INFORMED CONSENT REGARDING USE OF TELEHEALTH SERVICES

ProviderEntity: MD Integrations, LLC dba MD Integrations
ProviderName: Dr. Marc Serota or MD Integrations Designated Physician
ProviderLicense No: 1740410463 or MD Integrations Designated Physician License No.

‍PURPOSE
‍The purpose of this form is to provide you with information about telehealth and to obtain your informed consent to participate in a telehealth health visit with MD Integrations as part of your overall health and wellness.
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‍NATURE OF TELEHEALTH
‍Telehealth involves the use of electronic communications to enable a health care provider and a patient at different locations to share medical information for the purpose of evaluation, diagnosis, consultation, or treatment of the patient. The delivery of healthcare via telehealth allows the patient and provider to establish a relationship, much as they would during a traditional face-to-face appointment. For example, your telehealth encounter may include interaction through and with the use of the internet and real-time video, and may also include recorded audio communications, medical imaging, medical tests, and diagnoses, as well as related technologies known as “store-and-forward.” Providers are employees or contractors of MD Integrations. MD Integrations and all telehealth visits are conducted via MD Integrations. MD Integrations has a financial relationship with Signos, Inc.

‍BENEFITS
‍The benefits of telehealth include improved access to medical services and care, including the expertise of specialists and consultants that may not otherwise be available to you. Telehealth also permits increased efficiency in evaluations, diagnoses, consultations, and treatment.

‍POTENTIAL RISKS
‍The potential risks associated with the use of telehealth are rare, but include delays in medical evaluation and treatment due to equipment failures or information transmission deficiencies (such as poor image resolution); breach of privacy of protected health information due to security breaches or failures; and adverse drug interactions, allergic reactions, complications, or other errors due to patient’s failure to provide complete medical information or records.

‍INDEMNIFICATION
‍YOU AGREE TO INDEMNIFY AND HOLD HARMLESS MD INTEGRATIONS, ITS EMPLOYEES, CONTRACTORS, AGENTS, DIRECTORS, MEMBERS, MANAGERS, SHAREHOLDERS, OFFICERS, REPRESENTATIVES, ASSIGNS, AFFILIATES, PARENTS, PREDECESSORS, AND SUCCESSORS, INCLUDING SIGNOS, INC., FROM AND AGAINST ANY AND ALL LOSS, DAMAGE, EXPENSE, LIABILITY, CLAIM, OR DEMAND WHATSOEVER, ARISING OUT OF OR RELATED TO ANY FAILURE OF TECHNOLOGY OR EQUIPMENT IN CONNECTION WITH THE PROVISION OF TELEHEALTH WHETHER OR NOT ANY SUCH LOSS, DAMAGE, EXPENSE, LIABILITY, CLAIM, OR DEMAND ARISES FROM OR RELATES TO THE NEGLIGENCE OF MD INTEGRATIONS.

‍ALTERNATIVES
‍Alternative methods of care may be available to you, such as in-person services. Your provider will explain any such options to you, and you may choose an alternative at any time.

‍FOLLOW-UP CARE; EMERGENCY SITUATIONS
‍In some situations, telehealth is not an appropriate method of care. If there is an emergency situation, if you have an adverse reaction, if a technical failure prevents you from communicating with your telehealth provider, or if you believe telehealth will not provide sufficient safety and quality, you should contact MD Integrations as indicated below. If the contacts listed below are unavailable, you must seek care at an emergency room facility or other provider equipped to deliver emergent care. If the situation is an emergency, call 911.
‍MEDICAL PROVIDER NAME: MD Integrations
PHONE:(330) 301-5355
HOURS OF OPERATION: 9am – 5pm Eastern

‍YOUR PRIVACY RIGHTS
‍MD Integrations uses network and software security protocols to protect the confidentiality of your patient health information, including for example your medical record, EMR, imaging, and personal financial data. These protocols are designed to safeguard the data and to ensure its integrity against corruption; however, perfect data security is not possible. Personal information that identifies you or contains protected health information will not be disclosed to any third party without your consent, except as authorized by law for the purposes of consultation, treatment, payment/billing, and certain administrative purposes, or as otherwise set forth in MD Integrations' Notice of Privacy Practices.
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‍PRIMARY CARE
‍If you have a primary care physician, we encourage you to inform them about your visit with MD Integrations. This will help your primary care physician coordinate your medical care regarding your weight loss and other matters. Also, the primary care physician may be able to support you if in-person care is needed.

I understand that I should discuss my care with MD Integrations with my primary care physician. If you authorize MD Integrations to send records related to your telehealth visit to your primary care doctor, please email support@mdintegrations.com so that we can facilitate that process.

If you have a concern about a medical professional, you may contact the Medical Board or other licensing board regarding your concerns.

By signing this form, I understand the following:

Telehealth is the use of electronic information and communication technologies by a health care provider to deliver services to an individual when he/she is located at a different site than the provider. I understand how the video conferencing technology will be used to conduct the visit, and have been given the opportunity to ask questions regarding the technology. I understand that this visit will not be the same as an in-person visit due to the fact that I will not be in the same physical location as the healthcare provider at the distant site.
I understand that I need to provide a full and accurate medical history, including any pre-existing conditions, to my telehealth provider so that my provider can accurately determine what services I need. I further understand that my provider will determine whether telehealth is appropriate for me at this time, based on the condition being diagnosed and/or treated.
I understand that, if I am prescribed a prescription medication or device, I am free to obtain my prescription from any pharmacy of my choice. If I decide to use a pharmacy of my choice and not our partner pharmacy, I agree to email support@mdintegrations.com to provide my pharmacy information.
I understand that all providers are employees or contractors of MD Integrations and all telehealth visits are conducted via MD Integrations. MD Integrations has a financial relationship with Signos, Inc.
I understand that I may benefit from telehealth, but that results cannot be guaranteed. My provider will inform me who will be present at the provider’s location during the telehealth service and I have the right to exclude anyone from being present, if I so choose. I further understand that I have the right to object to the use of a telehealth service without prejudice to any future care or treatment and without risking the loss or withdrawal of any health benefits to which I am entitled.
I understand the costs to me associated with my telehealth encounter.
I understand that the laws that protect privacy and the confidentiality of medical information also apply to telehealth and I agree that MD Integrations may provide my confidential personal health information to other medical providers who may be located in other areas, including on rare occasions to providers outside the State, as necessary, and my medical information and records may also be made available to my insurance carrier for quality review and audits.
I have the right to inspect and obtain copies of all information received and recorded during any telehealth session, subject to the policies of the physicians, physician assistants, nurse practitioners and facilities involved in my care. I may be charged a fee for copies of my records in accordance with applicable rules. I have read and understand the information above and all of my questions have been answered to my satisfaction.
I consent to the contracted professionals of MD Integrations, including but not limited to, physicians, physician assistants, or nurse practitioners, providing services to me via telehealth.
I understand that this form only covers generally and my provider will personally discuss specific concerns and questions with me.
I further understand that I will be responsible for any payments that apply to my telehealth visit. I agree that I will not submit the bills for these services to any commercial health insurance plan or governmental health insurance plan, including but not limited to Medicare, Medicaid or Tricare.
I understand that my failure to comply with the terms of this agreement may result in MD Integrations terminating the relationship. I am also free to stop seeking services from MD Integrations at any time.

By checking the box connected to this form, I agree that I have read this form and I consent to treatment via telehealth.

This notice was last updated on October 21, 2022.