1. I hereby authorize Applied InGENuity Diagnostics to use secured telephone services for telecommunication for evaluating, interpreting and diagnosing my medical test results.
2. I understand that my current insurance may not cover the additional fees of the telehealth practices and I may be responsible for any fee that my insurance company does not cover.
3. I agree that my medical records on telehealth can be kept for further evaluation, analysis and documentation, and in all of these, my information will be kept private.
4. By your acceptance below, you hereby request, consent, and authorize medical care given to you or your minor child via telehealth by Applied InGENuity Diagnostics, LLC and its affiliated healthcare providers as set forth below, which may include orders for diagnostic procedures, medications, or treatment the physician(s) or other practitioners involved in your/your child's care consider medically necessary. You understand you have the right to consent or refuse to consent to any proposed procedure or therapeutic course. You acknowledge that no guarantees have been made to you regarding the outcome of any medical, surgical, diagnostic or therapeutic treatment. You understand that some physicians and other practitioners provide their services as independent contractors to the Practice, are not employees or agents of the Practice, and that the Practice is not liable for their acts or omissions. You agree to receive telehealth services as described in further detail below, which means the delivery of health care services, including assessment, treatment, diagnosis, and education, using interactive or asynchronous audio, video, and data communications. You understand that the Practice and its physicians or other practitioners are in a different location than you and that you must accurately report your location during registration.