Legal

Effective: October 1, 2018

Relief Telemed, Inc., on its own behalf and on behalf of its affiliates and/or wholly owned subsidiaries (collectively referred to as “Relief”, “we”, “us”, or “our”), owns and operates the websites located at www.relieftelemed.com, provider.relieftelemed.com and various mobile applications (collectively, the “Site” or “Sites”). and various mobile applications (collectively, the “Site” or “Sites”). Through these Sites we operate various online services that enable eligible individuals (“Members”) to receive various types of health care information and telehealth services (“Services”). The Sites also have public portions that allow anyone to educate themselves on the Services available from Relief.

APPLICABILITY OF THESE TERMS AND CONDITIONS

These Web and Mobile Terms and Conditions (“Terms and Conditions”) govern your use of the Sites. Use of any of the Sites constitutes your acceptance of these Terms and Conditions and the Web and Mobile Privacy Policy. If you do not agree to these Terms, you should immediately cease all use of and access to all of the Sites.

AGREEMENT TO THESE TERMS AND CONDITIONS

Your access and use of the Sites is subject to your agreement with these Terms and Conditions and the Web and Mobile Privacy Policy. By using the site, you expressly agree to the terms of this Terms of Use.

If you do not agree with this Terms and Conditions, please do not use or access the Sites for any purpose. Please print a copy of these Terms and Conditions for your records.

MODIFICATIONS TO THESE TERMS AND CONDITIONS

Relief Telemed may revise these Terms and Conditions at any time. Should these Terms and Conditions change materially, Relief Telemed will give notice to you and all users by posting a notice regarding the updated Terms and Conditions on the Site. New Terms and Conditions will be effective as of their posting unless otherwise stated. By accessing or using the Site after such changes are posted you agree and consent to all such changes.

DISCLAIMER

The Sites are provided “as is” and without warranties of any kind, either express or implied. To the fullest extent permissible pursuant to applicable law, Relief Telemed disclaims all warranties, express or implied, including, but not limited to, implied warranties of merchantability and fitness for a particular purpose. Relief Telemed does not warrant that the Sites will be uninterrupted or error-free, that defects will be corrected or that the Sites or the server that makes it available are free of viruses or other harmful components.

Relief Telemed will use reasonable efforts to keep the content timely and accurate, but makes no guarantees, and disclaims any implied warranty or representation about its accuracy, relevance, timeliness, completeness, or appropriateness for a particular purpose. Teladoc assumes no liability arising from or relating to the delay, failure, interruption, or corruption of any data or other information transmitted in connection with use of the Sites.

Applicable law may not allow the exclusion of implied warranties, so the above exclusion may not apply to you.

REGISTRATION ON THE SECURE PORTAL

Some of Relief Telemed’s sites can be used only by Teladoc Members, require Members to register and log-in, and are password protected (“Registered Users”). The password protected portions of the Sites are referred to as the Secure Portals. This Secure Portals allows you to access certain behavioral health and other medical consultation services (“Services”). Through the Secure Portals, you can also access your protected health information (“PHI”), whether submitted by you or generated as a result of your use of the Services. A complete description of the purposes for which Relief Telemed uses and discloses any PHI collected from our Members (including PHI collected on the Secure Portal) is described fully in its Notice of Privacy Practices or any other applicable notices provided to Members.

EMAIL ADDRESSES AND MOBILE PHONE NUMBER

Registers Users will need to provide us with an email address and mobile phone number. We will use email and text messages to send Registered Users important updates about the Sites as well as notifications when information and documents are added that Members need to be aware of, e.g. forms, consult appointments. Relief Telemed will also use email address and mobile phone number to send general information about the Services available through Relief Telemed. In some instances, but not all, you will be able to opt out of receiving emails and text messages. Relief Telemed does not sell your email address or mobile phone number to third parties.

