Welcome to Nest Collaborative! Gorman and Associates, LLC and its affiliated Nest Collaborative (collectively, the “Company,” “we” or “us”), operate the website www.nestcollaborative.com (the “Site”) with links to a third party telehealth platform provider, through which we offer online telehealth service (“the Service”). The Service enables our members to access and engage with healthcare professionals (the “Providers”) to obtain medical and healthcare services (“Services”).
To use the Service you must agree to be bound by all of the terms of this Agreement. By clicking the “AGREE” checkbox, you are indicating that you agree to be bound by all of the terms in this Agreement. If you do not agree to these terms and conditions, you are not authorized to access or use this website and should not use the Service.
THESE TERMS OF SERVICE REQUIRE BINDING ARBITRATION ON AN INDIVIDUAL BASIS TO RESOLVE DISPUTES, RATHER THAN JURY TRIALS, AND INCLUDE A CLASS ACTION WAIVER. THESE TERMS LIMIT THE REMEDIES THAT MAY BE AVAILABLE TO YOU IN THE EVENT OF A DISPUTE.
The Services you receive from our providers should not be used as replacement for a primary care provider relationship or be considered a replacement of your medical home. Your visit with a Provider serves as a consultation and may not necessarily give rise to an ongoing treatment relationship. You are expected to seek follow-up or emergency care when recommended by our Providers or when otherwise needed, and continue to consult your primary care provider and any other healthcare providers as needed or recommended. Additionally, our Providers may make arrangements for follow-up care through our Service as appropriate and you are welcome to access our Services for follow-up concerns regarding medications, side effects or other potentially adverse events. While our telehealth Service strives to provide benefits that include improved and convenient access to quality healthcare professionals, there do exist potential risks associated with its use which are outlined above our Consent to Treatment (the “Consent”).
Links and Third Parties
Our service, or third parties, may provide links to outside sites or resources. Additionally, the Site may integrate third party applications, products or services which may have access to your data and/or protected health information (PHI). These third parties are not affiliated with the Company and may have different policies regarding the handling of PHI and PII; your use of these third parties is subject to their terms and conditions and privacy practices and policies. We make no representations or warranties with respect to third party websites, technologies or applications, or how they operate, including operations involving privacy, security and data exchanges. We advise you to review the terms, policies and practices for all third parties that you with whom engage for we do not endorse or hold responsibility for the information and security practices and policies they hold.
As our Company is distinct from any third party websites with whom we partner for Service or otherwise link through our Site, you acknowledge and agree that we are not responsible for the quality, integrity, safety, accuracy, availability, reliability or legality of such websites or resources and are not responsible or liable for any content, advertising, products or other material available from such third parties. Further, you acknowledge that our Company shall not be responsible or liable, directly or indirectly, for any damage, harm, injury or loss of any kind caused or alleged to be caused by or in connection with the use of or reliance upon any content, material or services available or through any third party websites or resources.
By agreeing to these Terms, on behalf of each of your minor child(ren) enrolled in the Service, you agree that you have reviewed, understand, acknowledge and/or certify as true each of the terms below:
- The insurance information you have provided is accurate, complete and current and that no other unidentified coverage exists
- You assign your right to receive payment of authorized benefits to the Company
- You request that payment of authorized benefits be made on your behalf to Nest Collaborative for any services furnished to your child by our Providers.
- You authorize Nest Collaborative to file appeals on your behalf for any denials of payment and/or adverse benefit outcome related to your services provided.
- If your insurance provider will not direct payment to the Company, you agree to forward all insurance payments that you receive for the services rendered by Nest Collaborative.
- You authorize Nest Collaborative to release to your insurance provider any information needed to determine eligibility for benefits payable for related services.
- You are responsible for all charges for services provided to you or your child(ren) which are not covered by your insurance plan or for which you are responsible for under you insurance plan.
Further, you agree that, if permissible by law, you will reimburse the Company for all costs, expenses and attorney’s fees that may be incurred to collect payment for those charges related to you or your child’s services. These terms and assignment of benefits apply and extend to subsequent visits and appointments with the Service.
