Source: https://evens.com/legal/informed-consent
Timestamp: 2019-11-20 04:46:31
Document Index: 652855653

Matched Legal Cases: ['§ 12', '§ 12', '§ 36', '§ 4618', '§ 7511', '§ 329', '§ 40', '§ 9361']

KMG Medical Group MO, P.C. Informed Consent for Telehealth Services
Informed Consent - Evens
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 KMG Medical Group MO, P.C. and its affiliated entities KMG Medical Group TX, P.A., KMG Medical Group NJ, P.C., KMG Medical Group KS, P.A., and its related practices, including Michael Karagas, M.D., P.C. (collectively “KMG”), 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.
KMG physicians (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 KMG provider consults and obtains test results 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 KMG at (855) 443-8367 or help@evens.com.
By checking the box associated with "Informed Consent", you acknowledge that you understand and agree with the following: I hereby consent to receiving KMG’s services via telehealth technologies. I understand that KMG and its providers offer telehealth-based medical 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 KMG 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 KMG 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 KMG 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 KMG. I agree to hold harmless KMG 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 KMG 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 KMG 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 KMG 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 KMG website 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).
D.C.: I have been informed of alternate forms of communication between me and a physician for urgent matters. (17 DCMR § 4618.10).
Louisiana: I understand the role of other health care providers that may be present during the consultation other than the KMG provider. (46 La. Admin. Code Pt XLV, § 7511).
New Hampshire: I understand that the KMG provider may forward my medical records to my primary care or treating provider. (N.H. Rev. Stat. § 329:1-d).
Rhode Island: If I use e-mail or text-based technology to communicate with my KMG 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 KMG 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 1976 § 40-47-37).
Tennessee: I understand that I may request an in-person assessment before receiving a telehealth assessment if I am a Medicaid recipient.
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 KMG 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).
Note, these state-specific telehealth consent rules are constantly changing and being updated/revised. One approach is to have us update this form periodically to revise for new state specific changes. Another approach is to eliminate this state-specific section and just use an informed consent which substantially complies with the spirit and purpose of the rules, albeit might not meet each state’s specific language.