HMMG Telehealth Consent

The telehealth services should not be utilized in a medical emergency. If this is a medical emergency, dial 911 or visit an emergency room. If you are experiencing emotional distress or a mental health crisis, please contact the National Suicide Prevention Hotline: text 988 or text “Home” to 741-741, to obtain immediate assistance

Before you give your informed consent to request and receive healthcare services remotely, on behalf of yourself or your minor child, please be aware of the limitations and how obtaining telehealth services differs from in-person care. Some of the risks associated with receiving telehealth services are described in this Telehealth/Telemedical Outpatient Consent. There may be other risks to telehealth services that are not currently known.

Services

Telehealth/Telemedicine involves the use of information and electronic communication technologies to enable health care providers at different locations to interact with patients virtually to provide patient care services, including but not limited to, diagnosis, and treatment. The direct communication often requires the use of interactive computer, tablet or phone equipment with audio, text and video capabilities. The use of telehealth is voluntary.

Telehealth providers may include physicians, nurse practitioners, physician assistants, and other appropriately licensed professionals. Patients are provided with their telehealth provider’s name and credentials. Other staff and non- providers may also be present at the telehealth visit and have access to the telehealth/telemedicine visit to aid in delivery of medical care or for the purpose of improving the services. These persons (or, if applicable, technology) will adhere to applicable privacy and security policies. In addition, telehealth visits and communications, including data, chat text, audio, video, and/or digital photos may be recorded.

Due to the virtual nature of the telehealth services, they do not allow for an in-person physical examination by the treating provider and therefore use of this services is not intended in all cases to replace a full medical evaluation, or an in-person visit with a healthcare provider. The absence of an in-person physical examination may affect the provider’s ability to diagnose any potential condition, disease, or injury and may not reveal potentially serious medical conditions. In addition, providers may be limited by applicable law, regulations, medical policies, and standards in prescribing certain medications without first conducting an in-person physical examination.

Use of telehealth may involve asynchronous communications, such as completing forms and messaging your (or your minor child’s- if you are consenting on behalf of a minor child) care team, as well as direct virtual, synchronous, communications and the electronic transmission of medical information and other data such as:

Information about symptoms, diagnosis and medical history
Progress reports, assessments, or other intervention-related documents
Bio-physiological data transmitted electronically
Videos, pictures, text messages, audio and any digital form of data

The electronic nature of the telehealth services means that there is a greater risk to the privacy of the patients’ electronic health information relative to receiving in-person care. For information about the privacy and security practices as well as our information sharing practices, please read our Joint Notice of Privacy Practices. In addition, the information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical or healthcare decision making by the provider. In addition, technical failures could lead to delays in evaluation or to information lost due to such technical failures.

Hackensack Meridian Medical Group utilizes artificial intelligence based tools to support the telehealth visits and interactions, e.g., to create medical notes, update the medical record and provide the patient and the provider with information on potential diagnoses and treatment plans. These tools are an aid to the patient and the provider, but ultimately the provider will make a clinical decision using their own professional judgment. Information collected during the clinical encounter, including when using these artificial intelligence based tools, may be relied on by the provider and become part of the patient medical record. Such information is stored in compliance with HIPAA regulations and may be used for further improvements in the AI Model.

If you do not consent to this telehealth visit using AI technology, our staff can assist with scheduling an in-person visit.

Consent

By clicking on the “I Agree,” “Register,” “Continue,” or any similar button provided in connection with this document, you confirm that you have read and understand the information in this document, you understand the risks associated with the use of telehealth services, and, that you provide this informed consent (on behalf of yourself or your minor child- if you are consenting on behalf of a minor child) to the practices described in this document.

You agree, on behalf of yourself or your minor child- if you are consenting on behalf of a minor child, to receive consultation, diagnosis and treatment via telehealth services.

You represent that you are at least 18 years of age.

If you are consenting on behalf of a minor child, you represent that you are the parent or legal guardian of the minor child seeking telehealth services, and that you have the right to provide consent on behalf of your minor child under applicable law. In addition, You understand and agree that consent on behalf of your minor child remains valid and in effect until you revoke it or until the minor child has reached age of majority under applicable law. You agree that if you are providing this consent on behalf of your minor child, you will notify us immediately if you are no longer legally consent to treatment on behalf of your minor child.

You understand and agree , on behalf of yourself or your child- if you are consenting on behalf of a minor child, that the health information you (and your minor child, if applicable) provide at the time of the telehealth visit may be the only source of health information used by the health care providers during the course of the evaluation and treatment at the time of the telehealth visit, and that such providers may not have access to your (or your minor child, as applicable) full medical record or information.