You agree to pay all fees or charges to your account in accordance with the fees, charges, and billing terms in effect at the time a fee or charge is due and payable. By providing the Company with your credit card number and associated payment information, you agree that we are authorized to immediately invoice your account for all fees and charges due and payable to the Company hereunder and that no additional notice or consent is required. If your health plan has arranged with the Company to pay the fee or any portion of the fee, or if the fee is pursuant to some other arrangement with the Company, that fee adjustment will be reflected in the fee that you are ultimately charged. Please check with your health plan to determine if any Services will be reimbursed.
If you do not have insurance coverage for Services, or if your coverage is denied, you acknowledge and agree that you shall be personally responsible for all incurred expenses. The Company offers no guarantee that you shall receive any such reimbursement. We reserve the right to modify or implement a new pricing structure at any time prior to billing you for your initial payment or for future payments due pursuant to these Terms of Service. You understand and agree that for Services provided on an appointment basis, you may be responsible for a missed appointment fee according to the current fee schedule if you do not cancel a scheduled appointment at least 24 hours in advance.
If your health insurance coverage does not include or is not sufficient to satisfy the Service charges in full, you may be fully or partially responsible for payment. Your Provider may determine that the services are not appropriate for some or all of your treatment needs, and, accordingly, may elect not to provide Services to you.
- General Fees Payments for services rendered will be charged to the payment method (your “Payment Method”) you provide to our third party platform provider under the account (your “Billing Account”) you have established with that provider. You agree to by the Company all charges due at the prices then in effect for any Service rendered to you or your agents by the Company. You authorize the Company, or a third party billing partner, to charge you through your pre selected Payment Method for the Service. We reserve the right to correct any errors or mistakes made by any parties after payments have been requested or received. You may terminate your authorization for your Payment Method at anytime by contacting the company at email@example.com or by contacting the billing provider directly. Such notice will not affect any charges submitted to you for Services performed prior to the termination. We ask that you keep your billing information current and complete and promptly update any information as necessary. Please notify the Company should your Payment Method be canceled or suspended for any reason.
- Fraudulent Billing Should you become aware of a potential breach of security for your Billing Account, such as unauthorized disclosure or use of your user name and/or password, please change your password to your account immediately through your account settings. Unless you notify the Company of any such concern, you agree that the Company may continue billing your Billing Account for any use of the Service under your Billing Account, unless you otherwise terminate the authorization for the Billing Method as described above.
You can send messages to your Provider by emailing them at an address they provide to you or by calling the Company’s main phone line and recording a voicemail, however, emails or other messages may not be returned immediately.
Email messages received by the Company may be viewed by more than one Provider or other Company agent and will typically be answered in 48 hours.
Such messages do not give rise to a provider-patient relationship and do not constitute medical treatment, diagnosis, therapy, advice or service. If you are or could be experiencing a medical emergency, please call 911 or seek emergency care immediately.
You agree that we may send to you any privacy or other notices, disclosures, or communications regarding the Services (collectively, “Communications”) through electronic means including but not limited to: (1) by e-mail, using the address that you provided to us during registration, (2) short messaging service (“SMS”) text message to the mobile number you provided us during registration, (3) push notifications on your mobile device or (4) by posting the Communications on the Site. The delivery of any Communications from us is effective when sent by us, regardless of whether you read the Communication when you receive it or whether you actually receive the delivery. You can withdraw your consent to receive Communications by email by canceling or discontinuing your use of the Service. You can opt-out of future Communications through email, phone or SMS text message by replying “STOP” or by calling the Company directly.
You understand that our Service requires release of your personal health information to an online personal health record serviced by a third party (in accordance with our HIPAA policy) and communication with our Providers and Company agents. You consent to receiving emails or other communication from us regarding your healthcare.
Privacy and Security
We are required to comply with federal health care privacy and security laws and maintain safeguards to protect the security of your personal health information (PHI). Details of our privacy practices including electronic communication can be found in our HIPAA Notice of Privacy Practices (the “NPP”) which can be accessed on our Site.
As part of providing you our Service, we may need to provide you with certain communications, such as appointment reminders, service announcements and administrative messages. These communications are considered part of the Services and your Account. While secure electronic messaging is always preferred to insecure email, under certain circumstances, insecure email communication containing personal health information may take place between you and the Company. While we do aim to practice secure electronic communication with two-way encryption, we cannot completely ensure the security or confidentiality of messages sent by email. Information relating to your care, including clinical notes and medical records, are stored on secure, encrypted servers maintained by the Company and our third party partners.
