INFORMED CONSENT

Telehealth involves the use of secure electronic communications, information technology, or other means to enable a healthcare provider and a patient at different locations to communicate and share individual patient health information for the purpose of rendering clinical care. This “Telehealth Informed Consent” informs the patient (“patient,” “you,” or “your”) concerning the treatment methods, risks, and limitations of using a telehealth platform.

 

Services Provided:

Telehealth services offered by Woody’s Medical LLC, Doctor Matrix Medical Group, P.A., Doctor Matrix Medical Group of DE, P.A., Doctor Matrix Medical Group of NJ, P.C., Doctor Matrix Medical Group of NY, P.A., Doctor Matrix Medical Group of KS, P.A., and Matthew Brown, M.D., P.C. d/b/a Doctor Matrix Medical Group (collectively, “Group”), and the Group’s engaged providers (the “Providers”) may include a patient consultation, diagnosis, treatment recommendation, prescription, and/or a referral to other providers, as determined clinically appropriate (the “Services”).

 

UpScript does not provide the Services; it performs administrative, payment, and other supportive activities for Group and its other telehealth providers via its platform.

 

Electronic Transmissions:

The types of electronic transmissions that may occur using the telehealth platform include, but are not limited to:

• Appointment scheduling;
• Completion, exchange, and review of medical intake forms and other clinically relevant information (for example: health records; images; output data from medical devices; sound and video files; diagnostic and/or lab test results) between you and your Provider via:
  • asynchronous communications;
  • two-way interactive audio in combination with store-and-forward communications; and/or
  • two-way interactive audio and video interaction;
• Treatment recommendations by your Provider based upon such review and exchange of clinical information;
• Delivery of a consultation report with a diagnosis, treatment and/or prescription recommendations, as deemed clinically relevant;
• Prescription refill reminders (if applicable); and/or
• Other electronic transmissions for the purpose of rendering clinical care to you.

 

Expected Benefits:

Improved access to care by enabling you to remain in your preferred location while your Provider consults with you.

• Convenient access to follow-up care. If you need to receive non-emergent follow-up care related to your treatment, please contact your Provider by sending an email from your Patient Account or calling Patient Support at 844-723-3103.
• More efficient care evaluation and management.

 

Service Limitations:

• The primary difference between telehealth and direct in-person service delivery is the inability to have direct, physical contact with the patient. Accordingly, some clinical needs may not be appropriate for a telehealth visit and your Provider will make that determination.
• THE GROUP AND PROVIDERS DO NOT ADDRESS MEDICAL EMERGENCIES. IF YOU BELIEVE YOU ARE EXPERIENCING A MEDICAL EMERGENCY, YOU SHOULD DIAL 9-1-1 AND/OR GO TO THE NEAREST EMERGENCY ROOM. PLEASE DO NOT ATTEMPT TO CONTACT UPSCRIPT, GROUP, OR SUCH PROVIDERS. AFTER RECEIVING EMERGENCY HEALTHCARE TREATMENT, YOU SHOULD VISIT YOUR LOCAL PRIMARY CARE PROVIDER.
• The Providers are an addition to, and not a replacement for, your local primary care provider and your local medical specialist care providers. Responsibility for your overall medical care should remain with your local primary care and specialist providers, if you have one, and we strongly encourage you to locate one if you do not.
• Group does not have any in-person clinic locations.

 

Security Measures:

The electronic communication systems we use will be encrypted and 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. All the Services delivered to the patient through telehealth will be delivered over a secure connection that complies with the requirements of the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”).

 

Possible Risks:

• Delays in evaluation and treatment could occur due to deficiencies or failures of the equipment and technologies, or provider availability.
• In the event of an inability to communicate as a result of a technological or equipment failure, please contact the Group at 844-723-3103 AND DMMGinfo@upscripthealth.com
• In rare events, your Provider may determine that the transmitted information is of inadequate quality, thus necessitating a rescheduled telehealth consult or an in-person meeting with your local primary care doctor.
• In very rare events, security protocols could fail, causing a breach of privacy of personal medical information.

Lab Work and Appointment Requirement:

• As part of your treatment plan, lab work may be required. It is your responsibility to obtain the necessary blood work at a laboratory that is local to you and schedule a follow-up appointment with your provider once the lab results are available to review them. 
• Please note that your lab results can only be reviewed or discussed during a scheduled medical appointment with one of the Providers.   It is your responsibility to ensure you schedule and attend your appointment with Woody’s in order to have your lab results reviewed and to discuss any next steps.  

• Our Providers can only access your lab result during a scheduled appointment with them.
• If you fail to schedule and/or attend an appointment with Group’s Providers to share and discuss your lab results, Group cannot and will not be held responsible for any lab results, abnormalities or illness or other adverse health consequences that may arise therefrom. 

 

Patient Acknowledgements:
I further acknowledge and understand the following:

1. I understand that my health care provider wishes me to engage in a telemedicine consultation using UpScript.

2. Prior to the telehealth visit, I may be given an opportunity to select a Provider of the Group, as appropriate, including a review of the Provider’s credentials, or I have elected to visit with the next available Provider from Group, and have been given my Provider’s credentials.

3. I understand that I may be asked to provide my identification and confirm my physical location prior to or during the telehealth visit.

