Informed Consent for Telemedicine Services

Telemedicine involves the use of electronic communications to enable healthcare providers at different locations to share individual patient medical information for the purpose of improving patient care. Telemedicine services offered by Ethos Primary Care (EPC) and the members of its Affiliated Covered Entity may also include chart review, remote prescribing, appointment scheduling, health information sharing, and non-clinical services, such as patient education. The information you provide may be used for diagnosis, therapy, follow-up and/or patient education, and may include any combination of the following: (1) health records and test results; (2) images and asynchronous communications; (3) live two-way audio and video; (4) interactive audio with store and forward; and (5) output data from medical devices and sound and video files.

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.

We believe it is important for every patient to have a local primary care doctor. If EPC does not serve as your local primary doctor, we strongly encourage you to establish a relationship with one in your area. It is important for every patient who engages in EPC Telemedicine services to understand that these services are an addition to, but not a replacement for, local primary medical care. Responsibility for your overall medical care should remain with your local primary care doctor.

Expected Benefits:

Possible Risks:

Delays in evaluation and treatment could occur due to deficiencies or failures of the equipment and technologies.
In rare events, our provider may determine that the transmitted information is of inadequate quality, thus necessitating a rescheduled Telemedicine consult or a 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 judgment errors.

If you need to receive follow-up care, assistance in the event of an adverse reaction to the treatment, or in the event of an inability to communicate as a result of a technological or equipment failure, please contact Ethos Primary Care via 908 867 0060.

By clicking the button titled “I Agree and Consent”, you acknowledge that you understand and agree with the following:

General. Prior to accessing a Practitioner Encounter, you represent and warrant that you are at least eighteen years of age and possess the legal right and ability, on behalf of yourself or a minor child of whom you are a parent or legal guardian, to: (i) agree to these Terms and Conditions of Use; (ii) register for the Practitioner Encounters under your own name; and (iii) use such services in accordance with these Terms and Conditions of Use and abide by the obligations hereunder
Ethos Primary Care Patient Profile. You agree to: (i) fully, accurately and truthfully create your[Ethos Primary Care Profile]; and (ii) prohibit anyone else from using your Ethos Primary Care Profile. You agree to provide accurate, current and complete patient and payment information about yourself for your Ethos Primary Care Profile, and to periodically review and to update such information as needed to keep it accurate, current and complete. You agree to immediately notify Ethos Primary Care of any actual or suspected unauthorized use of your Ethos Primary Care Profile or credentials or other security concerns of which you become aware.
I hereby consent to receiving Ethos Primary Care services via Telemedicine technologies. I understand that Ethos Primary Care and its providers offer Telemedicine-based medical services, but that these services do not replace the relationship between me and my primary care doctor. I also understand it is up to the Ethos Primary Care provider to determine whether or not my specific clinical needs are appropriate for a Telemedicine encounter.
I understand that federal and state law requires health care providers to protect the privacy and the security of health information. I understand that Ethos Primary Care will take steps to make sure that my health information is not seen by anyone who should not see it. I understand that Telemedicine may involve electronic communication of my personal medical information to other health practitioners who may be located in other areas, including out of state.
I understand there is a risk of technical failures during the Telemedicine encounter beyond the control of Ethos Primary Care. I agree to hold harmless Ethos Primary Care for delays in evaluation or for information lost or divulged due to such technical failures.
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. I understand that I may suspend or terminate use of the Telemedicine services at any time for any reason or for no reason. I understand that if I am experiencing a medical emergency, that I will be directed to dial 9-1-1 immediately and that the Ethos Primary Care providers are not able to connect me directly to any local emergency services.
I understand that alternatives to Telemedicine consultation, such as in-person services are available to me, and in choosing to participate in a Telemedicine consultation, I understand that some parts of the services involving tests may be conducted by individuals at my location, or at a testing facility, at the direction of the Ethos Primary Care provider (e.g. labs or bloodwork).
I understand that I may expect the anticipated benefits from the use of Telemedicine in my care, but that no results can be guaranteed or assured.
I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. Persons may be present during the consultation other than the Ethos Primary Care provider in order to operate the Telemedicine technologies. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history/examination that are personally sensitive to me; (2) ask non-medical personnel to leave the Telemedicine examination; and/or (3) terminate the consultation at any time.
I understand that I will not be prescribed any controlled substances, nor is there any guarantee that I will be given a prescription at all.
I understand that if I participate in a consultation, that I have the right to request a copy of my medical records which will be provided to me at reasonable cost of preparation, shipping and delivery.
Payment. 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. You authorize Ethos Primary Care, Inc. to charge your credit card or other payment account for all fees and charges due and payable and agree that no additional notice or consent is required. This charge will take place before the start of your Telemedicine visit. Ethos Primary Care, Inc.’s fees are net of any applicable sales tax and if any services or payments for any goods or services are subject to sales tax in any jurisdiction. You will be responsible for payment of such sales tax and any related penalties or interest and will indemnify Ethos Primary Care, Inc. for any liability or expense incurred in connection with such sales taxes (including any use tax and any other tax measured by sales proceeds that Ethos Primary Care, Inc. is permitted to pass to you) and Ethos Primary Care, Inc. may automatically charge and withhold such taxes for services to be delivered within any jurisdictions that it deems is required. Unless otherwise agreed to by Ethos Primary Care, Inc. in writing, all fees paid are non-refundable. Ethos Primary Care, Inc. reserves the right, without notice, to modify, change, terminate, or suspend service for a subscription plan you are on if, for any reason, payment for such plan is not made or cannot be processed on the due date. This right to modify a subscription plan includes, but is not limited to, the right to change a subscription plan type (for example, from a fixed fee plan without consult co-pays to a lower priced fixed-fee plan with consult co-pays). You may adjust your subscription settings at any time (where applicable, by paying any amounts due).

