Patient Consent For Telehealth Services

Note: This consent form provides important information about how Upstate Concierge Medicine of Colorado, PLLC, DBA, United Concierge Medicine and its subsidiaries and affiliates (collectively, the “Company”), and their employed or contracted physicians, physician assistants, nurse practitioners, or other licensed health care professionals (the “Professionals”), will provide professional medical services to you, via Telehealth*. Please review this form carefully.

*Telehealth, as used in this consent form, means the use, in accordance with applicable state law, of electronic information and communication technologies to facilitate the assessment, diagnosis, consultation, treatment, education, care management and self-management of a patient’s health, while the patient the health care provider are at different locations. Subject to applicable state law, Telehealth includes synchronous interactions and asynchronous store-and-forward transfers.

I hereby request, consent, and authorize the Company and Professionals to utilize the Company’s proprietary systems, methods and protocols, to assess, diagnose, consult, treat and educate myself or those I am authorized to represent, via Telehealth (the “Services”). By signing this consent form, I am acknowledging that I have been advised of and understand the following:

THE SERVICES

I understand that the Services may not be deemed a covered service under a health insurance plan or program that I am enrolled under at the time the Service is provided.
I understand that I am responsible for any costs of any treatment, procedure, service, medicine, drug or product that may be prescribed or recommended by the Company or a Professional and that is provided by other individuals or entities. I understand that I and those I am authorized to represent may receive one or more separate bills for such prescription medicines and other treatments, procedures, services or products, and I am wholly responsible for payment of such costs. I further understand that the independent entities and individuals will have their own billing and collection practices.
I understand that once a Professional decides which medicines or other treatment, procedure, service or product to prescribe or recommend, if any, it is my responsibility to read and understand the risks, potential side-effects and the adverse drug interactions of the medications and any other medications I may be taking concurrently, or consult with my primary care or specialty physician and pharmacist regarding the same, and ultimately to determine if I accept the risks.
I understand that it is my right to contact my primary care or specialty physician before starting or acting on any prescription, diagnosis, recommendation or education provided by the Company or a Professional, to confirm that my primary care or specialty physician approves of the regimen.
I understand that all health care treatments carry a risk of potential adverse side effects. If adverse effects are noted, I understand that it is my responsibility to stop any prescription medicine or other treatment, procedure, service or product prescribed or recommended by the Company or Professional, and to report any adverse side-effects to the Company, the Professional, my primary care or specialty physician, or go to the nearest Emergency Room if I have any reason to suspect that I have a medical emergency.
I acknowledge that all health care treatment carries risks, and no particular outcome is guaranteed. I understand that the Professionals will exercise reasonable medical judgment in delivering the Services, but the condition with which I or the person I am authorized to represent present may worsen after the Service is provided. I further understand the Professionals may, in some cases, be limited in the Services they can provide, due to the nature of treatment via Telehealth or restrictions on Telehealth treatment under applicable state law. I acknowledge and accept these risks. I agree that I will not be entitled to a refund or recompense from Company or the Professionals for any reason stemming from such risks.
I ACKNOWLEDGE THAT IT IS MY RESPONSIBILITY TO INFORM THE COMPANY OR THE PROFESSIONAL OF ANY CONDITION THAT WOULD LIMIT MY ABILITY TO RECEIVE THE SERVICES PROVIDED OR THAT WOULD BE RELEVANT TO THE SERVICES THEMSELVES. IN PARTICULAR, I UNDERSTAND THAT IF I AM PLANNING TO BECOME PREGNANT, AM CURRENTLY PREGNANT, BECOME PREGNANT, OR AM BREASTFEEDING, I WILL: (A) ADVISE COMPANY AND THE PROFESSIONALS OF THIS FACT; AND (B) ASK MY OB/GYN OR PEDIATRICIAN IF THE TREATMENTS RECOMMENDED BY THE PROFESSIONALS ARE ACCEPTABLE DURING THIS PERIOD OF TIME.
I understand that it is my sole responsibility to communicate and provide the Company and the Professionals with detailed, accurate and complete information concerning medical, medication and other history, allergies to medications and procedures, physical, mental and other relevant symptoms and conditions, and any other information or records requested or pertinent to the diagnosis and treatment of myself or those I am authorized to represent. I understand that, as with any service, to the extent that information is not provided or, if provided, is not detailed, accurate and complete, the Services provided by the Company and the Professionals may be materially affected. I assume all risks, and assume full responsibility and waive all claims against the Company and the Professionals for personal injury, death or damages of any kind, as a result of my failure to provide accurate and complete information.

TELEHEALTH

The Company and Professionals will provide Services to me only via Telehealth. I understand that I have the option to withhold or withdraw my consent to receive the Services via Telehealth at any time, but that doing so will cause the Company and the Professionals to discontinue providing subsequent Services. In such case, I understand that I will need to seek treatment and care elsewhere.
I acknowledge and accept that the physical examination portion of the Services, if any, will be performed via Telehealth, in reliance upon either video, images, telephone consultation, questionnaire, medical records or otherwise. While the examination will approximate, as much as possible, an appropriate in-person examination, there are inherent risks and limitations in using Telehealth to perform it, including that the Professional may not be able to accurately diagnose or effectively treat any condition I have, which risks and limitations are not present in an in-person setting. I understand and accept these risks.
I understand the Company and Professionals will strive to treat or cure the symptoms or condition with which I or the person I am authorized to represent present, but in some cases state law may limit the ability of a Professional to prescribe certain medications via Telehealth, without performing a prior in-person examination. I also understand that, due to a specific medical condition or technical problems, a face-to-face consultation may be necessary after the Services are provided. I acknowledge that, in these cases, a Professional may recommend that I seek in-person treatment and it is my responsibility to arrange for such in-person treatment.
I understand that federal and state laws concerning the confidentiality of health information, including patient access and amendments to medical records, apply to Services delivered and information acquired via Telehealth, including mental health Services. I acknowledge that in rare circumstances, security safeguards and protocols could fail, causing a breach of patient privacy.
I understand that technical difficulties, such as service interruptions, may occur during a Telehealth encounter. If I am unable to reconnect with the Professional within ten (10) minutes of an interruption, I may be required to reschedule the Telehealth encounter.

MENTAL HEALTH SERVICES

I understand that if I am having suicidal or homicidal thoughts, actively experiencing psychotic symptoms, or experiencing a mental health crisis, the Company or a Professional may determine that remote treatment is not appropriate and recommend a higher level of care.

I hereby represent that I have read and fully understood and agreed to: (i) the Company Notice of Privacy Practices; (ii) the Company Website Privacy Policy; and (iii) the Company Website Terms of Use.

By electronically signing this form, I acknowledge and agree to all of the above. I am further agreeing to conduct transactions electronically, and intend for my electronic signature to be binding on myself and, if applicable, the person I am authorized to represent. I understand that I will receive a digital copy of this Agreement concurrently upon execution to print and/or retain.

By electronically signing this form, I assert that:

I am of legal age to request the services and consent hereto, or I am the parent, legal guardian, or person acting in loco parentis of the individual who will receive the services.
I have read, or had read to me, and understand the above information.
The decision to consent to, or to refuse, the services is voluntary and entirely mine.
I have had the opportunity to discuss the services, including the purposes, limitations, and possible risks, with a health care provider.
I have all the information desired, and all my questions have been satisfactorily answered.

Revised/Reviewed: August 22, 2022