Consent To Telehealth
Last Updated: March 1, 2019
By clicking the button titled "I Agree and Consent", you acknowledge that you understand and agree with the following:
Make sure you read all the important information below because we cover:
How our medical team consists of doctors and nurse practitioners.
How most states require you to do a video consultation with one of our doctors or nurse practitioners.
When our duty of care begins.
The benefits and risks of using our service.
The importance of reading all the information we provide.
The importance of answering all questions fully and truthfully.
The risks of accepting our treatment plan.
The risks to electronic health information.
Promo code programs from an employer, health insurer or other organization.
Only use our service if you've read this information and subsequently made an informed decision that our service is right for you. If you have any questions, please send us a message through the App or Website or call us at 424-334-9213
BACKGROUND INFORMATION
We have three medical groups. All three medical groups do business as 'Paloma Health'. If you are in Colorado, Tennessee, Arizona or California, this service is provided by Chrysalis Health of California PC, registered in California. If you are in Texas this service is provided by Chrysalis Health of Texas, A Professional Association, registered in Texas. If you are in Illinois, this service is provided by Chrysalis Health of Illinois, a Professional Corporation registered in Illinois. If you are in Florida, this service is provided by Chrysalis Health of Florida PC, a Professional Corporation registered in Florida.
Our medical team is made up of doctors and nurse practitioners. Whenever we use the term 'doctor' we mean both our doctors and nurse practitioners.
Most states require you to do a video consultation with our medical team. The video consultation allows you to ask any questions and allows our medical team to judge your suitability for our online model of care.
We are an online doctor's office and not a pharmacy. If you request that your medicines be delivered to you in the mail, we'll arrange for an independent third party US pharmacy to dispense and mail your medicines.
NOT FOR EMERGENCIES
I understand that I should never use Paloma Health in a medical or psychiatric emergency. I understand that in an emergency, I should dial 911 or go to an emergency department.
WHEN OUR DUTY OF CARE BEGINS
I understand that the doctor will take responsibility for my care only after I have created an account, answered all the required health questions and provided a photo and/or have had a video visit and made payment, and the doctor has subsequently reviewed my request for treatment and the health questions that I have completed and any photos and/or information received from a video visit, reviewed all my information, and then subsequently determined that I am a good candidate for the telehealth services. I understand that the duty of care does not begin at the point of me answering questions or making payment or starting a video visit but at the point at which the doctor accepts the duty of care.
I understand that the doctor has the right to refuse to take responsibility for my care if the doctor makes a professional judgment that I am not a good candidate for this service. I understand that making a request for treatment (by completing a visit on the Website and making payment or by starting a video visit) or sending a message through the app does not in and of itself create a duty of care or create a doctor-patient relationship.
I understand that there may be a delay until the next business day before a doctor reviews my request for treatment and any messages I send.
I understand that the only content in the App or Website that constitutes professional medical advice is the personalized messages the doctor sends me (once I have completed the health questions and made payment, and the doctor has subsequently taken responsibility for my care) and any content that the doctor links to in such messages and advice that a doctor provides in a video visit. No other content in the App or Website constitutes professional medical advice. Specifically the information provided in our health questions about who we can and cannot treat does not constitute professional medical advice.
I understand that all other content in the App or Website does not constitute professional medical advice and is instead for information purposes only. Never disregard professional medical advice or delay in seeking it because of something you have read on our App or Website.
BENEFITS AND RISKS OF USING OUR SERVICE
I understand that by using the service I'm seeking great care that's convenient and affordable.
I understand that important differences exist between Paloma Health’s model of care and traditional healthcare. Specifically by using Paloma Health I accept a far greater responsibility to read and understand information throughout the App and Website about the limitations of Paloma Health's model of care, the risks of seeking care this way, and the risks and benefits of a proposed treatment plan.
I understand that I must read and understand the Consent to Telehealth, the Terms of Use, the Privacy Policy, the FAQs, the information provided about a service before I answer health questions, the information provided in the health questions themselves, messages I receive from Paloma Health, and, very importantly, content provided via links in the message that the doctor sends me after the doctor has reviewed all my information and recommended a treatment plan and, when appropriate, prescribed a medicine.
I understand that to read important information I may need to both click on links and various titles to expand the information that's visible below, and that without clicking on links and titles I will not be able to read important information that enables me to give my informed consent to a treatment.
I understand that by using Paloma Health I accept the responsibility to provide full and truthful answers to all questions and, when requested, to provide unaltered photos of me that are taken at the time of using our service.
I understand that the doctor is unable independently to verify the information and photos I provide and that the doctor will make a professional judgment based on the information and photos I provide.
I understand that I won’t receive any other medical services that go beyond the diagnosis and treatment of hypothyroidism, the diagnosis and treatment of a Hashimoto’s and the diagnosis and treatment of hyperthyroidism. I need to seek other sources of care for my other medical needs.
