Telehealth involves the use of live audio-video or other forms of synchronous and asynchronous electronic communications to deliver health care services to patients while the health care provider (Provider) is located at a physical location different from the patient receiving the health care services (Telehealth Services).
By agreeing to receive Telehealth Services from Empower Sleep Medical Associates, Inc. (Medical Practice) via all websites provided by Empower Sleep, Inc. (“Empower Sleep”, “we”, “us” or “our”), including the Site hosted on the domain empowersleep.com (collectively, “Sites”), and all services provided by us in connection with such Sites or otherwise (Empower Sleep Platform).
I acknowledge that:
There are potential risks to using electronic communications for the purpose of a health care visit, including, but not limited to, service interruptions, unauthorized access, technical difficulties, call termination or other equipment failures. I acknowledge and accept those risks, understanding there are alternatives to receiving Telehealth Services.
I will receive protected health information via email or SMS text messaging. I understand that messages shared through these communication channels may not be secure in every instance.
Either I or the Provider can discontinue Telehealth Services if either of us determines that Telehealth Services are not right for my health care.
It is my responsibility to provide accurate, complete, and current information about me and my health condition(s) to the Provider while receiving Telehealth Services.
The Practice has made reasonable and appropriate efforts to eliminate any confidentiality risks associated with Telehealth Services. I am also responsible for mitigating any risks to my privacy or confidentiality stemming from the location or circumstances of my participation in Telehealth Services (e.g., joining the telehealth encounter from a quiet space, ensuring others do not overhear my conversation or see my computer or mobile device screen). All existing confidentiality protections under federal and state law apply to my information disclosed during Telehealth Services
I understand and acknowledge that Telehealth Services are not intended to be, and do not act as, emergency services. If I am experiencing an emergency, I should not rely on Telehealth Services and instead should call 911 or go to an emergency department.
I understand what it means to receive Telehealth Services and am legally authorized to acknowledge, agree, and consent to the use of Telehealth Services.
I am responsible for all charges (a) that I may incur from my mobile or internet service provider, as applicable, when receiving Telehealth Services.
By continuing, I, the patient, hereby:
Represent that I have read and understand this Consent to use Telehealth Services and the anticipated benefits and risks of the use of telehealth provided to me through the Empower Sleep Application. I hereby consent to receive Telehealth Services from providers engaged through the Empower Sleep Application.
Empower Sleep has partnered with Adept Labs, Inc. d/b/a Vital and affiliate Openloop Healthcare Partners, PC for blood testing/laboratory services to our patients. As part of the partnership, you are consenting to Vital and Openloop Healthcare Partners, PC providing telehealth services as described below.
I understand that Telehealth is a mode of delivering health care services via communication technologies (e.g., internet or cellphone) to facilitate diagnosis, consultation, treatment, education, care management, and self-management of a patient’s health care.
By acknowledging my consent below, I understand and agree to the following:
There are potential risks to using electronic communications for the purpose of a health care visit, including, but not limited to, service interruptions, unauthorized access, technical difficulties, call termination or other equipment failures. I acknowledge and accept those risks, understanding there are alternatives to receiving Telehealth Services.
I understand there are potential risks to the use of Telehealth technology, including but not limited to, interruptions, delays, unauthorized access, and or other technical difficulties. I understand that either my Telehealth provider or I can discontinue the Telehealth appointment if the technical connections are not adequate for my visit.
I understand that I could seek an in-office visit rather than obtain care from a Telehealth provider, and I am choosing to participate in a Telehealth consultation with Vital, an affiliate of Openloop Healthcare Partners, PC, Openloop Healthcare Partners, PC, Openloop Healthcare Partners California, PC, Openloop Healthcare Partners Colorado, PC, Openloop Healthcare Partners New Jersey, PC, Openloop Healthcare Partners Wisconsin SC, Reliant.MD Medical Associates, PLLC, Reliant.MD Medical Associates California, PC, Reliant.MD Medical Associates Colorado, PC, Reliant.MD Medical Associates New Jersey, PC, Reliant.MD Medical Associates Wisconsin, SC, MECNB Physician Services, PC, MECNB Physician Services California, PC, MECNB Physician Services Colorado, PC, MECNB Physician Services New Jersey, PC, and MECNB Physician Services, SC.
To protect the confidentiality of my health information, I agree to undertake my Telehealth consultation in a private location, and I understand that my Telehealth provider will similarly be in a private location.
I understand that I am responsible for payment of any amounts due and owing resulting from my Telehealth visit.
In an emergent situation, I understand that the responsibility of my Telehealth provider may be to direct me to emergency medical services, such as an emergency room.
By acknowledging below, I certify:
that I have read this form and/or had it explained to me
that I understand the risks and benefits of a Telehealth appointment
that I have been given the opportunity to ask questions and that such questions have been answered to my satisfaction.