YOUR RESPONSIBILITIES

Registered Users, are responsible for (i) controlling the dissemination and use of activation codes and passwords; (ii) authorizing, monitoring, and controlling access to and use of your user ID and password; and (iii) promptly informing Relief Telemed of any need to deactivate a password. You also agree to promptly notify Relief Telemed of any unauthorized use of your username, password or any other breach of security that you become aware of involving or relating to this Site by emailing Relief Telemed at [email protected]. In addition, you agree to exit from your secure account at the end of each session. Relief Telemed explicitly disclaims liability for any and all losses and damages arising from your failure to comply with this section.

ACCURATE AND COMPLETE MEDICAL HISTORY

The Services do not replace your existing primary care physician relationship, but are intended only to supplement that relationship for your non-emergency medical needs. Relief Telemed is not an insurance provider nor are we a prescription fulfillment warehouse. You agree that your medical history on the Secure Portals will have the most up to date and accurate information. Such information is vital for Relief Telemed to provide you with quality Services.

YOUR REPRESENTATIONS AND WARRENTIES

By registering on the Secure Portals, you represent and warrant that (i) you are at least eighteen (18) years of age, (ii) you have the legal ability and authority to enter into this Agreement with Relief, (iii) the information you have provided to Relief Telemed in your registration is accurate and complete (iv) you will comply with any and all laws applicable to your use of the Secure Portals, (v) you will not interfere with a third party’s use and enjoyment of the Secure Portals, and (vi) you will not interfere with or disrupt Relief’s or its vendor’s security measures. If any information you provide to Relief Telemed becomes inaccurate, incomplete or otherwise false or misleading, you will immediately notify Relief Telemed.

TERMINATION

If you violate these Terms and Conditions, your ability to use the Secure Portals will terminate. Relief Telemed may, in its sole discretion, terminate your access to the Secure Portals, or any portion thereof, for any reason whatsoever without prior notice. These actions are in addition to any other right or remedy Relief Telemed may have available at law. Further, Relief Telemed shall not be liable to you or any third party for any such termination or discontinuance.

PROHIBITED USES

In using the Sites, you agree not to:

● Send or otherwise transmit to or through the Sites any unlawful, infringing, harmful, harassing, defamatory, threatening, hateful or otherwise objectionable material of any kind, any material that can cause harm or delay to the Sites or computers of any kind, and any unsolicited advertising, solicitation or promotional materials;

● Misrepresent your identity or affiliation in any way;

● Restrict or inhibit any person from using the Sites, disclose personal information obtained from the Sites or collect information about users of the Sites;

● Reverse engineer, disassemble or decompile any section or technology on the Sites, or attempt to do any of the foregoing;

● Gain unauthorized access to the Sites, to other users’ accounts, names, personally identifiable information or other information, or to other computers or websites connected or linked to the Sites;

● Launch or use any automated system, including without limitation, “robots,” “spiders,” or “offline readers,” that access the Sites in a manner that sends more request messages to our servers in a given period of time than a human can reasonably produce in the same period by using a conventional web browser;

● Send or otherwise transmit to or through the Sites chain letters, unsolicited messages, so-called “spamming” or “phishing” messages, or messages marketing or advertising goods and services;

● Post, transmit or otherwise make available any virus, worm, spyware or any other computer code, file or program that may or is intended to damage or hijack the operation of any hardware, software or telecommunications equipment;

● Violate any applicable laws or regulations or these Terms and Conditions;

● Alter or modify any part of the Content or services offered on the Sites; or

● Assist or permit any persons in engaging in any of the activities described above.

INTELLECTUAL PROPERTY RIGHTS AND CONTENT

All materials on the Sites, including the design, layout, and organization (collectively referred to as “Content”), are owned and copyrighted by Relief Telemed or its suppliers or vendors, and are protected by all applicable intellectual property laws. The Content contains trademarks, service marks, and registered trademarks of Relief and its licensors. All rights and title to the Content, trademarks and service marks herein remain with Relief or its licensors.

You are authorized to view the site and Content. You are not authorized to alter, obscure, or remove any copyright or trademark notice present in the Content. All rights not expressly granted herein are reserved to Relief Telemed.