You understand and agree, on behalf of yourself or your minor child- if you are consenting on behalf of a minor child, that the information that you (and your minor child, if applicable) give the health care providers or upload during or in preparation for your (or your minor child, as applicable) telehealth visit, either through the AI based tools or that you (and your minor child, applicable) provide directly to the telehealth provider and care team, will be true, accurate, and complete, and may be relied on by the provider to use for diagnosis, treatment, follow-up and/or education. You understand that the information provided or uploaded, on behalf of yourself or your minor child, as applicable, through any AI based or other technology tools in connection with the telehealth visit in addition to any other information you (and your child, if applicable) provide to the care team may become part of your, or your child’s- if you are consenting on behalf of a minor child, medical record.

You understand and agree, on behalf of yourself (or your minor child- if you are consenting on behalf of a minor child) that the providers can share individual patient medical information for diagnosis, therapy, follow-up, and/or education purposes. You consent (on behalf of yourself or your minor child- if you are consenting on behalf of a minor child) to forwarding your (or you minor child, as applicable) information to a third party as needed to receive telehealth services, subject to applicable laws that protect the confidentiality of medical information.

You understand and acknowledge, on behalf of yourself or your minor child- if you consenting on behalf of a minor child, that while telehealth services can be used to provide improved access to medical care, they have certain limitations and, as with any medical care, potential risks exist and no results can be guaranteed or assured. These risks include, but are not limited to, technical problems with the information transmission and equipment failures that could result in lost information, inappropriate disclosures or delays in treatment. You also understand and agree, on behalf of yourself or your minor child- if you are consenting on behalf of a minor child, that diagnosis and treatment via a telehealth visit has its limitations, including not having an in-person physical examination from the telehealth provider and the limitations related thereto as described in this document.

You understand and acknowledge , on behalf of yourself or your minor child, if you are consenting on behalf of a minor child, that additional diagnostic exams, blood tests, or other procedures may be needed to evaluate or treat your (or your minor child, as applicable) medical condition.

You understand and acknowledge, on behalf of yourself or your minor child- if you are consenting on behalf of a minor child ,that the use of telemedicine is voluntary, and you have a right to withhold or withdraw the consent to the use of telemedicine in the course of your (or your minor child, as applicable( care at any time, without affecting right to future treatment and without risking the loss or withdrawal of any benefits to which you (or your minor child, as applicable) would otherwise be entitled. You understand and acknowledge, on behalf of yourself or your minor child-if you are consenting on behalf of a minor child, that receiving treatment through telehealth does not mean that you (or your child as applicable) cannot receive in-person health care services, either today or in the future. You understand and acknowledge , on behalf of yourself or your minor child- if you are consenting on behalf of a minor child, that limitations to the types of treatment that can be appropriately provided via telehealth exist, and that the telehealth provider will determine whether or not it is appropriate for you (or your child, as applicable) to receive treatment via a telehealth virtual visit.

You understand and agree, on behalf of yourself or your minor child- if you are consenting on behalf of a minor child, that when receiving telehealth services, you may be required to upload a copy of your or your child identification card (e.g., drivers’ license, state ID) and a self-photograph (“selfie”) or verification purposes, location purposes, and evaluation and treatment purposes. You also understand and agree that as part of the verification process, Hackensack Meridian Health’s vendor may utilize biometric measurements and analysis to compare and verify the image obtained from the ID and selfie. Such biometrics measurements will be deleted once they are no longer required.

You understand and agree that participation in a telehealth visit cannot be used for legal purposes by you and your minor child- if you are consenting on behalf of a minor child; and that your and your minor child attorney, if applicable, cannot attend the virtual telehealth visits. You further understand and agree, on behalf of yourself or your minor child- if you are consenting on behalf of a minor child, that the telehealth visit may be terminated should you and/or your minor child, as applicable, fail to adhere to this.

You understand and agree that audio or video recording of the telehealth visit by you and/or your child is strictly prohibited, and Hackensack Meridian Health does not consent to any such recording.

If you (or your minor child- if you are consenting on behalf of your minor child) are not a member of the Hackensack Meridian Health employer-sponsored health plans, you agree and represent, on behalf of yourself or your minor child- as applicable, that due to state medical licensure laws you will use the telehealth services, on behalf of yourself or your minor child, only when you (and your child- if you are consenting on behalf of a minor child) are physically located in New Jersey and that you will notify the telehealth provider immediately if you or your child, as applicable, are no longer located in New Jersey at the time of telehealth visit. If you (or your minor child- if you are consenting on behalf of your minor child) are a member of Hackensack Meridian Health employer-sponsored health plans, you agree and represent, on behalf of yourself or your minor child, as applicable. that due to state medical licensure laws you will use the telehealth services, on behalf of yourself or your minor child, only when you and your child-if you are consenting on behalf of a minor child, are physically located in the state you reported as the state that you will be located at the time of the telehealth visit and that you will notify the telehealth provider immediately if you or your child, if applicable, are no longer located in such at the time of telehealth visit.

