Cue Care and Medical Groups Telehealth Informed Consent
This is a legal and binding document between you, and your medical provider group, Wheel Medical, P.A., a Florida professional association, on behalf of itself and its affiliated professional entities (collectively, “Wheel Provider Group” or “Wheel”) and/or OpenLoop Healthcare Partners, PC and affiliates (OpenLoop Healthcare Partners California, PC, OpenLoop Healthcare Partners Colorado, PC, OpenLoop Healthcare Partners New Jersey, PC, OpenLoop Healthcare Partners Wisconsin, SC) (collectively, “OpenLoop Provider Group” or “OpenLoop”) (Wheel Provider Group and OpenLoop Provider Group, collectively referred to as “We,”“Our”, or “Us”).
Please read this carefully before clicking the checkbox indicating that you accept these terms.
By clicking “I agree”, you hereby consent to receive health care services from licensed health care providers (“Providers”) contracted with either Wheel Provider Group (“Wheel-affiliated Providers”) or OpenLoop Provider Group (“OpenLoop-affiliated Providers”), who are located at sites remote from you, to provide consultative services to you. The receipt of health care services from a Wheel-affiliated Provider or an OpenLoop-affiliated Provider (the “Services”) is a type of “telemedicine” or “telehealth” service. The Providers will not be present in the room with you.
By clicking “I agree”, you (a) further certify that you are the patient, or that you are duly authorized by the patient as the patient’s representative or legal guardian, (b) acknowledge and accept the risks identified above and the terms associated with the receipt of clinical services via the Services, and (c) give your informed consent to receive clinical services under the terms described herein.
Description of Services
Providers may include behavioral health or primary care practitioners, nurse practitioners, physician’s assistants, specialists, and/or subspecialists. The name, credentials, and specialty or subspeciality of your licensed health care provider will be disclosed to you before, during, or after the Services are provided. In some cases, telemedicine visits may not be the most appropriate way for you to seek medical care and treatment. For example, certain medical conditions may require an in-person procedure, more urgent attention, or a health care provider other than your Provider using the Services.
- We may ask you a series of initial questions to help you determine whether a telemedicine visit is appropriate for you. Based on your responses to these questions, we may determine that a telemedicine visit may not be appropriate for the particular issue for which you are seeking a telemedicine visit or for other reasons related to your health status. In such a case: (i) you will receive an alert notifying you that you will be unable to use the Services for the particular issue you submitted; (ii) your request for a telemedicine visit will not be submitted to your Wheel-affiliated Provider or OpenLoop-affiliated Provider; (iii) your Provider will not receive any of the information that you submitted; and (iv) you will need to seek any needed care in another way.
- Your Provider may, following submission of a telemedicine visit request, determine that your diagnosis or treatment requires an in-person office visit or is otherwise not appropriately addressed through use of the Services. In such a case, your Provider may notify you that you will be unable to use the Services for the particular issue you submitted and provide additional 2information regarding next steps. Your Provider is solely responsible for providing you any such notification, whether through the Services or by some other means.
- We will use store-and-forward technology, audio-only consultations, and/or audio-video consultations to provide the Services. To ensure privacy and confidentiality of the Services, we use industry standard security measures. The Services may, but not necessarily will, result in a new prescription, refilling an existing prescription, patient education, non-prescriptive recommendations, or a recommendation to seek follow-up care in-person or through a different provider.
- A Provider may also perform Clinician Oversight for laboratory tests provided by third-party healthcare providers. Clinician Oversight involves ordering tests when appropriate, providing Patient Outreach when appropriate (defined below), and reviewing and releasing test results. Wheel and OpenLoop do not provide laboratory tests and are not responsible for the provision of laboratory tests or other services provided by third parties or through third-party websites. If you receive a laboratory test result with a value that is outside the normal range to a degree that may constitute an immediate health risk to you or require immediate action on the part of the ordering Wheel-affiliated Provider or OpenLoop-affiliated Provider (“Critical Result”) or below the established norms for a particular test, but not as urgent as a Critical Result (“Abnormal Result”), a Provider will reach out to you directly (“Patient Outreach”). The Wheel-affiliated Provider or OpenLoop-affiliated Provider will review for symptoms, educate you on the test results, and make recommendations for follow-up treatment.
