OpenLoop Healthcare Partners, PC TELEHEALTH CONSENT FORM
Last Updated: October 2024
OUR HEALTHCARE PROVIDERS DO NOT ADDRESS MEDICAL EMERGENCIES. IF YOU BELIEVE YOU ARE HAVING A MEDICAL EMERGENCY, YOU SHOULD DIAL 911 OR GO TO THE NEAREST EMERGENCY ROOM.
INTRODUCTION
Telehealth is a mode of delivering health care services via communication technologies to facilitate diagnosis, consultation, treatment, education, care management, and self- management of a patient’s health care.
You are reviewing and acknowledging this Telehealth Consent Form because you are seeking healthcare services (the “Services”) from OpenLoop Healthcare Partners, PC and its affiliated entities (OpenLoop Healthcare Partners California, PC, OpenLoop Healthcare Partners Colorado, PC, OpenLoop Healthcare Partners New Jersey Professional
Corporation, OpenLoop Healthcare Partners, Wisconsin, S.C., OpenLoop Healthcare Partners Puerto Rico, P.C., Reliant MD Medical Associates PLLC) (collectively, “OpenLoop”) utilizing telehealth technologies facilitated through the OpenLoop Health Inc. website, iOS mobile app, web mobile app, or any partner platform, mobile app, or web mobile technologies (collectively, the “OpenLoop Platform”). This Telehealth Consent Form supplements but does not modify or supersede any Terms of Use, Privacy Policy, or Notice of Privacy Practices of OpenLoop Healthcare Partners, PC, OpenLoop Health Inc., or other healthcare providers offering services via the OpenLoop Platform.
By clicking “I consent to telehealth” you indicate that you have reviewed this Telehealth Consent Form or had it explained to you, that you understand the risks and limitations of using telehealth technologies, that you have been given the opportunity to ask questions and that such questions have been answered to your satisfaction, and that you consent to receiving the Services from licensed health care providers employed by or contracted with OpenLoop (“OpenLoop Providers”) who are located at sites remote from you.
TREATMENT-SPECIFIC CONSENT
By clicking “I consent to telehealth”, you understand and agree to the following:
I understand that OpenLoop offers telehealth visits, which are conducted through videoconferencing, telephonic, and asynchronous technology and my OpenLoop Provider will not be present in the room with me.
I am consenting to OpenLoop importing and accessing my medical records and medical list including prescription records.
To protect the confidentiality of my health information, I agree to undertake my telehealth visit in a private location, and I understand that my OpenLoop Provider will similarly be in a private location. If any other individuals are present (i.e., for technological or translation assistance), I will be informed of the individual’s
presence and such individual’s role, and I will be given the opportunity to consent to such individual’s presence.
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 OpenLoop Provider or I can
discontinue the telehealth appointment if the technical connections are not adequate for my visit. I AGREE TO HOLD HARMLESS OPENLOOP AND ITS MANAGEMENT COMPANY, OPENLOOP HEALTH, INC., TOGETHER WITH THEIR EMPLOYEES, CONTRACTORS, AGENTS, DIRECTORS, MEMBERS, MANAGERS,
SHAREHOLDERS, OFFICERS, REPRESENTATIVES, ASSIGNS, PREDECESSORS, AND SUCCESSORS, FOR DELAYS IN EVALUATION OR FOR INFORMATION LOST DUE TO SUCH TECHNICAL FAILURES.
I understand that in some cases, my OpenLoop Provider might be a nurse practitioner or a physician assistant and not a physician.
I understand that I could seek an in-office visit rather than obtain care from a
OpenLoop Provider, and I am choosing to participate in a telehealth visit with an OpenLoop Provider. I further understand that my OpenLoop Provider may not have access to a complete copy of my medical records and will not have the ability to
perform an in-person examination, which could result in negative health outcomes from the recommended treatment (e.g., adverse drug interactions or allergic reactions). I further understand that while using telehealth technologies may benefit me, no such benefits or specific results are guaranteed and my condition may not improve.
I agree that any information I provide as part of any telehealth visit is accurate, true, and complete.
