INFORMED CONSENT FOR TELEHEALTH SERVICES
Last modified: August, 04, 2021
Telehealth 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. Telehealth services offered by Meru Health Medical, P.A. and its affiliated provider groups (collectively, “Meru Medical”) 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.
Meru Medical physicians and healthcare professionals (our “providers”) are an addition to, and not a replacement for, your primary care physician. Responsibility for your overall medical care should remain with your local primary care doctor, if you have one, and we strongly encourage you to locate one if you do not.
EXPECTED BENEFITS
Improved access to care by enabling you to remain in your home while the Meru Medical provider consults at distant/other sites.
More efficient care evaluation and management.
Obtaining expertise of a specialist as appropriate.
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 Meru Medical at [email protected] or (650)-505-4947.
By checking the box associated with “Informed Consent”, you acknowledge that you understand and agree with the following. If you are a parent/legally-authorized guardian/representative of a minor/child, please read the following with the understanding that “I” and “me” means the minor/child.
I hereby consent to receiving Meru Medical’s services via telehealth technologies. I understand that Meru Medical and its providers offer telehealth-based 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 Meru Medical provider to determine whether or not my specific clinical needs are appropriate for a telehealth encounter.
I have been given an opportunity to select a provider from Meru Medical prior to the consult, including a review of the provider’s credentials.
I understand that federal and state law requires health care providers to protect the privacy and the security of health information. I understand that Meru Medical 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 Meru Medical. I agree to hold harmless Meru Medical 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 Meru Medical 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 Meru Medical 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 Meru Medical 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.
I understand that upon initiating the 12 week program, I will be paired with a therapist who is licensed in the state where I am currently physically located (my “home state”). I represent that I do not have plans to travel outside of my home state during the 12 week program. If I do travel outside my home state, I will inform my therapist, who will make reasonable efforts to pair me with another Meru Health therapist who is licensed in my state of travel. If a licensed Meru Health therapist is not available in my state of travel, I understand that my therapy services may be interrupted and I waive my rights to litigation or any adverse outcomes which may arise and I will not hold Meru Medical provider, or my therapist liable for any possible adverse outcomes which may arise from traveling outside my home state.
ADDITIONAL STATE-SPECIFIC CONSENTS
The following consents apply to users accessing the Meru Medical website for the purposes of participating in a telehealth consultation as required by the states listed below:
Alaska: I understand my primary care provider may obtain a copy of my records of my telehealth encounter. (Alaska Stat. § 08.64.364).
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. (Ariz. Rev. Stat. Ann. § 36-3602).
Connecticut: I understand that my primary care provider may obtain a copy of my records of my telehealth encounter. (Conn. Gen. Stat. Ann. § 19a-906).
D.C.: I have been informed of alternate forms of communication between me and a physician for urgent matters. (D.C. Mun. Regs. tit. 17, § 4618.10).
Georgia: I have been given clear, appropriate, accurate instructions on follow-up in the event of needed emergent care related to the treatment. (Ga. Comp. R. & Regs. 360-3-.07(7)).
Kansas: I understand that if I have a primary care provider or other treating physician, the person providing telemedicine services must send within three business days a report to such primary care or other treating physician of the treatment and services rendered to me during the telemedicine encounter. (Kan. Stat. Ann. § 40-2,212(2)(d)(1)(A)).
Kentucky: If I am a Medicaid recipient, I recognize I have the option to refuse the telehealth consultation at any time without affecting the right to future care or treatment and without risking the loss or withdrawal of a Medicaid benefit to which I am entitled. I understand that I have the right to be informed of any party who will be present at the site during the telehealth consult and I have the right to exclude anyone from being present. I also understand that I have the right to object to the videotaping of the telehealth consultation. (907 Ky. Admin. Regs. 3:170).
Louisiana: I understand the role of other health care providers that may be present during the consultation other than the Meru Medical provider. (46 La. Admin. Code Pt XLV, § 7511).
Maryland: Regarding audiologists, speech language pathologists, and hearing aid dispensers, I recognize the inability to have direct, physical contact with the patient is a primary difference between telehealth and direct in-person service delivery. The knowledge, experiences, and qualifications of the consultant providing data and information to the provider of the telehealth services need not be completely known to and understood by the provider. The quality of transmitted data may affect the quality of services provided by the provider. Changes in the environment and test conditions could be impossible to make during delivery of telehealth services. Telehealth services may not be provided by correspondence only. (Md. Code Regs. 10.41.06.04).
Nebraska: If I am a Medicaid recipient, I retain the option to refuse the telehealth consultation at any time without affecting my right to future care or treatment and without risking the loss or withdrawal of any program benefits to which the patient would otherwise be entitled. All existing confidentiality protections shall apply to the telehealth consultation. I shall have access to all medical information resulting from the telehealth consultation as provided by law for access to my medical records. Dissemination of any patient identifiable images or information from the telehealth consultation to researchers or other entities shall not occur without my written consent. I understand that I have the right to request an in-person consult immediately after the telehealth consult and I will be informed if such consult is not available. (Neb. Rev. Stat. Ann. § 71-8505; 471 Neb. Admin. Code § 1-006.05).
New Hampshire: I understand that the Meru Medical provider may forward my medical records to my primary care or treating provider. (N.H. Rev. Stat. § 329:1-d).
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. (N.J. Rev. Stat. Ann. § 45:1-62).
Pennsylvania: I understand that I may be asked to confirm my consent to behavioral health or tele-psych services.