Additional State-Specific Consents: The following consents apply to users accessing the Ethos Primary Care website, and only to the extent that the Ethos Primary Care Telemedicine is available to users in such states (the state specific language below does not imply the Ethos Primary Care Telemedicine is available in such state), for the purposes of participating in a Telemedicine consultation as required by the states listed below:

New Jersey: I understand I have the right to request a copy of my medical information and I understand my medical information may be forwarded directly to my primary care provider or health care provider of record, or upon my request, to other health care providers. (NJ Rev. Stat. § 45:1-62).

Emergency Situations

If there is an emergency situation Telemedicine is not an appropriate method of care.

IN CASE OF AN EMERGENCY, YOU SHOULD SEEK IMMEDIATE MEDICAL ATTENTION OR EMERGENCY CARE BY CALLING 911.

Indemnification

YOU AGREE TO INDEMNIFY AND HOLD HARMLESS THE PROVIDER, ITS EMPLOYEES, AGENTS, DIRECTORS, MEMBERS, MANAGERS, SHAREHOLDERS, OFFICERS, REPRESENTATIVES, ASSIGNS, PARENTS, PREDECESSORS, AND SUCCESSORS FROM AND AGAINST ANY AND ALL LOSS OR DAMAGE, INCLUDING ANY AND ALL INDIRECT, INCIDENTAL, SPECIAL, CONSEQUENTIAL OR EXEMPLARY DAMAGES, EXPENSES, LIABILITIES, CLAIMS, OR DEMANDS WHATSOEVER ARISING OUT OF OR RELATED TO ANY FAILURE OF TECHNOLOGY OR EQUIPMENT IN CONNECTION WITH THE PROVISION OF TELEMEDICINE, WHETHER OR NOT ANY SUCH LOSS, DAMAGE, EXPENSE, LIABILITY, CLAIM, OR DEMAND ARISES FROM OR RELATES TO THE PROVIDER’S NEGLIGENCE.

Click here to see the benefits of Telemedicine.