Informed Consent for Telehealth Services

Telehealth involves the use of electronic communications to enable healthcare providers at different locations to share individual client medical information for the purpose of improving client care. Telehealth services offered through Aspire Medical Group PC (herein referred to as "the Practice") by the Practice’s clinicians may include consultations by video or by phone, chart review, remote prescribing, appointment scheduling, health information sharing, and non-clinical services, such as client education.

The information you provide may be used for diagnosis, therapy, follow-up and/or client education, and may be provided through any combination of the following:

(1) health records and test results;

(2) images and asynchronous communications;

(3) live two-way audio and video;

(4) interactive audio with asynchronous communications;

(5) output data from medical devices and sound and video files.

The electronic communication systems we use will incorporate network and software security protocols to protect the confidentiality of client identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption. It is possible, though unlikely, that your information or data may be lost due to technical failures. You agree to hold the Practice harmless against any information or data that is lost due to technical failures.

During the telehealth consultation: details of your medical history, examinations, and tests will be discussed using interactive video and/or audio, a virtual examination may take place, and other medical professionals such as Medical Assistants and/or students may be present during the visit to assist the provider. You will be informed of the presence of other medical professionals prior to the consultation. In an emergency, it is the responsibility of the Telehealth provider to direct the patient to emergency medical services, such as an emergency room. The Telehealth provider may also discuss and collaborate with the patient's other providers (if applicable). The Telehealth provider's responsibility will end upon the termination of the Telehealth connection.

The Practice’s clinicians are an addition to, and not a replacement for, your primary care physician and/or primary mental health provider. Responsibility for your overall medical care should remain with your local primary care doctor, if you have one, and we strongly encourage you to locate one if you do not.

Your clinician may use software including artificial intelligence tools for recording and/or transcribing your consultation for the purposes of creating visit notes and supporting quality assurance. If you do not consent to recording your consultation for these purposes, you may request that your clinician or guide disable it.

Confidentiality: Your privacy is a priority and all treatment records will be kept confidential. They will be maintained with the same precautions as ordinary medical records. If you would like to provide other individuals or organizations with access to your records, contact us for a release form. You also understand that your personal information may be used and shared according to the electronic systems used.

These systems will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and ensure its integrity against intentional or unintentional corruption. Reasonable and appropriate efforts have been made to eliminate any confidentiality risks associated with the Telehealth consultation.

Your Rights: You may withhold or withdraw consent to telemedicine/telehealth services at any time 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. If you decline telemedicine/telehealth, you will have to come to the clinic to see a provider.

Billing and Payment: It is the patient's responsibility to contact their insurance company to verify whether their plan covers telehealth services. If your insurance does not cover the telehealth visit, you will be considered self-pay, and our published self-pay fee will apply. Non-covered telehealth visits will be the patient's responsibility. 

• Improved access to care
• More efficient care evaluation and management

• Delays in evaluation and treatment could occur due to deficiencies or failures of the equipment and technologies
• In rare events, a provider may determine that the transmitted information is of inadequate quality, thus necessitating a rescheduled telehealth consult or a visit with your local primary care doctor
• In very rare events, security protocols could fail, causing a breach of privacy of personal medical information
• In rare events, information transmitted may not be sufficient (e.g., poor resolution of images) to allow for appropriate medical decision-making by the provider. Lack of access to complete medical records may result in inaccurate and/or incomplete medical advice.
• The session may be discontinued by the patient and/or the provider if the video conference connection is not adequate for the situation.
• The FDA has advised that at-home administration of compounded ketamine may present additional risks because a health care provider is not available onsite to monitor for adverse outcomes resulting from sedation and dissociation.

• I have read and understand and fully understand the information provided by the healthcare provider and/or practice regarding the use of telehealth in the delivery of care, including the associated risks. 
• I have had ample opportunity to ask questions and seek clarification, and I am satisfied with the responses provided. 
• I consent to the conditions outlined above and agree to follow any additional instructions from the healthcare provider and/or practice regarding the use of telehealth.
• I understand that I may withdraw my consent for telemedicine/telehealth services at any time by providing written notice to Aspire Medical Group prior to my next scheduled appointment.
• By signing this form, I voluntarily consent to the use of telehealth in the delivery of care and the use of electronic records and signatures.
• I agree to electronic records and signatures.
• I confirm that I have the full legal authority to be bound by this agreement and accept the risks, conditions, and terms outlined in this document.