You may not reproduce, duplicate, copy, sell, trade, resell, or exploit for commercial gain any portion of the Sites or the Content. You agree not to change or delete any copyright or proprietary notice from materials downloaded from this site or any site accessible through this site. You may not link to this site.

THIS SITE CONTAINS NO MARKETING OR ADVERTISING

Relief Telemed does not market, advertise, or provide commercial sponsorship for the products, goods, or services of any third party and has no financial arrangements with any third party to advertise, market, or provide commercial sponsorship of specific products, goods or services.

EXTERNAL LINKS

The Sites may contain links to third-party websites. Linked sites are not under the control of Relief Telemed, and Relief Telemed is not responsible for the content of any linked site. Links are provided as a convenience only, and a link does not imply that Relief Telemed endorses, sponsors, or is affiliated with the linked site. Your use of third-party web sites is at your own risk and subject to the terms and conditions of use for such sites; these Terms do not apply to other websites. Relief Telemed disclaims any and all liability for any medical and health treatment information set forth on linked sites.

NO ENDORSEMENTS

Reference to any product, recording, event, process, publication, service, or offering of any third party by name, trade name, trademark, service mark, company name or otherwise does not constitute or imply the endorsement or recommendation of such by Relief. Any views expressed by third parties on this Site are solely the views of such third party and Relief assumes no responsibility for the accuracy or veracity of any statement made by such third party.

INDEMNIFICATION AND LIMITATION OF LIABILITY

You agree to defend, indemnify and hold Relief Telemed, its officers, directors, employees, agents, licensors and suppliers, harmless from and against any claims, actions or demands, liabilities and settlements (including without limitation reasonable attorney and accounting fees), resulting from or alleged to result from your violation of these Terms and Conditions.

IN NO EVENT SHALL RELIEF TELEMED BE LIABLE FOR ANY DIRECT, INDIRECT, SPECIAL, PUNITIVE, INCIDENTAL, EXEMPLARY, OR CONSEQUENTIAL DAMAGES, OR ANY DAMAGES WHATSOEVER RESULTING FROM ANY LOSS OF USE, LOSS OF PROFITS, LITIGATION, OR ANY OTHER PECUNIARY LOSS, WHETHER BASED ON BREACH OF CONTRACT, TORT (INCLUDING NEGLIGENCE), PRODUCT LIABILITY, OR OTHERWISE, ARISING OUT OF OR IN ANY WAY CONNECTED WITH THIS WEBSITE OR THE PROVISION OF OR FAILURE TO MAKE AVAILABLE ANY SUCH PRODUCTS, GOODS, OR SERVICES, EVEN IF ADVISED OF THE POSSIBILITY OF SUCH DAMAGES.

Relief Telemed is not liable to you or anyone else for any decision made or action taken based on use of this Site.

CHILDREN

The Sites are not intended for children under the age of 13. If you are under 13 years of age, please do not use or access the Sites at any time or in any manner. By using the Sites, you affirm that you are over the age of 13. Relief Telemed does not seek through this website to gather personal information from or about persons under the age of 13 without the consent of a parent or guardian.

CHOICE OF LAW AND JURISDICTION

These Terms and Conditions of Use are governed by the laws of Delaware. If any provision of these Terms and Conditions of Use is found to be invalid by any court having competent jurisdiction, the invalidity of such provision shall not affect the validity of the remaining provisions of these Terms and Conditions of Use, which shall remain in full force and effect.

Notice of Patient Privacy Policies

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Relief’s Commitment to Your Privacy

Relief is dedicated to maintaining the privacy of your protected health information (‘PHI’). PHI is information about you that may be used to identify you (such as your name, social security number or address), and that relates to (a) your past, present or future physical or mental health or condition, (b) the provision of healthcare to you, or (c) your past, present, or future payment for the provision of healthcare. In conducting its business, Relief will receive and create records containing your PHI. Relief is required by law to maintain the privacy of your PHI and to provide you with notice of its legal duties and privacy practices with respect to your PHI.

