Telemedicine Consent

OpenLoop Health Informed Consent for Evaluation and Treatment

Telemedicine is the remote delivery of healthcare services, such as clinical and diagnostic assessments, over a telecommunication infrastructure such as phones, tablets, and computers. Providers may include physicians, nurse practitioners, or physician assistants. The information may be used for diagnosis, therapy, follow-up and/or education, and may include any of the following:

• Patient medical records
• Diagnostic tests
• Medical images
• Live two-way audio and video
• Output data from medical devices and sound and video files
• Wearable devices used to gather biometric information such as ECG, pulse, blood pressure, etc.

Tele-electronic systems used 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. For more information about how OpenLoop Health protects your information, including health information, please see our Privacy Policy. The health care services rendered by health care professionals through access to the OpenLoop Health telemedicine platform does not replace the relationship you have with your primary care or specialist providers, and the day to day responsibility for your health care should remain with the your local clinician, if you have one, as does your longitudinal medical record.

Expected Benefits

• Improved access to medical care by enabling a patient to remain in his/her home while the healthcare practitioner is at distant site.
• More efficient medical evaluation and management.
• Improved cost.

Possible Risks

As with any medical care, there are potential risks associated with the use of telemedicine. These risks include, but may not be limited to:

• In rare cases, the consultant may determine that the transmitted information is of inadequate quality, thus necessitating a face-to-face meeting with the patient that the OpenLoop Health health care professionals may or may not be able to conduct;
• Your symptoms might be too severe or concerning to be treated by a telemedicine visit and you will be referred to another health care resource, including an urgent care center or emergency room;
• Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment;
• In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information; and
• In rare cases, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors.

By checking the box associated with “Informed Consent”, you acknowledge that you understand and agree with the following

• I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine.
• I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment.
• I understand the alternatives to telemedicine consultation as they have been explained to me, and in choosing to participate in a telemedicine consultation.
• I understand that telemedicine may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas, including out of state.
• I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured.

Patient Consent to the Use of Telemedicine

By checking the box labeled "I agree to the terms of use, privacy policy, HIPAA notice, and telehealth consent" as part of account creation, I agree to the following:

• I have read this document carefully, and understand the risks and benefits of the telemedicine services and I hereby give my informed consent to participate in a telemedicine visit under the terms described herein.
• I have read, understood, and agree to the terms of this document.
• I am allowing RedBox Rx and OpenLoop Health to import my medication history list and medical history