4. If I am experiencing a medical emergency, I will be directed to dial 9-1-1 immediately and my Provider is not able to connect me directly to any local emergency services.

5. I may elect to seek services from a medical group with in-person clinics as an alternative to receiving telehealth services from the Group.

6. I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time.

7. Federal and state law requires health care providers to protect the privacy and the security of health information. I am entitled to all confidentiality protections under applicable federal and state laws. I understand all medical reports resulting from the telehealth visit are part of my medical record.

8. Group will take steps to make sure that my health information is not seen by anyone who should not see it. Telehealth may involve electronic communication of my personal health information to other health practitioners who may be located in other areas, including out of state. I consent to the Group using and disclosing my health information for purposes of my treatment (e.g., prescription information) and care coordination, to receive reimbursement for the services provided to me, and for the Group’s health care operations.

9. Dissemination of any patient-identifiable images or information from the telehealth visit to researchers or other educational entities will not occur without my consent unless authorized by state or federal law.

10. There is a risk of technical failures during the telehealth visit beyond the control of Group.

11. In choosing to participate in a telehealth visit, I understand that some parts of the Services involving tests (e.g., labs or bloodwork) may be conducted at another location such as a testing facility, at the direction of my Provider.

12. Persons may be present during the telehealth visit other than my Provider who will be participating in, observing, or listening to my consultation with my Provider (e.g., in order to operate the telehealth technologies). If another person is present during the telehealth visit, I will be informed of the individual’s presence and his/her role. I understand that if others are present during the consultation other than the applicable Provider, they will maintain confidentiality of the information obtained. 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/physical examination that are personally sensitive to me; 2) ask non-medical personnel to leave the telemedicine examination room and or 3) to terminate the consultation at any time.

13. My Provider will explain my diagnosis and its evidentiary basis, and the risks and benefits of various treatment options.

14. I understand that by creating a treatment plan for me, my Provider has reviewed my medical history and clinical information and, in my Provider’s professional assessment, has made the determination that the provider is able to meet the same standard of care as if the health care services were provided in-person when using the selected telehealth technologies, including but not limited to, asynchronous store-and-forward technology.

15. I have the right to request a copy of my medical records. I can request to obtain or send a copy of my medical records to my primary care or other designated health care provider by contacting Group at: 844-723-3103. I understand that I will be charged fees for copying and sending a copy of my records to a designated recipient, unless not permitted under applicable state law.

16. It is necessary to provide my Provider a complete, accurate, and current medical history. I understand that I can log into my “Portal” at any time to access, amend, or review my health information.

17. There is no guarantee that I will be issued a prescription and that the decision of whether a prescription is appropriate will be made in the professional judgement of the Provider. If the Provider issues a prescription for a non-proprietary medication, I have the right to select the pharmacy of my choice.

18. There is no guarantee that I will be treated by a Group provider. My Provider reserves the right to deny care for potential misuse of the Services or for any other reason if, in the professional judgment of my Provider, the provision of the Services is not medically or ethically appropriate.

19. I understand a video consultation will not be the same as a direct patient/health care provider visit due to the fact that I will not be in the same room as my Provider.

20. I understand there are potential risks to this technology including interruptions, unauthorized access, and technical difficulties. I understand that my health care provider or I can discontinue the telemedicine consult/visit if it is felt that the UpScript video conferencing connections are not adequate for the situation.

21. I’m choosing to participate in the telemedicine consultation on the UpScript platform.

22. I have had a direct conversation with my Provider during which I had the opportunity to ask questions in regard to this treatment. My questions have been answered, and the risks, benefits and any practical alternatives have been discussed with me in a language in which I understand.

23. I understand that some medications and supplements may cause some side effects in certain sensitive individuals, may interact with certain prescription medications or lab tests, or cause symptoms due to certain pre-existing disease conditions. I do not expect my medical provider to be able to anticipate and explain all risks and potential complications. I wish to rely on the judgment of the medical providers in recommending programs that they feel are in my best interest, based on the available knowledge. The Medical Providers of this establishment and all subsidiaries, use the manufacturer’s labeling as a source of information when prescribing medications, along with their own experience, the experience of colleagues, recent longer-term studies, and recommendations of
    university-based investigators. You must decide if you are willing to accept
    the risks of possible side effects (even if they may be serious), for the possible help the medications (used in a manner we may deem necessary) may give. Though these effects are unlikely, some may be serious & fatal if left uncontrolled. They include but are not limited to the following:

*Allergic reactions 

Injection site reaction (for injected medications)

*Side effects of medications, with more common possible reactions being:

Headache

Flushing

Dizziness

Runny nose

Nausea

Joint pain

Elevated liver enzymes

Acne

Hair loss

Elevated blood lipids

Much less likely side effects but more serious could be:

Low blood pressure

Chest pain, heart attack

Seizures

Priapism (prolonged erection)

Prostate enlargement

Prostate cancer

Polycythemia (increased red blood cell count)

For the potential side effects of any specific medication prescribed to you, please consult the package labeling included with your medication.

 

Additional State-Specific Consents: The following consents apply to patients accessing Group’s website for the purposes of participating in a telehealth consultation as required by the states listed below:

 

Alaska: 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.

 

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; Or, the Maine Board of Osteopathic Licensure’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.

 

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: I have been informed of the following notice:

 

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.