I understand that my OpenLoop Provider may determine that a telehealth visit is not appropriate for me due to my particular health concern or for other reasons related to my health status. In such a case: (i) I will receive an alert notifying me that I will be unable to use the Services for the particular issue I submitted; (ii) my request for a telehealth visit will not be submitted to my OpenLoop Provider; (iii) my OpenLoop Provider will not receive any of the information that I submitted; and (iv) I will need to seek any needed care in another way.
I understand that participating in a telehealth visit is not a guarantee that I will be given a prescription, and that the decision as to whether a prescription is appropriate for my condition will be made in the professional judgment of my
OpenLoop Provider.
I understand that while the OpenLoop Platform may make available access to certain pharmacy or diagnostic lab services, I may request to use any pharmacy or lab of my preference.
I understand that I am responsible for payment of any amounts due and owing resulting from my telehealth visit.
I understand that OpenLoop Providers do not address medical emergencies via the OpenLoop Platform. I understand that the responsibility of my OpenLoop Provider may be to direct me to emergency medical services, such as an emergency room.
13. I (we) the parent(s) or legal guardian of a minor, do hereby authorize consent to any medical order, laboratory order, medical diagnosis, or treatment and that I (we) have legal authority to consent to such treatment or order.
I agree that OpenLoop Health, Inc. is a third party beneficiary of the Telehealth Consent Form and has the right to enforce it against me.
I understand and agree that I give permission to OpenLoop Providers to use and
disclose my protected health information including my entire medical record. This protected health information is being used or disclosed for the purpose of telehealth treatment. This authorization expires when you contact
If the person or entity receiving this information is not a health care provider or health plan covered by HIPAA, the information described above may be redisclosed to other individuals or institutions and therefore no longer protected by HIPAA.
I may refuse to agree to this authorization. My refusal to sign will not affect my payment, ability to obtain treatment, or eligibility for health plan benefits unless this authorization is requested prior to research related to treatment, enrollment in a health plan, or providing health care that is solely for the
purpose of giving that information to a third party, such as to a court for a legal proceeding.
I may inspect or copy the protected health information to be used or
disclosed under this authorization. For protected health information created as part of a clinical trial, your right to access is suspended until the clinical trial is completed.
I may revoke this authorization in writing at any time by sending a written notification to Privacy Officer at 317 6 th Ave. Ste. 400, Des Moines, IA 50309. Your notice of revocation will not apply to actions taken by OpenLoop Providers prior to the date of receipt of the notice.
ADDITIONAL TREATMENT-SPECIFIC CONSENT (Teletherapy)
The following consent applies to patients accessing the Services to receive a telehealth consultation related to mental or behavioral health.
I acknowledge that I may be offered a telehealth consultation related to my mental or
behavioral health as part of the Services. This type of telehealth consultation, known as “Teletherapy,” involves the communication of my mental health information to my
OpenLoop Provider. Teletherapy has the same purpose or intention as therapy sessions that are conducted in person. However, due to the nature of the technology used, I
understand that Teletherapy may be experienced somewhat differently than face-to-face treatment sessions.
I understand that I have the following rights with respect to Teletherapy:
Patient’s Rights, Risks, and Responsibilities:
I have the right to withhold or withdraw consent for my treatment at any time without affecting my right to future care or treatment.
2. The laws that protect the confidentiality of my medical information also apply to Teletherapy. As such, I understand that the information disclosed by me during the course of a Teletherapy session generally is confidential unless an exception to confidentiality applies (e.g., mandatory reporting of child, elder or vulnerable adult abuse; if my OpenLoop Provider believes I may be a danger to myself or others; or if I raise emotional or mental health as an issue in a legal proceeding).
In addition, I understand that Teletherapy services and care may not be as complete as face-to-face services. I also understand that if my OpenLoop Provider believes I would be better served by another form of therapeutic services (e.g., face-to-face services) I will be referred to a professional who can provide such services in my area.
I understand that I may benefit from Teletherapy, but that results cannot be guaranteed or assured. I understand that there are potential risks and benefits associated with any form of counseling, and that despite my efforts and the efforts of my OpenLoop Provider, my condition may not improve, and in some cases may even get worse.
I accept that Teletherapy is not meant to cover emergency situations. If I am having suicidal thoughts or making plans to harm myself, I can call the National Suicide Prevention Lifeline at 1.800.273.TALK (8255) for free 24 hour hotline support. Patients who are actively at risk of harm to self or others are not suitable for Teletherapy services. If this is the case or becomes the case in future, my OpenLoop Provider will recommend more appropriate services.