You acknowledge, on behalf of yourself or your minor child- if you are consenting on behalf of a minor child, that during the telehealth visit, the patient’s physical environment may impact the privacy and security of the information discussed. You understand and acknowledge, on behalf of yourself or your minor child- if you are consenting on behalf of a minor child, that you and your child, as applicable, will be having a conversation using technology, and that it is important to find a quiet spot where no one can listen in so that you and your minor child, if applicable, may speak freely with the provider.

You understand and agree, on behalf of yourself or your minor child- if you are consenting on behalf of a minor child, that the AI based tools that are available in connection with the telehealth service may provide you with some information, however, you understand and acknowledge that these tools do not provide clinical advice and do substitute such advice. You agree that you will not disregard professional clinical advice or delay in seeking care for yourself or your minor child- if you are consenting on behalf of a minor child, because of any information provided by these tools and not by the provider.

You understand and agree, on behalf of yourself or your minor child- if you are consenting on behalf of a minor child, that there is no guarantee that any prescription will be written for you or your minor child through the telehealth services. All decisions whether to prescribe are based on the Provider’s independent medical judgment. Providers do not prescribe U.S. Drug Enforcement Administration controlled substances, such as those containing opioids.

To the extent a prescription is written through the telehealth services, you understand that you can choose to fill a prescription at a pharmacy of your choice.

You understand and agree, on behalf of yourself or your minor child- if you are consenting on behalf of a minor child, to receive electronic communications from the telehealth providers, Hackensack Meridian Medical Group and their affiliates, agents, representatives, suppliers and service providers, including but not limited to email communications, push notification, calls (including automated calls) and SMS text messages (including automated messages) about services provided and you and your minor child care. You agree that you are providing this information for the purpose of communicating with you about appointment information, test results, other clinical information as well as account information or other information related to telehealth services.

You also understand that your consent, on behalf of yourself or your minor child- if you are consenting on behalf of a minor child, to receive communications relating to the telehealth services in electronic form may also include, but shall not be not limited to: (i) any initial disclosure statement or agreement governing the access to or use of the telehealth services; (ii) any disclosure statement or agreement required by federal, state, provincial, territorial, or local law, including any disclosure or agreement pursuant to the federal Health Insurance Portability and Accountability Act; (iii) any notice, alert, or letter regarding the access to or use of the telehealth services; and (iv) any other disclosures, notices, or communications in connection with the telehealth services.

For additional information regarding account information and electronic communications please refer to the Terms of Use.

You acknowledge , on behalf of yourself or your minor child- if you are consenting on behalf of a minor child, that by clicking on the “I Agree,” “Register,” “Continue,” checking a related box to signify your acceptance, or any similar button provided in connection with this Telehealth/Telemedicine Outpatient Consent, you have carefully read this document, understand the risks associated with the use of telehealth services, and give , on behalf of yourself or your minor child- if you are consenting on behalf of a minor child, your informed consent to all the consents and terms of this Telehealth/Telemedicine Outpatient Consent as well as indicating your intent to sign up for electronic communications, and that such action shall constitute your signature.

Additional State Specific Consents and Notices – Applicable to members of the Hackensack Meridian Health employer-sponsored health plans accessing the telehealth services on behalf of themselves or their minor child- if consenting on behalf of such minor child, within state specified below

California

Open Payments Notice
For informational purposes only, a link to the federal Centers for Medicare and Medicaid Services (CMS) Open Payments web page is provided below. The federal Physician Payments Sunshine Act requires that detailed information about payment and other payments of value worth over ten dollars ($10) from manufacturers of drugs, medical devices, and biologics to physicians and teaching hospitals be made available to the public. The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. It can be found at https://openpaymentsdata.cms.gov.

Notice to Patients
Medical doctors are licensed and regulated by the Medical Board of California. For more information, please visit: http://www.mbc.ca.gov or contact tel:8006332322.
Nurse practitioners are licensed and regulated by the Board of Registered Nursing. For more information, please visit: http://www.rn.ca.gov or contact tel:9163223350

Connecticut, Ohio, Utah, and Texas- If you would like your medical records to be forwarded to another provider, please include the name and contact information in a message to your Provider.