I understand that by using the service for a telemedical consultation, I won't have an in person consultation and physical exam that might identify a medical condition that needs further investigation or immediate treatment.
I understand that by using the service I won't necessarily speak or message with a doctor or nurse in real time. The only exception to this is patients who will have a video visit with a doctor.
I understand that I must check the App or Website for messages because this is the way that the doctor will communicate important information to me. I understand that if I don't check the App or Website regularly, then my care may be delayed.
I understand that if I have any questions relating to my care that aren't urgent, I can message the doctor through the App or Website. I understand that the doctor may not review and respond to my messages until the next business day.
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 telehealth 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 Group at contact@palomahealth.com or call us at 424-334-9213.
I understand that federal and state law requires health care providers to protect the privacy and the security of health information. I understand that Paloma Health will take steps to make sure that my health information is not seen by anyone who should not see it. I understand that telehealth 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 telehealth encounter beyond the control of Paloma Health. I agree to hold harmless Paloma Health for delays in evaluation or for information lost due to such technical failures.
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. I understand that I may suspend or terminate use of the telehealth 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 Paloma Health providers are not able to connect me directly to any local emergency services.
I understand that alternatives to telehealth consultation, such as in-person services are available to me, and in choosing to participate in a telehealth 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 Paloma Health provider (e.g. labs or bloodwork).
I understand that I may expect the anticipated benefits from the use of telehealth 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 Paloma Health provider in order to operate the telehealth 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 telehealth examination; and/or (3) terminate the consultation at any time.
I understand that I will not be prescribed any narcotics for pain, 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.
Additional State-Specific Consents: The following consents apply to users accessing the Group website, and only to the extent that the Group website is available to users in such states (the state specific language below does not imply the Group website is available is available in such state), for the purposes of participating in a telehealth consultation as required by the states listed below:
Arizona: I understand I am entitled to all existing confidentiality protections pursuant to A.R.S. § 12-2292. I also understand all medical reports resulting from the telemedicine consultation are part of my medical record as defined in A.R.S. § 12-2291. I also understand dissemination of any images or information identifiable to me for research or educational purposes shall not occur without my consent, unless authorized by state or federal law. (A.R.S. § 36-3602).
Colorado: The patient may refuse telemedicine services at any time, without loss or withdrawal of treatment. All applicable confidentiality protections shall apply to the services. The patient shall have access to all medical information from the services, under state law. (CO 25.5-5-320. )
Texas: I understand that my medical records may be sent to my primary care physician with my consent. (V.T.C.A., Occupations Code § 111.005).
IMPORTANCE OF READING ALL THE INFORMATION WE PROVIDE
I understand that Paloma Health will provide detailed information in the App and Website to help me make an informed decision about whether to accept a proposed treatment plan. The most important information about a treatment plan is in the link that the doctor will send me when the doctor prescribes a treatment. This information includes detailed information to help me decide if the benefits of the treatment plan outweigh the risks, given the alternative options available to me, which includes the option of not taking any treatment.
I understand the importance of reading the information the doctor provides about adverse events, including the signs and symptoms of serious side effects and common side effects from taking a medicine, as this will ensure that I seek appropriate medical attention in a timely manner.
IMPORTANCE OF ANSWERING ALL QUESTIONS FULLY AND TRUTHFULLY
I understand that by using Paloma Health I seek to enter into a relationship where the doctor relies exclusively upon information and photos that I provide to decide whether or not treatment is safe and appropriate.
I understand that the doctor has no way of verifying the information and photos that I provide and that the doctor will consider information to be accurate, true and complete, including my age, gender and all my answers to health questions, and the photos to be of me, taken at the time of me using the service, and unaltered.
I understand that if I provide information that isn't true and complete, then I'll be at greater risk of adverse events from any treatment that the doctor prescribes and I may take a treatment that isn't necessary, appropriate, or safe.
I understand that if I provide photos that are altered, not of me or not taken at the time of me using the service, then I'll be at greater risk of adverse events from any treatment that the doctor prescribes and I may take a treatment that isn't necessary, appropriate, or safe.
I understand that even if I provide information that is true and complete, I'm still at risk of adverse events from any treatment that the doctor prescribes.
I understand that even if I provide photos that are unaltered, of me and taken at the time of using the service, I'm still at risk of adverse events from my treatment that the doctor prescribes.
I understand that it is important that I don't create more than one account. Creating more than one account makes it impossible for the doctor to see the full history of care that I've received from Paloma Health. This increases the chances that the doctor will not have access to important information and photos in my medical record that could influence the doctor's clinical decision.
I understand that by using Paloma Health I'm giving my explicit consent for the doctor to access medication history, where it's available, from records provided by pharmacy databases via the services of Surescripts and/or DoseSpot. I understand that, if appropriate, the doctor may take this information into account when making a treatment and prescribing decision but this doesn't change how important it is that I provide full, true and complete information during the Paloma Health visit.