I understand that dissemination of any personally identifiable images or information from the Teletherapy interaction to researchers or other entities shall not occur without my written consent.
I understand that my OpenLoop Provider may need to contact my emergency contact and/or the appropriate authorities in case of an emergency. I agree to inform my OpenLoop Provider of the address where I am located at the beginning of each session, and agree to provide the name of a contact person who my OpenLoop Provider may contact on my behalf in an emergency situation.
ADDITIONAL TREATMENT-SPECIFIC CONSENT (HIV Testing)
The following consent applies to patients accessing the Services to receive a telehealth consultation related to Human Immunodeficiency Virus (“HIV”) testing.
HIV is the virus that causes acquired immunodeficiency syndrome (“AIDS”) and can be transmitted through unprotected sex with some who has HIV; contact with blood, including via contaminated hypodermic needles or blood transfusions; by HIV-infected pregnant women to their infants during pregnancy or delivery; or while breastfeeding.
HIV can be detected via an HIV antibody test. The HIV antibody test is a blood test that shows whether you have antibodies to the virus that causes AIDS. A sample of blood will be taken from your arm with a needle. If the first test shows that you have antibodies, a series of tests will then be done on the same blood sample to ensure the first test was
correct. A positive result means that you have been exposed to the virus and are infected with HIV. It does not mean that you have AIDS or that you will become sick with AIDS in the future. While HIV can lead to AIDS, this test does not say whether you have AIDS. However, a positive result also means you could pass the virus to other people. There is treatment for HIV that can help you stay healthy. Individuals with HIV and/or AIDS can adopt safe practices to protect uninfected and infected people in their lives from becoming infected, or being infected themselves with different strains of HIV.
A negative test means you are unlikely to be infected with the virus. It takes time for the
body to produce HIV antibodies. If you have been exposed to HIV recently, you will need to be retested in several months to be sure you’re not infected. Your OpenLoop Provider will explain this to you.
Taking an HIV test is entirely voluntary. If you do not wish to take the test, you may decline and we will not perform the test. This test is not provided on an anonymous basis. Please seek an anonymous test site if you prefer for your HIV test information and results to remain anonymous. Anonymous testing sites are places where you can receive counseling and the HIV test without giving your name or address. You can find the nearest anonymous test site by contacting your local health department.
There are federal and state laws that protect the confidentiality of your HIV test results and related information. Please note, however, that we may disclose your results as required by law for reporting to appropriate public health authorities. There are federal and state laws that prohibit discrimination based on your HIV status and there may be services available to help with any such discrimination.
ADDITIONAL TREATMENT-SPECIFIC CONSENT (Genetic Testing)
The following consent applies to patients accessing the Services to receive a telehealth consultation related to genetic testing.
I acknowledge that I may be offered genetic testing as part of the Services. Testing for genetic conditions can be complex and the specifics of the test, including the methods for collecting a biologic specimen, will vary depending on the condition tested for. There are
risks and benefits to genetic testing. If I am offered genetic testing as part of the Services, my OpenLoop Provider will explain the specifics of my particular test to me, and I will have the opportunity to obtain professional genetic counseling prior to completing the test to fully understand the risks and benefits.
AUTHORIZATION TO BILL INSURANCE AND ASSIGNMENT OF BENEFITS
By clicking “I accept”, I confirm that the above information is true, correct, and complete to the best of my knowledge. I authorize OpenLoop Healthcare Partners, PC and its affiliated entities (OpenLoop Healthcare Partners California, PC, OpenLoop Healthcare Partners Colorado, PC, OpenLoop Healthcare Partners New Jersey Professional Corporation,
OpenLoop Healthcare Partners, Wisconsin, S.C., OpenLoop Healthcare Partners Puerto
Rico, P.C., Reliant MD Medical Associates PLLC) (collectively, “OpenLoop”) to bill my insurance company directly and I further authorize any third-party payer through which I have benefits to make payment directly to OpenLoop. I understand that I am financially responsible for any balance. I also authorize OpenLoop or my insurance company to use and disclose any healthcare information for the purpose of obtaining payment for services and determining insurance benefits. Services provided by outside companies (i.e., lab, pathology, radiology) are billed separately by those companies.