To access our Service, you must create a User account and agree to provide us with the most accurate, complete and up-to-date information, updating such information as needed to maintain its accuracy. You are responsible for maintaining the confidentiality of your password and are fully responsible for all activities that occur under your account. Please use caution when accessing your account from public or shared computers. You agree to notify the Company immediately of any unauthorized use of your account or any breach in its security. You are responsible for exiting your account completely at the end of each session. We will not be held liable for any loss or damage arising from your failure to comply with the above.
To create an account, you must be of legal age to form a binding contract. If you are not of legal age to form a binding contract, you may not register for or use our Services. By agreeing to these Terms of Service, you certify that the information you provide under your Account, at all times, and any information you upload to your Account, is true, accurate, current and complete to your knowledge and belief. You may not share or transfer your Account with anyone, or create more than one Account, with the exception of subaccounts established for children of whom you are the parent or legal guardian.
You are responsible for maintaining the confidentiality of your Account and its password, and for all activities that occur under your Account. We reserve the right to take any and all action, as it deems necessary or reasonable, regarding the security of the Site and your Account Information. In no event and under no circumstances shall the Company be held liable to you for any liabilities or damages resulting from or arising out of your use of the Site, your use of the Account Information or your release of the Account Information to a third party. You may not use anyone else’s account at any time.
Use of the Services by Children
The Services are available for use by children, but the Member for all patients under the age of 18 must be the patient’s parent or legal guardian. If you register as the parent or legal guardian on behalf of a minor, you will be fully responsible for complying with these Terms of Service.
We hereby grant to you a limited, non-exclusive, nontransferable right to access our Services solely for your personal non-commercial use and only as permitted under these Terms of Service and any separate agreements you may have entered into with us (“Access Rights”). We reserve the right, in our sole discretion, to deny or suspend use of our Services to anyone for any reason. You agree that you will not, and will not attempt to: (a) impersonate any person or entity, or otherwise misrepresent your affiliation with a person or entity; (b) use the Services to violate any local, state, national or international law; (c) reverse engineer, disassemble, decompile, or translate any software or other components our Services including our third party platforms; (d) distribute viruses or other harmful computer code through our Site or that of our third party partners (e) otherwise use the Services in any manner that exceeds the scope of use granted above. In addition, you agree to refrain from abusive language and behavior which could be regarded as inappropriate, or conduct that is unlawful or illegal, when communicating with Providers through the Service and to refrain from contacting Providers for telehealth services outside of the Service. The Company is not responsible for any interactions with Providers that are not conducted through the Service. We strongly recommend that you do not use the Services on public computers. We also recommend that you do not store your Account password through your web browser or other software.
Our Service is intended for personal use and may not be used for or in conjunction with commercial endeavors. Entities other an individuals, including organizations, companies and businesses, are not permitted to use the Services. Unauthorized use of the Service or Site may be investigated, and legal action taken. Use of the Service is with the permission of our Company and can be revoked for any reason and at any time at our discretion.
You may deactivate your Account and end your registration at any time, for any reason by sending an email to info@nestcollaborative. The Company may suspend or terminate your use of the Service, your Account and/or registration for any reason at any time. Subject to applicable law, we reserve the right to maintain, delete or destroy all communications and materials posted or uploaded to the Site pursuant to its internal record retention and/or content destruction policies. After such termination, the Company will have no further obligation to provide you Services, except to the extent we are obligated to provide you access to your health records or Providers are required to provide you with continuing care under their applicable legal, ethical and professional obligations to you.
Right to Modify
We may at our sole discretion change, add, or delete portions of these Terms of Service at any time. Any modifications will be communicated to our users in writing and provided to users by email at the address they have provided, or by posting to the Website. Continued use of the Service following notice of any such changes will indicate your acknowledgement of such changes and agreement to be bound by the revised Terms of Service, inclusive of such changes.
DISCLAIMER OF WARRANTIES.