Relief must abide by the terms of this Notice while it is in effect. This current Notice takes effect on October 1, 2018, and will remain in effect until Relief replaces it. Relief reserves the right to change the terms of this Notice at any time, as long as the changes are in compliance with applicable law. If Relief changes the terms of this Notice, the new terms will apply to all PHI that it maintains, including PHI that was created or received before such changes were made. If Relief changes this Notice, it will post the new Notice on its Web site and will make the new Notice available upon request.

Uses and Disclosures of PHI

Relief may use and disclose your PHI in the following ways:

Treatment, Payment and Healthcare Operations. Relief is permitted to use and disclose your PHI for purposes of (a) treatment, (b) payment and (c) healthcare operations. For example:

1. Treatment. Relief may disclose your PHI to another physician or healthcare provider for purposes of a visit or in connection with the provision of follow-up treatment.

2. Payment. Relief may use and disclose your PHI to your health insurer or health plan in connection with the processing and payment of claims and other charges.

3. Healthcare Operations. Relief may use and disclose your PHI in connection with its healthcare operations, such as providing customer services and conducting quality review assessments. Relief may engage third parties to provide various services for Relief. If any such third party must have access to your PHI in order to perform its services, Relief will require that third party to enter an agreement that binds the third party to the use and disclosure restrictions outlined in this Notice.

Authorization. Relief is permitted to use and disclose your PHI upon your written authorization, to the extent such use or disclosure is consistent with your authorization. You may revoke any such authorization at any time.

As Required by Law. Relief may use and disclose your PHI to the extent required by law.

Special Circumstances

The following categories describe unique circumstances in which Relief may use or disclose your PHI:

Public Health Activities. Relief may disclose your PHI to public health authorities or other governmental authorities for purposes including preventing and controlling disease, reporting child abuse or neglect, reporting domestic violence and reporting to the Food and Drug Administration regarding the quality, safety and effectiveness of a regulated product or activity. Relief may, in certain circumstances disclose PHI to persons who have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition.

Workers’ Compensation. Relief may disclose your PHI as authorized by, and to the extent necessary to comply with, workers’ compensation programs and other similar programs relating to work-related illnesses or injuries.

Health Oversight Activities. Relief may disclose your PHI to a health oversight agency for authorized activities such as audits, investigations, inspections, licensing and disciplinary actions relating to the healthcare system or government benefit programs.

Judicial and Administrative Proceedings. Relief may disclose your PHI, in certain circumstances, as permitted by applicable law, in response to an order from a court or administrative agency, or in response to a subpoena or discovery request.

Law Enforcement. Relief may, under certain circumstances, disclose your PHI to a law enforcement official, such as for purposes of identifying or locating a suspect, fugitive, material witness or missing person.

Decedents. Relief may, under certain circumstances, disclose PHI to coroners, medical examiners and funeral directors for purposes such as identification, determining the cause of death and fulfilling duties relating to decedents.

Organ Procurement. Relief may, under certain circumstances, use or disclose PHI for the purposes of organ donation and transplantation.

Research. Relief may, under certain circumstances, use or disclose PHI that is necessary for research purposes.

Threat to Health or Safety. Relief may, under certain circumstances, use or disclose PHI if necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.

Specialized Government Functions. Relief, may in certain situations, use and disclose PHI of persons who are, or were, in the Armed Forces for purposes such as ensuring proper execution of a military mission or determining entitlement to benefits. Relief may also disclose PHI to federal officials for intelligence and national security purposes.

Your Rights Regarding Your PHI

You have the following rights regarding the PHI maintained by Relief:

Confidential Communication. You have the right to receive confidential communications of your PHI. You may request that Relief communicate with you through alternate means or at an alternate location, and Relief will accommodate your reasonable requests. You must submit your request in writing to Relief.

