prescriptions, may be limited.
- I understand that the different treatments (including but not limited to any supplements, vitamins, or medications) that may or may not be administered through GoalsRx each have different risks of adverse events and different side effects.
- I understand that adverse events can be caused by a number of things, including but not limited to: other health conditions, allergic reactions, side effects, interactions between treatments, nutritional supplements, dietary choices, weight, and underlying and/or unknown medical conditions, etc.
Physician-Patient Relationship, Reliance on Self-Reporting, and Importance of Patient Information and Honesty
- I give my informed consent to the use of telehealth by Providers affiliated with GoalsRx.
- I understand my communications with GoalsRx Providers must be through GoalsRx, and I will not attempt to contact these Providers outside of GoalsRx.
- I understand that Providers may ask me to self-report certain health information like my medical history, vitals, height, weight, etc. I understand that I am required to be fully honest, transparent, forthcoming, and correctly relay the requested health information. I understand that if I am asked a question I do not know the answer to, I will not lie, guess, or estimate, and I will disclose to the Provider that I do not know the requested information.
- I understand if I am not fully honest, transparent, forthcoming, and correct in relaying my requested information, I may be at a greater risk of suffering an adverse event.
- I understand my Providers only have access to the non-GoalsRx medical records that I affirmatively provide to GoalsRx.
- I understand my Providers and GoalsRx have no way to independently verify the information I provide to them, and must rely upon my information being accurate, true, honest, and complete.
- I understand that while the use of telemedicine may provide potential benefits to me, as with any medical care service no such benefits or specific results can be guaranteed. My condition may not be cured or improved, and in some cases, may get worse.
- I understand that “Providers” may determine in his or her sole discretion that my condition is not suitable for treatment using telemedicine, and that I may need to seek medical care and treatment in-person or from an alternative source.
- I understand that requesting a treatment, making an initial payment, filling out initial forms, or undergoing intake does not in and of itself create a physician-patient relationship, or establish a duty of care.
- I understand that I must be responsive to ongoing requests for information from me, including but not limited to responding to ongoing assessments with complete answers.
- I understand that I must provide complete, honest, and forthcoming responses to any questions, assessments, or requests for information about my symptoms and side effects.
- I understand that if I am not responsive to requests for information, I will no longer be considered under the care of the treating Provider, and GoalsRx has reserved the right to terminate our relationship.
- I understand I may have treatments recommended to me, including but not limited to supplements, vitamins, or medications. I understand that any treatments may have adverse effects.
- I understand that supplements, vitamins, or medications I am recommended, provided, or treated with through GoalsRx will have potential risks, potential side effects, potential interactions, and potential risks of misuse and overdose explained to me. By continuing with the treatment, I accept these risks.
- I agree to only participate in treatments as prescribed or recommended by my Providers.
- I agree to attend all scheduled appointments.
- I understand any supplements, vitamins, medications, or other treatments, are for my personal use only. I understand that it is illegal, and can be reported to the authorities, if I give or sell any of my supplements, vitamins, medications, or other treatments to other people.
- I agree not to use any illegal substances, including but not limited to marijuana, cocaine, or any other “street drugs”. I agree not to use any medications that are not prescribed to me.
- I understand I am solely responsible for my own supplements, vitamins, and medications, and that any lost or stolen items will not be replaced.
- I understand that inappropriate use of supplements, vitamins, medications, or treatments may result in my discharge from GoalsRx.
Security Risks, Privacy, & Sharing Information
- I understand that as with any technology, security protocols or safeguards could fail, causing a breach of privacy.
- I understand that the same confidentiality and privacy protections that apply to my other health care services also apply to these telemedicine services.
- I understand that due to the electronic nature of GoalsRx, there may be a greater risk of privacy violations to health information compared to visiting a traditional medical provider’s office in person. I understand that GoalsRx cannot guarantee the privacy and confidentiality of my health information, but GoalsRx does implement a wide range of administrative, physical, and technical safeguards to protect my health information.
- I understand that I have access to all of my health and wellness information pertaining to the telemedicine services in accordance with applicable laws and regulations.
- I understand that I can withhold or withdraw this consent at any time by emailing GoalsRx with such instruction. Otherwise, this consent will be considered renewed upon each new telemedicine consultation with “Providers”.
- I agree and authorize my health care provider to share information regarding the telemedicine exam with other individuals for treatment, payment and health care operations purposes.
- I agree and authorize my health care provider to release information regarding the telemedicine exam to GoalsRx and its affiliates.
- I agree to this Consent to Telehealth, and acknowledge that using GoalsRx constitutes an ongoing agreement to this Consent to Telehealth.