- Wheel and OpenLoop will have no responsibility or liability for your Wheel-affiliated Provider’s or OpenLoop-affiliated Provider’s delay or failure to respond to a telemedicine visit request, to notify you that your telemedicine visit cannot be completed, or to provide you with next steps or follow-up information, or for any care, medical advice or treatment provided by your Provider.
The following consents apply to patients accessing the Services for purposes of receiving Clinician Oversight or a telehealth consultation for a following treatment area:
- Human Immunodeficiency Virus (“HIV”) Testing
- What is HIV?
- HIV is the virus that causes AIDS and can be transmitted through unprotected sex (vaginal, anal, or oral sex) with someone who has HIV; contact with blood as in sharing needles (piercing, tattooing, drug equipment); by HIV-infected pregnant women to their infants during pregnancy or delivery; or while breast feeding.
- How does the test work?
- The HIV antibody test is a blood test. The test shows if you have antibodies to the virus that causes AIDS. A sample of your blood will be taken from your arm with a needle. If the first test shows that you have antibodies, a series of tests, including a different test, will then be done on the same blood sample to make sure the first test was right. A positive test result means that you have been exposed to the virus and are infected. It does not mean that you have AIDS, or that you will necessarily become sick with AIDS in the future. While HIV can lead to AIDS, this test does not say whether or not you have AIDS. A negative test means that you are probably not infected with the virus. It takes the body time to produce HIV antibodies. If you have been exposed to HIV recently, you 3need to be retested in several months to make sure you are not infected. Your doctor or counselor will explain this to you.
- Do I have to take this test?
- No. Taking an HIV test is completely voluntary. If you do not want to take the test, you may decline, and we will not perform the test.
- What does it mean if the test is negative?
- A negative test means you're probably not infected with HIV. But it takes the body time to produce the HIV antibodies. It may just be too soon for the antibodies to be seen in the test. If you recently had sex without a condom or shared needles with someone who may be infected, you may want to be tested again in three to six months. Please talk to your doctor or HIV tester about this.
- What does it mean if the confirmatory test is positive?
- A positive confirmatory test result means you are infected with HIV. It doesn't necessarily mean you have AIDS, but HIV is the virus that causes AIDS. It also means you could give the virus to other people. People who are infected can pass the virus during sex or by sharing needles during drug use. A pregnant woman who is infected can pass the virus to her baby during pregnancy or childbirth.
- There is treatment for HIV that can help you stay healthy.
- Individuals with HIV/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.
- These Services are not provided on an anonymous basis, so please seek an anonymous test site if you prefer for your HIV test information and results to remain anonymous. This is a place 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 department of health.
- There are federal and state laws that protect the confidentiality of your HIV test results and related information. However, 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 such consequences.
Benefits and Risks to using the Services
Your use of the Services may have the following possible benefits:
- Making it easier and more efficient for you to seek medical care and treatment for the conditions treated by the applicable health care provider;
- Allowing you to seek medical care and treatment by your Wheel-affiliated Provider or OpenLoop-affiliated Provider at times that are convenient for you; and
- Enabling you to communicate with your Wheel-affiliated Provider or OpenLoop-affiliated Provider without the necessity of an in-office appointment.
As with any medical procedure, there are potential risks associated with the use of telemedicine or telehealth services, which may include, without limitation, the following:
- The information transmitted to your Provider may not be sufficient (e.g., poor resolution of images) to allow your Provider to make an appropriate medical decision;
- Your Provider’s inability to conduct certain tests or assess vital signs in-person may in some cases prevent the provider from providing a diagnosis or treatment or from identifying the need for emergency medical care or treatment for you;
- Your Provider may not be able to provide medical treatment for your particular condition and you may be required to seek alternative health care or emergency care services;
- Delays in medical evaluation/treatment or a failure to obtain needed treatment could occur due to unavailability of your Wheel-affiliated Provider or OpenLoop-affiliated Provider, deficiencies or failures of the technology or electronic equipment used, a transmission delay or failure, issues with the internet or other communications means, or for other reasons;
- The electronic systems, public networks, or security protocols or safeguards used in the Services could fail, causing a breach of privacy of your medical or other information;
- Your Wheel-affiliated Provider’s or OpenLoop-affiliated Provider’s diagnosis and treatment options, especially pertaining to certain prescriptions, may be limited;
- Lack of access to your medical records or ability to perform an in-person examination, which could result in negative health outcomes (e.g., adverse drug interactions, allergic reactions).
