Consent To Telehealth Services
Last revision: Oct 1, 2021
This Consent to Telehealth Services (“Consent to Telehealth”) should be read in conjunction with the Terms and Conditions of Use for the website of which it forms part (the “Terms”). In this Consent to Telehealth, the terms “you” and “yours” refer to the person using the telehealth service, or in the case of a use of the service by or on behalf of a minor, “you” and “your” refer to include (i) the parent or legal guardian who provides consent to the use of the telehealth services by such minor or uses the service on behalf of such minor, and (ii) the minor for whom consent is being provided or on whose behalf the service is being utilized. The purpose of this form is to obtain your consent to participate in Klarity’s telehealth services.
PLEASE READ THIS CONSENT TO TELEHEALTH SERVICES CAREFULLY BEFORE CLICKING THE “ACCEPTANCE” BOX AND USING TELEHEALTH SERVICES. BY CLICKING THE “I ACCEPT” BUTTON DISPLAYED TO UTILIZE TELEHEALTH SERVICES, YOU ARE CONSENTING TO THE PROVISION OF TELEHEALTH SERVICES AND CONFIRM YOU HAVE READ THE “CONSENT TO TELEHEALTH SERVICES.”
IF YOU DO NOT CONSENT TO TELEHEALTH SERVICES, DO NOT SELECT THE “I ACCEPT” BUTTON.
Telehealth involves the delivery of healthcare services using electronic communications, information technology or other means between a healthcare provider and a patient who is not in the same physical location. Telehealth 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 by Klarity 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.
You may discuss these risks and benefits with your Klarity provider and will be given an opportunity to ask questions about telehealth services.
1. Possible Benefits of Telehealth
- Can be easier and more efficient for you to access medical care and treatment.
- You can obtain medical care and treatment at times that are convenient for you.
- You can interact with providers without the necessity of an in-office appointment.
2. Possible Risks of Telehealth
- Information transmitted to your provider(s) may not be sufficient to allow for appropriate medical decision making by the provider(s).
- The inability of your provider(s) to conduct certain tests or assess vital signs in-person may in some cases prevent the provider(s) from providing a diagnosis or treatment or from identifying the need for emergency medical care or treatment for you.
- Your provider may not be able to provide medical treatment for your particular condition via telehealth and you may be required to seek alternative care.
- Delays in medical evaluation/treatment could occur due to failures of the technology and none of the foregoing can guarantee that their services will be provided without error or interruption at all times that you may wish to use those services.
- Security protocols or safeguards could fail to cause a breach of privacy. While we use robust security systems, no system can guard against risks of intentional intrusion or inadvertent disclosure of information. When using telehealth services, information may be transmitted over media that is beyond the control of Klarity and that may not be secure. For example, you may receive email, text, or telephone communications in connection with your use of telehealth services, all of which are inherently unsecured and subject to disclosure to or access by third parties.
- Given regulatory requirements in certain jurisdictions, your provider(s) treatment options, especially pertaining to certain prescriptions may be limited.
- On rare occasions, a practitioner that you have been working with may decide to stop offering their services through the Klarity technology platform. All practitioners operating on Klarity are autonomous, independent practitioners, and may decide to leave at any time. In the event a practitioner leaves, Klarity will typically attempt to contact the patients this practitioner was seeing and offer them a discounted transfer to another provider ($59 instead of the $149 initial session fee). It is in the sole discretion of each practitioner to decide a course of treatment and it is not possible to guarantee your treatment plan will remain the same with a new practitioner.
3. Will my telehealth visit be private?
- We will not record visits with your provider.
- If people are close to you, they may hear something you did not want them to know. You should be in a private place, so other people cannot hear you.
- Your provider will tell you if someone else from their office can hear or see you.
- We use telehealth technology that is designed to protect your privacy.
- If you use the Internet for telehealth, use a network that is private and secure.
- There is a very small chance that someone could use technology to hear or see your telehealth visit.
4. Your Rights
You may withhold or withdraw your consent to telehealth services at any time before and/or during your telehealth visit without affecting your right to future care or treatment, or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled.
By accepting this Consent to Telehealth, you acknowledge your understanding and agreement to the following:
- By using the telehealth services provided by Klarity, I agree to telehealth services. I understand that telehealth involves the delivery of health care services, including assessment, treatment, diagnosis, and education, using interactive audio, video and data communications.