YOU EXPRESSLY AGREE THAT USE OF THE SITE OR SERVICES IS AT YOUR SOLE RISK. BOTH THE SITE AND SERVICES ARE PROVIDED ON AN “AS IS” AND “AS AVAILABLE” BASIS. THE COMPANY DISCLAIMS ALL WARRANTIES OF ANY KIND, WHETHER EXPRESS OR IMPLIED, INCLUDING, BUT NOT LIMITED TO ANY WARRANTIES OF MERCHANTABILITY, FITNESS FOR A PARTICULAR USE OR PURPOSE, NON-INFRINGEMENT, TITLE, OPERABILITY, CONDITION, QUIET ENJOYMENT, VALUE, ACCURACY OF DATA AND SYSTEM INTEGRATION.
The Company is not responsible for any inaccurate or incorrect content posted on the Site or through the Service. We are not responsible for any error, omission, interruption, deletion, defect, delay in operation or transmission, communications line failure, theft or destruction or unauthorized access to, or alteration of any Communication. The Company is not responsible for any problems or technical malfunctions of network or phone lines, computer equipment or systems, servers, providers, software, email providers or internet traffic, including injury or damage to your or any other person’s computer related to or resulting from using our Site or Service. Under no circumstances will the Company or any of its affiliates or third parties be responsible for any loss or damage, including personal injury or death, resulting from anyone’s use of the Service, or any content posted on or transmitted from the Site or Service. The Company does not guarantee or promise any specific results from your use of our Service.
General advice posted to the Site or Service is for informational purposes and is thus not intended to replace or substitute for any medical service or advice. We disclaim any and all liability regarding any treatment, action by or affect on any person following any general information offered or provided within our Service or Website. Specific concerns that require medical advice should be directed to an appropriately trained medical provider.
The Service is intended for use within the United States; those choosing to access the Site outside of the the U.S. are responsible for compliance with all local laws, including those which may apply to Content on the Site which may be prohibited locally.
Limitation of Liability
TO THE EXTENT PERMITTED UNDER APPLICABLE LAW, IN NO EVENT WILL GORMAN AND ASSOCIATES, LLC, OR ITS AFFILIATE NEST COLLABORATIVE, OR ANY OF THEIR OFFICERS, EMPLOYEES, PARENTS, SUBSIDIARIES, AFFILIATES, AGENTS OR LICENSORS BE LIABLE FOR ANY CONSEQUENTIAL, INCIDENTAL, INDIRECT, SPECIAL, ACTUAL, PUNITIVE AND/OR EXEMPLARY DAMAGES (INCLUDING BUT NOT LIMITED TO LOSS OF PROFITS, REVENUES, GOODWILL, USE OR DATA, SERVICE INTERRUPTION, COMPUTER DAMAGE OR SYSTEM FAILURE, THE COST OF SUBSTITUTE PRODUCTS OR SERVICE, BODILY INJURY OR DEATH OR OTHER INTANGIBLE LOSSES) ARISING OUT OF OR RELATED IN ANY WAY TO YOUR USE OF THE SERVICE OR WEBSITE, REGARDLESS OF WHETHER SUCH DAMAGES ARE UNDER THEORY OF BREACH OF CONTRACT, TORT, NEGLIGENCE, CONTRACT, WARRANTY, STATUTE, STRICT LIABILITY OR OTHERWISE, EVEN IF WE OR THEY HAVE BEEN ADVISED OF THE POSSIBILITY OF SUCH DAMAGES. NOTWITHSTANDING ANYTHING CONTRARY CONTAINED HEREIN, THE COMPANY’S LIABILITY TO YOU ARISING FROM THESE TERMS, THE USE OF OR INABILITY TO USE THE WEBSITE OR SERVICE, WILL AT ALL TIMES BE LIMITED TO THE GREATER OF $100.00 USD OR THE AMOUNT PAID BY YOU TO THE COMPANY FOR ACCESS TO AND USE OF THE SERVICE.
YOU RELEASE THE COMPANY AND HOLD IT AND ITS THIRD PARTY TECHNOLOGY PLATFORM PROVIDER, SUPPLIERS AND PROVIDERS AND ANY THIRD PARTY WHO PROMOTES THE SERVICE OR PROVIDES YOU WITH A LINK TO THE WEBSITE HARMLESS FROM ANY AND ALL CLAIMS, DEMANDS, AND DAMAGES OF EVERY KIND AND NATURE AS CITED ABOVE, ARISING OUT OF OR IN ANY WAY CONNECTED WITH YOUR USE OF THE WEBSITE AND OUR SERVICE. WE, AND THOSE REFERENCED DIRECTLY ABOVE, EXPRESSLY DISCLAIM ANY AND ALL LIABILITY RESULTING FROM THE DELIVERY OF HEALTHCARE VIA OUR WEBSITE OR THIRD PARTY TECHNOLOGY PLATFORM PROVIDER, INCLUDING, BUT NOT LIMITED TO LIABILITY FOR MEDICAL MALPRACTICE. YOU WAIVE THE PROVISION OF ANY STATE OR LOCAL LAW LIMITING OR PROHIBITING A GENERAL RELEASE.