Rhode Island: If I use e-mail or text-based technology to communicate with my Meru Medical provider, then I understand the types of transmissions that will be permitted and the circumstances when alternate forms of communication or office visits should be utilized. I have also discussed security measures, such as encryption of data, password protected screen savers and data files, or utilization of other reliable authentication techniques, as well as potential risks to privacy. I acknowledge that my failure to comply with this agreement may result in the Meru Medical provider terminating the e-mail relationship. (Rhode Island Medical Board Guidelines).
South Carolina: I understand my medical records may be distributed in accordance with applicable law and regulation to other treating health care practitioners. (S.C. Code Ann. § 40-47-37).
South Dakota: I have received disclosures regarding the delivery models and treatment methods or limitations. I have discussed with the Meru Medical provider the diagnosis and its evidentiary basis, and the risks and benefits of various treatment options. (S.D. SB136 (not yet codified)).
Tennessee: I understand that I may request an in-person assessment before receiving a telehealth assessment if I am a Medicaid recipient.
Texas: I understand that my medical records may be sent to my primary care physician. (Tex. Occ. Code Ann. § 111.005).
Utah: I understand (i) any additional fees charged for telehealth services, if any, and how payment is to be made for those additional fees, if the fees are charged separately from any fees for face-to-face services provided in combination with the telehealth services; (ii) to whom my health information may be disclosed and for what purpose, and have received information on any consent governing release of my patient-identifiable information to a third-party; (iii) my rights with respect to patient health information; (iv) appropriate uses and limitations of the site, including emergency health situations. I understand that the telehealth services Meru Medical provides meets industry security and privacy standards, and comply with all laws referenced in Subsection 26-60-102(8)(b)(ii). I was warned of: potential risks to privacy notwithstanding the security measures and that information may be lost due to technical failures, and agree to hold the provider harmless for such loss. I have been provided with the location of Meru Medical’s website and contact information. I was able to select my provider of choice, to the extent possible. I was able to select my pharmacy of choice. I am able to a (i) access, supplement, and amend my patient-provided personal health information; (ii) contact my provider for subsequent care; (iii) obtain upon request an electronic or hard copy of my medical record documenting the telemedicine services, including the informed consent provided; and (iv) request a transfer to another provider of my medical record documenting the telemedicine services. (Utah Admin. Code r. 156-1-602).
Virginia: I acknowledge that I have received details on security measures taken with the use of telemedicine services, such as encrypting date of service, password protected screen savers, encrypting data files, or utilizing other reliable authentication techniques, as well as potential risks to privacy notwithstanding such measures; I agree to hold harmless Meru Medical for information lost due to technical failures; and I provide my express consent to forward patient-identifiable information to a third party. (Virginia Board of Medicine Guidance Document 85-12).
Vermont: I understand that I have the right to receive a consult with a distant-site provider and will receive one upon request immediately or within a reasonable time after the results of the initial consult. I understand that receiving tele-dermatology or tele-ophthalmology services via Meru Medical does not preclude me from receiving real-time telemedicine or face-to-face services with the distant provider at a future date. (Vt. Stat. Ann. § 9361).
CONFIDENTIALITY, EXEMPTIONS, AND EXCLUSIONS.
The laws that protect the confidentiality of a patient’s personal information also apply to telehealth. Meru Medical has a legal and ethical responsibility to safeguard privacy of all patients and to protect the confidentiality of their health information. All identifying information about patient assessment and treatment as well as personal information contained in patient health records are kept confidential, except as mandated by law. Meru Medical will not release any confidential or private information without a patient’s express written consent such as a signed release of information form, except as mandated by law. In certain situations, mental health professionals are required by law to reveal information obtained during therapy to other persons or agencies without patient consent and my do so without informing said patient. Please note that the following exceptions, without limitation, apply to confidentiality:
Confidentiality does not apply to cases where there is reasonable suspicion of physical, emotional, or sexual abuse or neglect of minors; the elderly (i.e. ages 65 or older); or a dependent adult.
Confidentiality does not apply to cases of potential harm to self or others.
A mental health professional may disclose confidential information in proceedings brought by a client against a professional.
Confidentiality does not apply to cases involving criminal proceedings, except communications by a person voluntarily involved in a substance abuse program.
Confidentiality may not apply in cases involving legal proceedings affecting a parent-child relationship.
Confidentiality may not apply to cases involving a minor child. In such cases, the mental health professional may advise a parent, managing conservator or guardian of a minor, with or without minor’s consent, of the treatment needed by or given to the minor.
It is also important to note that, where applicable, insurance and managed care companies require personal identification information, diagnosis, symptoms, treatment goals, prognosis, evaluation of progress, and other information before reimbursement is considered. Such companies may also maintain the right to have a copy of your records.
TERMINATION, CANCELLATION, OR DISCHARGE
Pursuant to this consent agreement, patients have the right to terminate treatment or seek a second opinion at any time. Patients wishing to end treatment with Meru Medical should notify the appropriate Meru Medical provider in an express written notice addressed to said provider. Upon receipt, if Meru Medical has reasonable concerns such as potential patient harm to self or others, the Meru Medical provider shall make all reasonable efforts to continue treatment or care. In the alternative, if Meru Medical has reasonable concerns that a patient is not benefitting from its treatment or care, the Meru Medical provider may elect to refer patient to other services and, in its sole discretion, the provider may terminate the patient’s treatment or care with Meru Medical. In the event a patient terminates or discontinues treatment or care with Meru Medical without an express written notice, the Meru Medical provider will make all reasonable efforts to contact said patient; provided, however, the provider is unable to reasonably communicate with the patient within three (3) weeks from the first communicative attempt, Meru Medical will consider the relationship fully terminated, at which point, Meru Medical, in its discretion, may send the patient official termination correspondence with alternative referrals.