Either your Provider or you can discontinue the Telehealth Services if the technical connections are not adequate for the Services.
By clicking “I accept”, you also represent and warrant the following:
- Your Provider has discussed the use of telemedicine services with you, including the benefits and risks of such use and alternatives to the use of the Services, and you have provided consent to your Wheel-affiliated Provider or OpenLoop-affiliated Provider for the use of the Services.
- You understand that you have the right to access your medical information created during use of the Services or to have the medical information forwarded to a third-party or alternative provider. Wheel and OpenLoop will not forward any personally identifiable information to third-parties or other providers without your written consent.
- You understand Wheel and OpenLoop may use third-party vendors to provide the Services.
- You understand that the use of the Services involves electronic communication of your personal medical information to your Wheel-affiliated Providers or OpenLoop-affiliated Providers who may be located in other areas, including outside of the state in which you reside, and that the electronic systems, public networks, or security protocols or safeguards used in the Services could fail, causing a breach of privacy of your medical or other information. You agree to hold Wheel and OpenLoop harmless for any information lost due to technical failures.
- You understand that, despite the privacy risks associated with the Services, all federal and state laws, rules, and regulations regarding privacy and confidentiality will apply to the Services, including HIPAA.
- You understand that it is your duty to provide your Wheel-affiliated Provider or OpenLoop-affiliated Provider truthful, accurate, and complete information, including all relevant information regarding care that you may have received or may be receiving from other health care providers or outside of the Services. You also understand that if you are uncomfortable with receiving the Services or the method in which the Services are provided, you should inform your Wheel-affiliated Provider or OpenLoop-affiliated Provider.
- You understand that your Provider may determine that your condition is not suitable for diagnosis or treatment using the Services, or may fail to respond promptly or ever to your request for a telemedicine service, and that you may need to seek medical care and treatment from your Provider, a specialist, or other health care provider outside of the Services.
- You understand that in the event of an emergency or an adverse reaction to treatment, you should dial 911 to receive appropriate follow-up care. In the event of technology failure or your Wheel-affiliated Provider or OpenLoop-affiliated Provider determining you need see another provider or make an in-person appointment, he or she will provide you with next steps or follow-up information.
- You understand the risks and benefits of the Services and its use in the medical care and treatment provided to you by your Wheel-affiliated Provider or OpenLoop-affiliated Provider. You also understand that you may refuse or withdraw from care at any time, and that your refusal or withdrawal will not affect your ability to receive care in the future.
- You understand that failure to comply with the terms of this document may result in the termination of your ability to use the Services.
- No potential benefits from the use of the Services, care provided via the Services, or specific results can be guaranteed. Your condition may not be cured or improved, and in some cases, may get worse. You understand that you could seek an in-office visit rather than obtain Services from a telehealth provider, and you are choosing to participate in Telehealth Services with your Wheel-affiliated Provider or OpenLoop-affiliated Provider.
- To protect the confidentiality of your health information, you agree to undertake your Services in a private location, and you understand that your Provider will similarly be in a private location.
- You understand that you are responsible for payment of any amounts due and owing resulting from your Services.
Additional State-Specific Consents:
The following consents apply to patients accessing the Services for the purposes of participating in a telehealth consultation within the states listed below, as required by state law:
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 Wheel or 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 Wheel at firstname.lastname@example.org, and I can contact OpenLoop via a web form at https://openloophealth.com/contact.
- Alaska: I understand that my primary care provider may obtain a copy of my records of my telehealth encounter.
- 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.
- Formal Complaints:
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.