The failure of our Company to enforce any right or provision of these Terms does not constitute a waiver of future enforcement of any right or provision. If for any reason a court of competent jurisdiction or an arbitrator finds any portion of a provision of these Terms unenforceable or invalid, that provision will otherwise be enforced to the maximum extent permissible. All other provisions of these Terms will remain in full force and effect.
You agree to indemnify, defend and hold harmless the Company, its providers, officers, directors, employees, agents, subsidiaries, affiliates, licensors, and suppliers, harmless from and against any claim, actions, demands, liabilities and settlements, including without limitation reasonable legal and accounting fees (“Claims”), resulting from, or alleged to result from, your violation of these terms and conditions. In addition, you agree to indemnify, defend and hold harmless your Provider(s) from and against any third party Claims resulting from your lack of adherence with the advice or recommendation(s) of such Treating Provider(s).
The Company makes no representation that all products, services and/or material described on its Site, or the Services available through the Site, are appropriate, legal or available for use in locations outside the United States or all territories within the United States.
Additionally, you hereby certify that you and your child are physically located in the State of Maryland at the time you are receiving our Service. The Providers at Nest Collaborative rely upon this certification in order to provide the Service to you and your ability to access the Service is fully conditioned upon your truthfulness of this certification. Should your certification of your location be inaccurate or untruthful, you agree to indemnify the Company, its Providers, subsidiaries, affiliates, officers, agents and other partners harmless from any resulting loss, liability, damages, costs or claims, made by you or any third party.
All medical providers on this site hold professional licenses issued by the professional licensing boards in the states where they practice. Non-medical providers hold certifications in lactation education and consulting. You can report a complaint relating to services provided by a Medical Provider by contacting the professional licensing board in the state where the services were received or the Company directly. In a professional relationship, sexual intimacy is never appropriate and should be reported to the board that licenses, registers, or certifies the licensee.
Any clinical records created as a result of your use of the Site will be securely maintained by the Company and/or its third party partners on behalf of your Treating Provider(s) for a period that is no less than the minimum number of years such records are required to be maintained under state and federal law, and which is typically at least six years.
Except as otherwise set forth in these Terms, you hereby agree to resolve any and all controversies, claims and/or disputes (each, a “Dispute”) arising as a result of your use of our Service solely pursuant to the terms of the section below.
- Management Resolution Disputes shall first be referred to each party or their authorized representatives for discussion and resolution (“Management Resolution”).
- Arbitration Should Management Resolution fail to resolve the Dispute, then you agree that the Dispute shall be resolved by final, binding arbitration (“Arbitration”) administered by the American Arbitration Association (AAA) under the AAA’s Commercial Arbitration Rules. Under any event of Arbitration, including but not limited to any action to compel, enforce award of Arbitration or seek injunctive relief pursuant to these Terms, the prevailing party shall be entitled to an award of their reasonable attorney’s fees and costs for such proceeding, including any related trial or levels of appeal.
- Governing Law This agreement is governed by the laws of the State of Maryland. For any action to compel Arbitration, enforce an Arbitration award or seek injunctive relief pursuant to these Terms, the parties consent to the venue of Baltimore County, Maryland, USA and each party expressly waives any objection to jurisdiction and venue in such courts.
Injunctive Relief Each party retains the right to seek injunctive or other equitable relief in a court of competent jurisdiction to prevent the actual or threatened infringement, misappropriation or violation of a party’s copyrights, trademarks, trade secrets, patents or other intellectual property rights.
Agreement to Service
I HAVE READ THIS AGREEMENT AND AGREE TO ALL OF THE PROVISIONS
The Company devotes considerable effort to optimizing signal strength and diagnosis deficiencies but is not responsible for the internet or data bandwidth and signal of your mobile device.
