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Informed Consent

INFORMED CONSENT/CONSENT FOR TREATMENT

Please review this Informed Consent/Consent for Treatment (this “Consent”) before agreeing to its terms and conditions and beginning your telehealth visit with Ballad Health (“We” or “Us” or “Ballad”). By agreeing to this Consent, I (“I” or “Me” or “You”) understand and agree with the following:

I ACKNOWLEDGE THAT TELEHEALTH IS NOT DESIGNED OR INTENDED OR APPROPRIATE TO ADDRESS SERIOUS, EMERGENCY, OR LIFE-THREATENING MEDICAL CONDITIONS AND SHOULD NOT BE USED IN THOSE CIRCUMSTANCES. IF YOU BELIEVE YOU ARE EXPERIENCING A MEDICAL EMERGENCY, YOU SHOULD DIAL 911 AND/OR GO TO THE NEAREST EMERGENCY ROOM.

“Telehealth” involves the use of electronic communications, information technology or other electronic means to enable a licensed health care provider (“Provider”) and a patient at different locations to share individual patient medical information for the purpose of treatment or patient care. The health information I share may be used for diagnosis, therapy, follow-up and/or education. Telehealth may include, but is not limited to:

  • Electronic transmission of medical records, photo images, personal health information or other data between a patient and a Provider;
  • Interactions between a patient and the Provider via audio, video and/or asynchronous data communications, such as secure messaging and email; and
  • Use of data from remote monitoring devices, medical devices, and sound or video files.

By accepting this Consent, I acknowledge my understanding and agreement to the following:

  • I have read this Consent thoroughly and carefully. I understand the risks and benefits of the use of telehealth in my medical care and treatment. I understand that the risks and benefits described herein are non-exhaustive examples. I understand that my medical care may involve the use of technology not specifically described in this Consent.
  • I give my informed consent to receive medical care and treatment by telehealth from a Provider.
  • I understand that I will be given information about test(s), treatments(s) and procedures(s), as applicable, including the benefits, risks, possible problems or complications, and alternate choices for my medical care through the telehealth/telemedicine visit.
  • I understand that my Provider may determine in his or her sole discretion that my condition is not suitable for treatment using telehealth, and that I may need to seek medical care and treatment in-person or from an alternative source.
  • I acknowledge that I am located in the state I selected when requesting a telehealth visit and at the time I start a telehealth visit.
  • I acknowledge that I have agreed to the Terms of Service and the Privacy Policy.

I have the right to withhold or withdraw consent to the use of telehealth services at any time and revert back to traditional in-person clinic services. I understand that if I withdraw my consent for telehealth, it will not affect any future services or care benefits to which I am entitled.

I understand and acknowledge that my interactions with the Provider will be used for a provider-patient relationship and that my visit information will result in the creation of a medical record with Ballad. I understand and acknowledge that I have a duty to answer questions about my health and medical history honestly and accurately, and to keep all of my health care providers, including my Provider, up-to-date on any changes in my health, symptoms, treatments, or medications. I understand and agree that the health information I provide at the time of my telehealth service may be the only source of health information used by the medical professionals during the course of my evaluation and treatment at the time of my telehealth visit, and that my Provider may not have access to my full medical record or information.

The laws that protect the privacy and confidentiality of health and care information also apply to telehealth. For more information on how your information may be used and disclosed, please see the Privacy Policy and the Notice of Privacy Practices. I understand, agree, and expressly consent to Ballad obtaining, using, storing, and disseminating to necessary third parties, information about me, including my image, as necessary to provide the telehealth/telemedicine services.

Expected Benefits of Telehealth:

I understand that the use of telehealth may:

  • Reduce the need for travel to a distant consultation site;
  • Reduce cost and improve access to limited services and to care management; and/or
  • Allow me, as the patient, to obtain the expertise of a distant health care provider or specialist.

Potential Risks of Telehealth:

I understand that, as with any health care service, there are potential risks associated with the use of telehealth. Potential risks may include but are not limited to:

  • In rare instances, information transmitted as part of a telehealth encounter may not be sufficient or complete (e.g., poor resolution of images) to allow for appropriate health care decision making by the Provider.
  • In rare instances, a lack of access to complete health care records may result in clinical judgment errors by your Provider, including but not limited to adverse drug interactions or allergic reactions.
  • Your Provider may not be able to provide medical treatment for your condition via telehealth, and you may be required to seek alternative care.
  • The inability of your Provider to conduct certain tests or assess vital signs in person may in some cases prevent the Provider from diagnosing or treating you or identifying that you need urgent medical care.
  • Data security protocols or safeguards could fail and cause a breach of privacy of your personal health information.
  • Due to the nature of a telehealth visit and regulatory requirements in certain jurisdictions, your treatment options, especially pertaining to certain prescriptions, may be limited.
  • Delays in medical evaluation and treatment could occur due to deficiencies or failures of telehealth equipment, including but not limited to the disconnection of the technology during a telehealth consult.

I hereby release and hold harmless Ballad and all members of my care team, including my Provider, from any loss of data or information due to technical failures associated with the telehealth service.

I certify that I am the legal representative of the participant or that I am the patient and am 18 years of age or older, or otherwise legally authorized to consent. I have carefully read and understand the above statements. I understand that this Consent will become a part of my medical record.

I hereby consent to the use of telehealth in the provision of care and the above terms and conditions.