Florida – Each provider is a physician licensed by the Florida Board of Medicine or the Florida Board of Osteopathic Medicine. Each Provider’s hours are variable.

Georgia

NOTICE CONCERNING COMPLAINTS
You have the right to file a grievance with the Georgia Composite Medical Board, concerning the physician, staff, office, and treatment received. You should send a written complaint to the board. You should be able to provide the physician or practice name, the address, and the specific nature of the complaint. Complaints or grievances may be reported to the Board at the following address or telephone number:

Georgia Composite Medical Board
Attn: Complaints Unit
2 Martin Luther King Jr. Drive SE
11th floor, East Tower
Atlanta, GA 30334
(404) 656-3913
www.medicalboard.georgia.gov

Iowa– You understand and agree that if you want to register a formal complaint about a Provider, you can visit the medical board’s website (https://medicalboard.iowa.gov/consumers/filing-complaint).

Idaho– You understand and agree that if you want to register a formal complaint about a Provider, You can visit the medical board’s website (https://elitepublic.bom.idaho.gov/IBOMPortal/AgencyAdditional.aspx?Agency=425&AgencyLinkID=650).

Indiana– You understand and agree that if you want to register a formal complaint about a Provider, you can visit the medical board’s website or the Consumer Protection Division Office of the Indiana Attorney General (https://www.in.gov/attorneygeneral/consumer-protection-division/consumer-complaint/).

Kansas – Notice to Patients – Required Signage for K.A.R. 100-22-6 Prepared by the State Board of Healing Arts April 5, 2007: It is unlawful for any person who is not licensed under the Kansas Healing Arts Act to open or maintain an office for the practice of the healing arts in Kansas. Services are provided by a person who is licensed to practice the healing arts in Kansas. Questions and concerns regarding this professional practice may be directed to: KANSAS STATE BOARD OF HEALING ARTS 800 SW Jackson, Lower Level – Suite A, Topeka, Kansas 66612 — PHONE: (785) 296-7413 TOLL FREE: 1(888) 886-7205 FAX: (785) 368-7102: www.ksbha.org.

Kentucky– You understand and agree that if you want to register a formal complaint about a provider, you can visit the medical board’s website (https://kbml.ky.gov/grievances/Pages/default.aspx).

Louisiana – In addition to any informed consent and right to privacy and confidentiality pursuant to state and federal law or regulations, you shall be informed of the relationship between the Provider, you and the respective role of any other health care provider with respect to the management of your care and treatment; and you may decline to receive Services and may withdraw from such care at any time.

Maine- You understand and agree that if you want to register a formal complaint about a Provider, you can visit the medical board’s website (https://www.maine.gov/md/complaint/file-complaint).

Oklahoma– You understand and agree that if you want to register a formal complaint about a provider, you should visit the medical board’s website, here (https://www.okmedicalboard.org/complaint); or, the Oklahoma Board of Osteopathic Examiners’ website (https://osboe.us.thentiacloud.net/webs/osboe/register/#/complaint-form).
Oregon– You understand and agree that if you want to register a formal complaint about a Provider, You can visit the medical board’s website (https://www.oregon.gov/omb/investigations/Pages/How-to-File-a-Complaint.aspx)

Rhode Island– You understand and agree that if you want to register a formal complaint about a Provider, You can visit the medical board’s website (https://ohic.ri.gov/consumer-protection).
Texas– NOTICE CONCERNING COMPLAINTS – Complaints about physicians, as well as other licensees and registrants of the Texas Medical Board, including physician assistants, may be reported for investigation at the following address: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018, Assistance in filing a complaint is available by calling the following telephone number: 1-800-201-9353, For more information, please visit website at www.tmb.state.tx.us.
AVISO SOBRE LAS QUEJAS – Las quejas sobre médicos, asi como sobre otros profesionales acreditados e inscritos del Consejo Médico de Tejas, incluyendo asistentes de médicos, practicantes de acupuntura y asistentes de cirugia, se pueden presentar en la siguiente dirección para ser investigadas: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018, Si necesita ayuda para presentar una queja, llame al: 1-800-201-9353, Para obtener más información, visite sitio web en www.tmb.state.tx.us.

Vermont: You understand and agree that if you want to register a formal complaint about a Provider, You can visit the medical board’s website (https://www.healthvermont.gov/systems/medical-practice-board); Or, the Vermont Office of Professional Regulation’s website (https://sos.vermont.gov/opr/complaints-conduct-discipline/).

Wisconsin– You have the right to request and receive information within a reasonable period of time after your request the fees charged for a health care service, diagnostic test, or procedure provided by Hackensack Meridian Health.