Restrictions. You have the right to request restrictions on certain uses and disclosures of PHI for treatment, payment or healthcare operations. You also have the right to request that Relief restrict its disclosures of PHI to only certain individuals involved in your care or the payment of your care. You must submit your request in writing to Relief. Relief is not required to comply with your request. However, if Relief agrees to comply with your request, it will be bound by such agreement, except when otherwise required by law or in the event of an emergency.

Inspection and Copies. You have the right to inspect and copy your PHI. You must submit your request in writing to Relief. Relief may impose a fee for the costs of copying, mailing, labor and supplies associated with your request. Relief may deny your request to inspect and/or copy your PHI in certain limited circumstances. If that occurs, Relief will inform you of the reason for the denial, and you may request a review of the denial.

Amendment. You have a right to request that Relief amend your PHI if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is maintained by Relief. You must submit your request in writing to Relief and provide a reason to support the requested amendment. Relief may, under certain circumstances, deny your request by sending you a written notice of denial. If Relief denies your request, you will be permitted to submit a statement of disagreement for inclusion in your records.

Accounting of Disclosures. You have a right to receive an accounting of all disclosures Relief has made of your PHI. However, that right does not include disclosures made for treatment, payment or healthcare operations, disclosures made to you about your treatment, disclosures made pursuant to an authorization, and certain other disclosures. You must submit your request in writing to Relief and you must specify the time period involved (which must be for a period of time less than six years from the date of the disclosure). Your first accounting will be free of charge. However, Relief may charge you for the costs involved in fulfilling any additional request made within a period of 12 months. Relief will inform you of such costs in advance, so that you may withdraw or modify your request to save costs.

Breach Notification. You have the right to be notified in the event that Relief (or a Relief Business Associate) discovers a breach of unsecured PHI.

Paper Copy. You have the right to obtain a paper copy of this Notice from Relief at any time upon request. To obtain a paper copy of this notice, please contact Relief by emailing [email protected].

Complaint. You may complain to Relief and to the Secretary of the Department of Health and Human Services if you believe that your privacy rights have been violated. To file a complaint with Relief, you must submit a statement in writing to Relief Telemed, Attn: Security Officer, 7117 Florida Blvd, Baton Rouge, LA 70806. Relief will not retaliate against you for filing a complaint.

Further Information. To the extent you are required to send a written request to Relief to exercise any right described in this Notice, you must submit your request to Relief Telemed, Attn: Security Officer, 7117 Florida Blvd, Baton Rouge, LA 70806.

Web and Mobile Privacy Policy

Relief understands that privacy of information is of great importance to our Members and the people that visit our public sites (“Visitors”). As Relief Telemed is a leading provider of health services throughout the world, we would not be able to operate in this global marketplace without proper policies and procedures to meet stringent international regulations.

Applicability of this privacy policy

This Web and Mobile Privacy Policy (“Privacy Policy”) describes what information Relief Telemed collects about Member’s and Visitors on its Sites and how that information is used.

Agreement to this privacy policy

Your access and use of the Sites is subject to your agreement with this Privacy Policy and the Web and Mobile Terms and Conditions. By using the site, you expressly agree to the terms of this Privacy Policy and consent to the collection and use of information as discussed in this Privacy Policy.

If you do not agree with this Privacy Policy, please do not use or access the Sites for any purpose. Please print a copy of this Privacy Policy for your records.

Modifications to this privacy policy

Relief Telemed may revise this Privacy Policy regarding the collection of information at any time. Should this Privacy Policy changed materially, Relief Telemed will give notice to you by posting a notice regarding the new policy on the Site. New Privacy Policies will be effective as of their posting unless otherwise stated.

By accessing or using the Site after such changes are posted you agree to all such changes.

Collection use and disclosure of non identifiable information

Either Relief Telemed or a third party vendor on behalf of Relief Telemed may collect non-identifiable information, which is automatically collected as you browse or otherwise access the Sites. We may collect such information by tracking, or asking a third party vendor to track, your click-stream activity when such information is not tied to a user ID through the use of “cookie” technology or by tracking internet protocol (IP) addresses, as explained below.

