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.
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.
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.
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.
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.
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.
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
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.
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.
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:
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.