If you have any questions about these Terms of Service, or the Service itself, or would like to report any violations of our Terms, please contact the Company at firstname.lastname@example.org.
INFORMED CONSENT TO TREATMENT
Gorman & Associates, LLC offers telemedical services to their patients. Telemedicine, or distance care, is a form of health care that relies on an interactive audio-video interface that allows a patient in one location to see, speak with, and consult a provider in another. The information so exchanged may be used for diagnosis, therapy, follow-up and/or education, and may include any of the following:
- Patient medical records
- Medical images
- Live two-way audio and video communications
- Output data from medical devices and sound and video files
Electronic systems used 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 protect their integrity against intentional or unintentional corruption.
This document summarizes the main risks and benefits of this kind of care and affords you the opportunity to agree to it or to decline.
BENEFITS OF TELEMEDICINE
Telemedicine provides access to care in circumstances where it may be difficult to provide otherwise. The benefits, then, may include:
- Improved and easier access to medical care by enabling patients to remain in their own locations;
- More efficient health care evaluation and management, often at lower cost;
- Greater convenience and less need to travel for care.
RISKS OF TELEMEDICINE
Telemedicine is a tool, a method of providing care, and not a specialty itself. Like any tool, it is useful in some circumstances, but not all. In particular, telemedicine does not permit the provider to physically touch the patient. As with any medical procedure or method, there are potential risks associated with the use of telemedicine. Among the most important are the following:
- The information available to the practitioner 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 provider
- Access to the patient’s complete medical records; this could lead to:
- incorrect diagnoses, or
- adverse drug interactions or allergic reactions
- The physical examination that Gorman & Associates, LLC can perform; in particular, information that can be obtained only by touching the patient will not be available.
- In some cases, Gorman & Associates, LLC may conclude that the information transmitted is not sufficient (e.g. poor resolution of images), or on some other basis the nature of your or your child’s problem is such that it does not allow for appropriate medical or healthcare decision-making without an in-person evaluation.
- Telemedicine relies on electronic communications and devices. Any technical failure or power outage could therefore delay or disrupt communication and hinder, delay, or erase telemedicine’s ability to assist you.
- These limitations could result in an incorrect diagnosis, which in turn could lead to treatment that is not helpful, or that could even be harmful; or to adverse drug interactions, allergic reactions or other problems.
- Gorman & Associates, LLC is aware of these limitations and takes them into account in making clinical decisions within the scope of their practice. Where necessary, Gorman & Associates, LLC refers patients to in-person care. The risk of error nevertheless exists.
- In some cases, applicable law may prevent Gorman & Associates, LLC from providing the services you desire.
- Since telemedicine remains a relatively new approach to care, risks not yet identified, possibly significant, could also exist.
You are under no obligation, of course, to obtain care via telemedicine. You may do so through conventional, in-person services instead or in addition. Please feel free to provide feedback to Gorman & Associates, LLC should you become concerned that telemedicine may be insufficient for your needs.
Gorman & Associates, LLC DOES NOT PROVIDE EMERGENCY CARE. If you think you or your child is facing an emergency, or that you or he or she might be facing an emergency, please do not rely on Gorman & Associates, LLC for help. Immediately call 911 or go to your nearest emergency room.
Gorman & Associates, LLC offers pediatric services, subject to these restrictions:
Children Under 18
If you wish to allow Gorman & Associates, LLC to diagnose or treat a child under the age of 18, except where under applicable law at the site of treatment parental consent is not required, you must, at the time and for the duration of your communication with Gorman & Associates, LLC, be physically present with the child. You must identify yourself as the child’s parent or guardian. You must decide whether, on your child’s behalf, to grant informed consent to the Provider’s care and treatment.
In certain circumstances determined by Maryland law, a minor is himself or herself deemed capable of granting informed consent, independent of a parent or guardian. Gorman & Associates, LLC is solely responsible for determining whether those circumstances apply to the case of any given minor. Where they do, your consent is not required, nor is your presence, during the communication between the child and the Provider. In fact, the child may lawfully forbid the Provider to disclose to you any information concerning care to which these exceptions apply and may prohibit your physical presence during the consultation.
ADULT PATIENT CONSENT TO THE USE OF TELEMEDICINE
I am over the age of 18. 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 telemedicine. I have had the opportunity to discuss it with Gorman & Associates, LLC or such assistants as may be designated. I have been given all 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.
