BIOVERSE, Inc.
Telehealth Informed Consent
This “Telehealth Informed Consent” informs the patient (“patient,” “you,” or “your”) concerning the treatment methods, risks, and limitations of using a telehealth platform, and should be read in conjunction with the Terms of Use (available at www.gobioberse.com) (“Terms”) for the website (“Site”).
Telehealth
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.
Services Provided
Telehealth services offered by Outlast Health, P.A., a Florida corporation and affiliated medical groups (collectively, “Group”), and the Group’s engaged providers (our “Providers” or your “Provider”) may include a patient consultation, diagnosis, treatment recommendation, prescription, and/or a referral to in-person care, as determined clinically appropriate (the “Services”). Your Provider will be licensed in the state where you are located at the time of your consultation, or otherwise meet a professional licensure exception under applicable state law, and will establish a provider-patient relationship in accordance with the laws and rules in the applicable state.
BIOVERSE Inc. does not provide any medical Services; it performs administrative, payment, and other supportive activities for Group and our Providers.
Electronic Transmissions
The types of electronic transmissions that may occur using the telehealth platform include, but are not limited to:
• Appointment scheduling;
• Completion of medical intake forms;
• Exchange and review of patient medical intake forms, patient health records, images, diagnostic and/or lab test results via asynchronous communications;
• Two-way interactive audio in combination with store-and-forward communications between you and your Provider;
• Two-way interactive audio-video interaction between you and your Provider;
• Review and treatment recommendations by your Provider based upon output data from medical devices and sound and video files;
• Delivery of a consultation report;
• Prescription refill reminders; and/or
• Other electronic transmissions for the purpose of rendering clinical care to you.
Expected Benefits
• Improved access to care by enabling you to remain in your preferred location while your Provider consults with you.
• Convenient access to follow-up care. If you need to receive non-emergent follow-up care related to your treatment, please contact your Provider by sending a message through the patient portal of your Bioverse account.
• More efficient care evaluation and management. Bioverse strives to respond to all clinical questions within 48 hours, M-F (excluding holidays).
Service Limitations
• The primary difference between telehealth and direct in-person service delivery is the inability to have direct, physical contact with the patient. Accordingly, some clinical needs may not be appropriate for a telehealth visit and your Provider will make that determination.
• OUR PROVIDERS DO NOT ADDRESS MEDICAL EMERGENCIES. IF YOU BELIEVE YOU ARE EXPERIENCING A MEDICAL EMERGENCY, YOU SHOULD DIAL 9-1-1 AND/OR GO TO THE NEAREST EMERGENCY ROOM. PLEASE DO NOT ATTEMPT TO CONTACT GROUP OR BIOVERSE, INC. AFTER RECEIVING EMERGENCY HEALTHCARE TREATMENT, YOU SHOULD VISIT YOUR LOCAL PRIMARY CARE PROVIDER.
• Our Providers are an addition to, and not a replacement for, your local primary care provider. Responsibility for your overall medical care should remain with your local primary care provider, if you have one, and we strongly encourage you to locate one if you do not.
• Group does have any in-person clinic locations.
Security Measures
The electronic communication systems we use 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 to ensure its integrity against intentional or unintentional corruption. All the Services delivered to the patient through telehealth will be delivered over a secure connection that complies with the requirements of the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”).
Possible Risks
• Delays in evaluation and treatment could occur due to deficiencies or failures of the equipment and technologies, or provider availability.
• In the event of an inability to communicate as a result of a technological or equipment failure, please contact support@gobioverse.com if you cannot access your Patient Portal (“Portal”) or by phone at (747) 666-8167.
• The quality of transmitted data may affect the quality of services provided by your Provider. Changes in the environment and test conditions could be impossible to make during delivery of telehealth services.
• In rare events, your Provider may determine that the transmitted information is of inadequate quality, thus necessitating a rescheduled telehealth consult or an in-person meeting 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, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other clinical judgment errors.
Patient Acknowledgments
I further acknowledge and understand the following:
1. Prior to the telehealth visit, I have been [or will be] given an opportunity to select a provider as appropriate, including a review of the provider’s credentials, or I have elected to visit with the next available provider from Group, and have been given my Provider’s credentials.
2. If I am experiencing a medical emergency, I will be directed to dial 9-1-1 immediately and my Provider is not able to connect me directly to any local emergency services.
3. I may elect to seek services from a medical group with in-person clinics as an alternative to receiving telehealth services.
4. I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time without affecting my right to future care or treatment.
5. Federal and state law requires health care providers to protect the privacy and the security of health information. I am entitled to all confidentiality protections under applicable federal and state laws. I understand all medical reports resulting from the telehealth visit are part of my medical record.
6. Group will take steps to make sure that my health information is not seen by anyone who should not see it. Telehealth may involve electronic communication of my personal health information to other health practitioners who may be located in other areas, including out of state.
7. Dissemination of any patient identifiable images or information from the telehealth visit to researchers or other educational entities will not occur without my affirmative consent.
8. There is a risk of technical failures during the telehealth visit beyond the control of Group. I agree to hold harmless Group and my Provider for delays in evaluation or for information lost due to such technical failures.
9. In choosing to participate in a telehealth visit, I understand that some parts of the Services involving tests (e.g., labs or bloodwork) may be conducted at another location such as a testing facility, at the direction of my Provider.
10. Persons may be present during the telehealth visit other than my Provider in order to operate the telehealth technologies. If another person is present during the telehealth visit, I will be informed of the individual’s presence and his/her role.
11. My Provider will explain my diagnosis and its evidentiary basis, and the risks and benefits of various treatment options.
12. I have the right to request a copy of my medical records and I understand upon my affirmative consent my medical records will be forwarded directly to my local primary care provider or other designated health care provider of record. I can request to obtain or send a copy of my medical records through me Patient Portal ("Portal"). A copy will be provided to me at reasonable cost of preparation, shipping and delivery.
13. It is necessary to provide my Provider a complete, accurate, and current medical history. I understand that I can log into my “Portal” at any time to access, amend, or review my health information.
14. There is no guarantee that I will be given a prescription and that the decision of whether a prescription is appropriate will be made in the professional judgement of my Provider. If my Provider issues a prescription, I have the right to select the pharmacy of my choice.
15. There is no guarantee that I will be treated by a Group provider. My Provider reserves the right to deny care for potential misuse of the Services or for any other reason if, in the professional judgment of my Provider, the provision of the Services is not medically or ethically appropriate.
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Patient Informed Consent
By starting treatment, I acknowledge that I have carefully read, understand, and agree to these Terms of this “TELEHEALTH INFORMED CONSENT” and consent to receive the Services.
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 Group provides, and the use of telehealth in the medical care and treatment provided to me by Group’s 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.
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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.