RISKS OF ACCEPTING OUR TREATMENT PLAN
I understand that all the medicines that the doctor may prescribe or recommend, including over-the-counter medicines and ‘behind-the-counter' medicines, can cause serious side effects and adverse events that include severe allergic reaction, permanent disability, and death.
I understand that it is my responsibility to make an informed decision whether to accept a treatment plan that the doctor proposes after weighing the risks and benefits of the medicine being prescribed, alternative treatment options and the risks and benefits of such alternatives, and the option of not seeking any treatment.
I understand the importance of reading the manufacturer's leaflet that comes with a medicine, including an over-the-counter or behind-the-counter medicine, before I take a medicine because this leaflet includes important information about risks and warnings.
I understand that adverse events can be caused by a number of things, including an allergic reaction, side effects, or interactions between a medicine that the doctor prescribes and any medical conditions I may have, other prescription medicines or other things (e.g., supplements, herbs, over-the-counter medicines, or recreational drugs) I'm taking, and lifestyle choices such as smoking tobacco products or drinking alcohol.
At home blood test kit
I understand that the test Paloma Health orders looks at my thyroid hormone levels and TPO antibodies levels only. A normal test result means my levels for these biomarkers are normal. Alone it doesn’t provide a comprehensive view about my overall health.
I understand that it’s my responsibility to seek further evaluation from a doctor in person if the test shows that I have higher than normal blood sugar levels.
I understand that hypothyroidism is not the only cause of high or low thyroid hormones levels. The test Paloma Health Health orders can’t tell me the cause of hypothyroidism.
I understand that I can’t use insurance to pay for the test that Paloma Health will order. I understand that if I have insurance, my insurance might pay for a similar test if I saw a doctor in person.
I understand that if I have symptoms of hypothyroidism, a family history of hypothyroidism, or I’m 40 and over and overweight or obese, or I have hypothyroidism or subclinical hypothyroidism, then the generally accepted medical opinion is that I can benefit from an at home thyroid blood test. I understand that if I don’t fall into these groups then there isn’t sufficient data to show if the benefits of the test outweigh the potential harms. Potential harms can include ‘false-positive’ results (a result that says a condition exists when, in fact, it doesn’t) and overtreatment (treating abnormal thyroid hormone levels that may return to normal on their own and would have never caused health problems on their own).
PROMO CODE PROGRAMS
I understand that if I received a promo code for Paloma Health's services from a third party such as my employer, health insurer, or other organization ('Promo-Code-Provider'), I assume all risks associated with my use of the promo code. I understand and agree to fully release, waive, and forever discharge the Promo-Code-Provider from any and all losses, rights, liabilities, claims, demands, legal actions or right of action that I may have now or in the future, known or unknown, for any damages or personal injury that may occur during my use of a promo code for Paloma Health. I understand that by consenting to these terms and using the Paloma Health service, I forfeit any and all right to bring a suit against the Promo-Code-Provider arising from my use of the coupon. This release applies even if the injury or damage is caused in whole or in part by the negligence or fault of the Promo-Code-Provider, however, I understand that the forgoing release does not apply to gross negligence or willful misconduct by the Promo-Code-Provider.
I understand that in the event that Paloma Health, or any of its affiliates (including business associates and vendors) unintentionally discloses or disseminates my personal health information, my only recourse is against Paloma Health and its affiliates, and not against Promo-Code-Provider.
RISKS TO ELECTRONIC HEALTH INFORMATION
I understand that although Paloma Health implements a wide range of administrative, physical, and technical safeguards to protect my health information and comply with HIPAA, Paloma Health cannot guarantee the privacy and confidentiality of my health information.
For more details about how Paloma Health protects and uses your health information and complies with HIPAA, see our Privacy Policy.
SURESCRIPTS
I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form:
In accordance with your State Law and the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I understand that:
1.Paloma Health uses SureScripts, Inc., a prescription system that allows prescriptions and related information to be exchanged between my providers and the pharmacy. The information sent between these systems may include details of any and all prescription drugs I am currently taking and/or have taken in the past. This information will be utilized to Paloma Health.
2.This authorization may include disclosure of prescription information related to alcohol and drug abuse, mental health treatment, and/or confidential HIV related information by SureScripts, Inc. to Paloma Health
3. I have the right to revoke this authorization at any time by writing to Paloma Health. I understand that I may revoke this authorization except to the extent that action has already been taken based on this authorization.
4. Signing this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditioned upon my authorization of this disclosure.
5. Information disclosed under this authorization might be re-disclosed by the recipient, and this re-disclosure may no longer be protected by state or federal law.
6. This authorization expires one year from the date of my signature below.
7. THIS AUTHORIZATION DOES NOT AUTHORIZE PALOMA HEALTH TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CARE WITH ANYONE OTHER THAN THOSE PERMITTED UNDER APPLICABLE LAW.