If I obtain clinical services through telemedicine, I may obtain the anticipated benefits from the use of telemedicine in my care, but I may not, because as with all health care, no results can be guaranteed. In fact, as with all medical or health care, I may even by obtaining clinical services through telemedicine experience some harm, including potentially serious harm.
I understand that a variety of alternative methods of medical care may be available to me, and that I may choose one or more of these at any time. Gorman & Associates, LLC has explained the alternatives to my satisfaction.
I acknowledge that, in the exercise of their clinical judgment, Gorman & Associates, LLC may determine that 1) the nature of my problem is such that it is not professionally appropriate to assist me with that problem through telemedicine; or 2) it may not be lawful for Gorman & Associates, LLC to diagnose or treat me through telemedicine; or 3) both. Should Gorman & Associates, LLC make any such determination, they will be unable to assist me through telemedicine and will confer with me about other possible approaches to handling my medical problems.
I understand that it is my duty to inform my provider of electronic interactions regarding my care that I may have with other healthcare providers.
I understand that Gorman & Associates, LLC may or may not prescribe medications to treat my problem.
I may have to pay for Gorman & Associates, LLC’s services in advance through a charge to my credit card or other payment method requested.
I understand that telemedicine may involve electronic communication of my personal medical 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 information also apply to telemedicine, and that no information obtained in the use of telemedicine, which identifies me, will be disclosed to researchers or other entities without my consent. I also acknowledge, however, that the security and privacy of electronic communications cannot be guaranteed.
I understand that I have the right to inspect all information obtained and recorded in the course of a telemedicine interaction, and may receive copies of this information for a reasonable fee.
I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment.
By acknowledging “I agree,” I hereby authorize Gorman & Associates, LLC to use telemedicine in the course of my diagnosis and treatment.
Electronic agreement to this document is equivalent to the Signature of Patient. I understand a copy of this consent form is available by printing this document or by request.
PEDIATRIC PATIENT CONSENT TO THE USE OF TELEMEDICINE
I am the parent/guardian of the minor(s) identified under my registration with Gorman and Associates, LLC.
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 telemedicine. I have had the opportunity to discuss it with Gorman & Associates, LLC or such assistants as may be designated. I have been given all the opportunity I require to ask all my questions, and all my questions have been answered to my satisfaction in words I understand.
If I obtain clinical services through telemedicine, my child may obtain the anticipated benefits from the use of telemedicine in my care, but he may not, because as with all health care, no results can be guaranteed. In fact, as with all medical or health care, my child may even by obtaining clinical services through telemedicine experience some harm, including potentially serious harm.
I understand that a variety of alternative methods of medical care may be available to my child, and that I may choose one or more of these at any time. Gorman & Associates, LLC has explained the alternatives to my satisfaction.
I acknowledge that, in the exercise of their clinical judgment, Gorman & Associates, LLC may determine that 1) the nature of my child’s problem is such that it is not professionally appropriate to assist him with that problem through telemedicine; or 2) it may not be lawful for Gorman & Associates, LLC to diagnose or treat him through telemedicine; or 3) both. Should Gorman & Associates, LLC make any such determination, they will be unable to assist my child through telemedicine and will confer with me about other possible approaches to handling my child’s medical problems.
I understand that it is my duty to inform my child’s provider of electronic interactions regarding care that my child may have with other healthcare providers.
I understand that Gorman & Associates, LLC may or may not prescribe medications to treat my child’s problem.
I may have to pay for Gorman & Associates, LLC’s services in advance through a charge to my credit card or other payment method requested.
I understand that telemedicine may involve electronic communication of my child’s personal medical 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 information also apply to telemedicine, and that no information obtained in the use of telemedicine, which identifies my child, will be disclosed to researchers or other entities without my consent. I also acknowledge, however, that the security and privacy of electronic communications cannot be guaranteed.
I understand that I have the right to inspect all information obtained and recorded in the course of a telemedicine interaction with my child, and may receive copies of this information for a reasonable fee.
I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my child’s care at any time, without affecting my right to future care or treatment.
I hereby authorize Gorman & Associates, LLC to use telemedicine in the course of my child’s diagnosis and treatment.
By agreeing herein, I certify that I am the legal parent or guardian of the child identified above and am acting within my authority in agreeing to this consent form.