INFORMED CONSENT TO TELEHEALTH SERVICES 

Nest Collaborative, Inc. d/b/a Nest Collaborative offers telehealth-based lactation consulting services provided by certified lactation consultants by appropriately certified lactation consultants “Health Care Professional.” The term “telehealth,” refers to a form of health care services that relies on telecommunications technology, such as an interactive audio-video interface, that allows a patient or provider in one location to see, speak with, share information with, and consult with a provider in another distant location. The information so exchanged may be used for diagnosis, therapy, treatment, follow-up care, consultation, education, care management, and/or self-management of a patient’s health care, and may include any of the following:

• Patient medical records;
• Patient medical images;
• Live two-way audio and video communications; and/or
• Output data from medical devices and sound and video files.

Electronic systems used to provide telehealth services will incorporate network and software security protocols to protect the confidentiality and integrity of patient identifying information , including patient imaging data, and will include measures to safeguard the data to protect its confidentiality, integrity against unauthorized use/disclosure and/or intentional or unintentional corruption, and availability. For more information, see Nest Collaborative’s Privacy Policy and Notice of Privacy Practices.

The below information summarizes the main risks and benefits of telehealth services and affords you the opportunity to agree to or to decline to consent to receiving such services.

BENEFITS AND RISKS OF TELEHEALTH SERVICES

Telehealth provides access to care in circumstances where it may be otherwise difficult to provide such care. The benefits of telehealth services may include improved and easier access to health care by enabling patients to remain in their own locations and more efficient health care evaluation and management, often at a lower cost compared to other alternatives.

POTENTIAL RISKS

Yet, as with any type of health care service, there are potential risks associated with the use of telehealth services and, hence, the Services provided via this Site. Among the most important are the following:

1. Information available to the Health Care Professional may not be sufficient to make a correct diagnosis or other medical decisions. There could be limitations, for example, in the information transmitted to the Health Care Professional; access to the patient’s complete medical records, which could lead to incorrect diagnoses or adverse drug interactions or allergic reactions; and the physical examination that Health Care Professional can perform (in particular, information that can be obtained only by touching the patient or being physically present with the patient will not be available).
2. In some cases, the Health Care Professional may conclude that the information transmitted is not sufficient (e.g., poor resolution of images), or on some other basis the nature of you or your child’s problem is such that it does not allow for the Services to be provided appropriately by the Health Care Professional without an in-person evaluation.
3. Telehealth relies on electronic communications and devices. Any technical failure or power outage could therefore delay or disrupt such communications and hinder, delay, or erase our ability to assist you. 
4. No electronic communication is entirely safe from intruders. In rare instances, security protocols could fail, causing a breach of privacy of personal medical information. See our Privacy Policy https://nestcollaborative.com/privacy-policy/.
5. Nest’s Health Care Professionals providing services are aware of the above imitations and take them into account in making health care decisions within the scope of their practice. Scope of practice for International Board Certified Lactation Consultants can be referenced on the home site of their certifying body, the International Board of Certifying Lactation Examiners. Where necessary, these Health Care Professionals will refer patients to in-person care. 

INFORMED CONSENT TO THE USE OF TELEHEALTH

By checking the box “I AGREE” in the consent document, I hereby:

• Agree that my electronic agreement to this document is equivalent to my signature. 
• Acknowledge that I am not under the influence of any medications or other substances that could impair my understanding of the information in this document. 
• Acknowledge I have had sufficient time to read and understand the information provided above regarding telehealth. 
• I have had the opportunity to ask any and all of my questions, and such questions have been answered to my satisfaction in words I understand.
• Acknowledge my agreement and understanding of the this Informed Consent and the below
  1. I am over the age of 18.
  2. I consent to receive telehealth services via telehealth technologies.  I understand that Nest and its Health Care Professionals provide telehealth services but they do not replace my relationship with my primary care provider.  
  3. I understand NEST DOES NOT PROVIDE EMERGENCY CARE. If I or my child is  facing an emergency, I will not rely on Nest for help and will immediately call 911 or go to the nearest emergency room.
  4. I have been given an opportunity to select a Health Care Professional from Nest prior to the consult, including a review of the professional's credentials.
  5. I am under no obligation  to obtain care via telehealth. I may do so through conventional, in-person services instead of or in addition to these Services. I understand I may provide feedback to Nest should I become concerned that care via telehealth may be insufficient for my needs.
  6. I understand that a variety of alternative methods of health care may be available to me, and that I may choose one or more of these at any time. The Health Care Professional has explained these alternatives to my satisfaction.
  7. I acknowledge that, in the exercise of their professional/clinical judgment, a Health Care Professional may determine: (a) that the nature of my problem is such that it is not professionally appropriate to assist me with that problem through telehealth; (b) that it may not be lawful for the Health Care Professional to diagnose or treat me through telehealth; or (c) both. Should the Health Care Professional make any such determination that they will be unable to assist me through telehealth, he/she will confer with me about other possible approaches to handling my medical problems, such as referring me to my primary care physician.
  8. In addition, I understand that lactation consultants may only perform services within their certified scope of practice and, in some cases, applicable laws may prevent lactation consultants from providing the Services you desire through the Site or in the exercise of their professional judgment, may determine, they cannot adequately provide Services to you via telehealth. When that is the case, the Health Care Professional will refer you to an appropriate provider who can provide the services you desire, which may be via in-person care.
  9. If I obtain Services through telehealth, I may obtain the anticipated benefits from the use of telehealth in my care, but I may not, because as with all medical or health care services provided, no results can be guaranteed. In fact, as with all medical or health care services provided, I may be subject to lactation consulting services provided through telehealth that may cause some harm, including potentially serious harm.
  10. I understand that it is my duty to inform my primary care provider of any or other interactions regarding my health care that I may have with other health care providers.
  11. I understand that telehealth may involve electronic communication of my personal health information to other medical professionals who may be located in other areas, including out of state. I understand that the laws that protect privacy and the confidentiality of medical or health information also apply to telehealth, and that no information obtained in the use of telehealth, which identifies me, will be disclosed in violation of those laws.
  12. I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. I further understand that individuals other than Nest Health Care Professionals may be present during the consultation to operate the health technologies and that I will be informed of their presence and given the opportunity to request: (a) omission of specific details of my consultation that are sensitive to me; (b) as non-Health Care Professionals to leave the telehealth consultation; and/or (c) terminate the consultation at any time.
  13. I understand there is a risk of technical failures during the telehealth consultation beyond the control of Nest. I agree to hold harmless Nest for delays in consultation or for information lost due to such technical failures.
  14. I understand that in the event of any problem with the website or related telehealth technologies, I agree that my sole remedy is to cease using the website or terminate access to the service. Under no circumstances will Nest Collaborative be liable in any way for the use of the telehealth services, including but not limited to, any errors or omissions in content or infringement by any content on the website of any intellectual property rights or other rights of third parties, or for any losses or damages of any kind arising directly or indirectly out of the use of, inability to use, or the results of use of the website, and any website linked to the website, or the materials or information contained on any or all such websites. I agree that I will not hold Nest Collaborative, its subsidiaries or affiliates liable for any punitive, exemplary, consequential, incidental, indirect or special damages (including, without limitation, any personal injury, lost profits, business interruption, loss of programs or other data on my computer or otherwise) arising from or in connection with your use of the website whether under a theory of breach of contract, negligence, strict liability, malpractice or otherwise, even if we or they have been advised of the possibility of such damages.
  15. I understand that Nest Collaborative makes no representation that materials on this website are appropriate or available for use in any other location. I understand that if I access these services from a location outside of the United States, that I do so at my own risk and initiative and that I am ultimately responsible for compliance with any laws or regulations associated with my use.
  16. I understand that I have the right to inspect all information obtained and recorded in the course of a telehealth interaction, and may receive copies of this information for a reasonable fee.
  17. I understand that lactation consultants will not prescribe medications to treat my problem. 
  18. I understand that 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.
  19. I understand a copy of this consent form is available by printing this document or by request.

PEDIATRIC PATIENT CONSENT TO THE USE OF TELEHEALTH

I am the parent/guardian of the child(ren) under the age of 18 (“Minors”) who are identified under my registration with Nest. 

I am not under the influence of any medications or other substances that could impair my understanding of the information in this document. I have had sufficient time to read and understand the information provided above regarding telehealth. I have had the opportunity to discuss this consent with the treating Health Care Professional providing lactation consulting services through Nest. I have been given all of the opportunity I require to ask any and all of my questions, and such questions have been answered to my satisfaction in words I understand.

By acknowledging “I AGREE,” in the consent document, I hereby acknowledge my agreement and understanding of the above Informed Consent and certify that I am the legal parent or guardian of the child(ren) identified below and that I am acting within my authority in agreeing to this Informed Consent form. I further agree that my electronic agreement to this document is equivalent to my signature.