CONSENT TO TEXT OR EMAIL USAGE FOR APPOINTMENT AND OTHER HEALTHCARE REMINDERS AND GENERAL INFORMATION
By clicking “I accept”, I further authorize OpenLoop to contact me by phone or SMS/ text message at the telephone number I have provided, or to send emails at the email address I have provided, with appointment reminders and general health information. I understand that this request is to receive emails and/or text messages will apply to all future
appointment reminders/feedback/health information unless I request a change in writing. I also acknowledge this means of communication is not considered secure for the
transmission of private information.
ADDITIONAL STATE-SPECIFIC DISCLOSURES
The following consents apply to patients accessing the Services for the purposes of participating in a telehealth visit within the states listed below, as required by state law: Alaska: I understand that my primary care provider may obtain a copy of my records of my telehealth encounter.
California Patients: The Open Payments database is a federal tool used to search
payments made by drug and device companies to physician and teaching hospitals. It can be found at https://openpaymentsdata.cms.gov.
For informational purposes only, a link to the federal Centers for Medicare and Medicaid Services (CMS) Open Payments web page is provided above. The federal Physician Payments Sunshine Act requires that detailed information about payment and other payments of value worth over ten dollars ($10) from manufacturers of drugs, medical
devices, and biologics to physicians and teaching hospitals be made available to the public.
Treatment Records: I understand that If I live in one of the following states, my primary care provider or other treating physician may obtain a copy of my telehealth treatment records with my consent, and OpenLoop may securely send a copy of my telehealth treatment records to my primary care provider or other treating physician. If I need help sending my telehealth treatment records to my primary care provider I can contact call 1- 855-597-1248 If I would like OpenLoop to do so, I can contact call 1-855-597-1248 and provide information necessary for OpenLoop to securely send my records.
Connecticut: I understand that my primary care provider may obtain a copy of my records of my telehealth encounter.
Kansas: I understand that if I have a primary care provider or other treating physician, the person providing telemedicine services must send a report to such primary care or other treating physician of the treatment and services rendered to me during the telemedicine encounter within three days of me providing consent to the person providing telemedicine services to send such report.
New Hampshire: I understand that my primary care provider or treating provider may obtain a copy of my records of my telehealth encounter.
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.
Ohio: I understand that my primary care provider may obtain a copy of my records of my telehealth encounter.
South Carolina: I understand that my medical records may be distributed only with my consent and in accordance with applicable laws and regulations to other treating health care practitioners.
Texas: I understand that with my consent my medical records may be sent to my primary care physician within 72 hours after receiving Services.
Billing:
Patients residing in New Jersey, New York, and Rhode Island have the right under each states respective billing laws to request an itemized price list for laboratory results.
Formal Complaints:
California: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website here, or the physician assistant board’s website here.
Georgia: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here.
Idaho: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here.
Indiana: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here.
Iowa: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here.
Kentucky: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here.
Maine: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here.
New York: I have been informed that to get information regarding your rights and how to report professional misconduct, I should visit here.
Oklahoma: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here; or, the Oklahoma Board of Osteopathic Examiners’ website, here.
Oregon: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here.
Rhode Island: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here.
Texas:
NOTICE CONCERNING COMPLAINTS - Complaints about physicians, as well as other licensees and registrants of the Texas Medical Board, including physician assistants, acupuncturists, and surgical assistants may be reported for investigation at the following address: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018, Assistance in filing a complaint is available by calling the following telephone number: 1-800-201-9353, For more information, please visit our website at www.tmb.state.tx.us.
AVISO SOBRE LAS QUEJAS - Las quejas sobre médicos, asi como sobre otros profesionales acreditados e inscritos del Consejo Médico de Tejas, incluyendo asistentes de médicos, practicantes de acupuntura y asistentes de cirugia, se pueden presentar en la siguiente
dirección para ser investigadas: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018, Si
necesita ayuda para presentar una queja, llame al: 1-800-201-9353, Para obtener más información, visite nuestro sitio web en www.tmb.state.tx.us.
Vermont: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here; or, the Vermont Board of Osteopathic Examiners’ website, here.
Wyoming: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here.