- I have read this special Consent to Telehealth carefully, and understand the risks and benefits of the use of telehealth in the medical care and treatment provided to me through the Klarity platform by providers.
- I give my informed consent to the use of telehealth by providers affiliated with Klarity.
- I understand that the delivery of healthcare services via telehealth is an evolving field and that the use of telehealth in my medical care and treatment may include uses of technology not specifically described in this consent.
- I understand that while the use of telehealth 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 telehealth, and that I may need to seek medical care and treatment in-person or from an alternative source.
- I understand that the same confidentiality and privacy protections that apply to my other health care services also apply to these telehealth services.
- I understand that I have access to all of my health and wellness information pertaining to the telehealth services in accordance with applicable laws and regulations.
- I understand that I can withhold or withdraw this consent at any time by emailing Klarity with such instruction. Otherwise, this consent will be considered renewed upon each new telehealth consultation with providers.
- I agree and authorize my health care provider to share information regarding the telehealth 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 telehealth exam to Klarity and its affiliates.
INFORMED CONSENT FOR CONTROLLED MEDICATION
This Informed Consent for Controlled Medication (“Informed Consent”) is incorporated into the Klarity Terms and Conditions of Use the(“Terms”). In this Informed Consent, the terms “you” and “yours” refer to the person using the service, or in the case of a use of the service by or on behalf of a minor, “you” and “yours” refer to and include (i) the parent or legal guardian who provides consent to the Informed Consent for Controlled Medication by such minor or uses the service on behalf of such minor, and (ii) the minor for whom consent is being provided or on whose behalf the service is being utilized.
If your physician has indicated that a controlled medication may assist in your symptomatic relief, please read this Informed Consent and agreement thoroughly and ask any questions you may have. If you are in agreement and fully understand the benefits and risks of the medications, sign and date below.
- I understand that controlled medicine can be dangerous and habit forming.
- I understand that these medicines must be taken only as prescribed by my health care provider.
- I understand that I have the right to discuss the risks and benefits of all procedures and courses of treatment proposed by my health care provider(s), together with any available alternatives.
- Klarity will provide care consistent with the prevailing standards of medical practice but makes no assurances or guarantees as to the results of treatment,
- Before prescribing any controlled substance to me, my provider may review information from the Prescription Drug Monitoring Program in my state of residence regarding my prior receipt of controlled substances.
- I understand that the medication I am being prescribed may cause addiction, but my physician feels it is necessary for the treatment of my condition. My physician has explained to me the potential risks, the potential short and long-term side effects; the risk of drug interactions and over-sedation; the risk of misuse and overdose. I accept these risks.
- I agree to take this medication only as prescribed by my physician.
- I agree to attend all scheduled appointments with my health care provider.
- I understand that refills will not be given early.
- I will not obtain controlled substances from any other providers unless authorized by my primary prescriber, because it may be considered illegal to obtain controlled substances from multiple providers.
- I understand that these medications are for my personal use only.
- I understand that it is illegal, and can be reported to the police, to give or sell my medication to others.
- I agree to not use any illegal substances, including but not limited to marijuana, cocaine, or any other “street drugs”.
- I understand that it is illegal for me to use medications that are not prescribed to me.
- I understand that I am responsible for my own medication. Lost or stolen medication will not be replaced.
- I give up the right to privacy protections with regard to my prescription for controlled substances. The physician or his staff may talk with other physicians, pharmacists or family members to confirm appropriate medication use.
- I understand that I may obtain my controlled substances from only one pharmacy, and I agree to update my physician’s office of any changes in the pharmacy I use.
- I understand these medications may interfere with my ability to drive and/or operate heavy machinery.
- I have reviewed this Informed Consent for Controlled Substances. I understand it and continue to agree to honor the agreement. I understand that failure to do so may result in my discharge from this medical practice.
By clicking the acceptance box, I understand and agree that I am signing this Informed Consent electronically and that (a) I have read this Informed Consent carefully, (b) I understand the risks and benefits of the services Klarity provides and the use of telehealth in the medical care and treatment provided to me by Klarity providers, including the prescribing of controlled substances, and (c) I have the legal capacity and authority to provide this consent for myself and/or the minor for which I am consenting under applicable federal and state laws, including laws relating to the age of majority and/or parental/guardian consent.