Because we want our Sites to better serve Visitors’ needs, we collect some basic information about Visitors’ computers, including, but not limited to:

○ IP address (the computer’s address on the internet)

○ Operating system (e.g. Windows Vista)

○ Browser software (e.g. Microsoft Internet Explorer, Firefox)

○ Internet Service Provider (e.g. AOL)

○ Geographic location (e.g. Boston, Mass.)

We use this information to continuously enhance our Sites and to better serve our Visitors’ needs. For example, we use this information to know what browsers people most commonly use, what pages are most often visited, and what functionality is most used. All the information Relief collects from Visitors’ computers is deidentified and is not personal information.

The non-identifiable information we collect may be shared with our suppliers and vendors and used in the aggregate to create summary statistics that help us analyze Site usage trends, assess what information is of most and least importance, determine technical design specifications, arrange the Sites in the most user-friendly way, and identify system performance or problem areas.

We may also use your geographic location to provide you with specific content and direct you to your closest service providers to the extent permitted by applicable law.

Like many companies, we use “cookies” to help you better navigate the Sites. A “cookie” is a small piece of information sent by Relief Telemed’ web-based applications that are stored by your Web browser on your computer’s hard drive. Cookies enhance your online experience by saving your preferences while you are visiting a particular website. The cookies do not contain any identifiable information and cannot profile your system or collect information from your hard drive. Most Internet browsers automatically accept cookies, but you can set your browser to refuse them or to alert you when they are being sent.

For more information about the cookies that are used on the Sites and your ability to opt out of use of those cookies, please

see Relief’s Cookies Policy.

Privacy and security of the secure portal

Some of Relief’s Sites can be used only by Relief Members, require Members to register and log-in, and are password protected (“Registered Users”). The password protected portions of the Sites are referred to as the Secure Portals. The Secure Portals contain protected health information (PHI) or personal information about Members. Because of this, on the Secure Portals, Relief Telemed must be able to link a Member’s activity back to their identity, for example to verify identity in our systems and eligibility for Services. Therefore, in the Secure Portals, Relief Telemed does collect identifiable information about Members. This includes pages visited and Services initiated.

While no web site can guarantee security, we maintain physical, administrative, and technical safeguards to help protect your PHI collected via the Secure Portals as required by applicable law. While we cannot guarantee that loss, misuse or alteration to data will not occur, we use industry standards, such as Secure Socket Layers (“SSL”) technology, to help safeguard against such occurrences. On the Secure Portals, the information passed between your browser and our system is encrypted with SSL technology to create a protected connection between you and our website to ensure confidentiality.

Our data center is both physically and electronically secured. Our servers are protected behind the Internet by using firewall and encryption technology. All data is stored and transferred in encrypted formats that either meet or exceed standards defined by state and federal laws. No data is transferred to users that do not have rights to access such information.

All information and data you submit through Relief’s Sites are stored on secure servers located in the United States.

Mobile applications

We allow Members to access the Services through a software application on a mobile device (an “Application”). If you choose to an Application, Relief Telemed will collect additional information about you including (1) location data, (2) device IDs and (3) other information regarding your use of the Application. Relief uses the information collected to analyze and improve the Member’s experience using the Application and otherwise communicate with the Member about the Services. Additionally, we track your location and send push notifications from time to time in order to update you about the Services and what is available to you as a Member. If you no longer wish to receive such communications, you may turn them off at the device level.

A complete description of the purposes for which Relief Telemed uses and discloses any PHI collected from our Members (including PHI collected on the Secure Portal) is described fully in its Notice of Privacy Practices or any other applicable notices provided to Members.

How to contact us

Questions or comments regarding this Policy should be submitted to Relief Telemed, Inc. by mail or electronic means as follows:

Relief Telemed Privacy Officer

Relief Telemed, Inc.

7117 Florida Blvd

Baton Rouge, LA 70806

[email protected]

Informed Consent for Limitations of a Video Consultation

Telemedicine 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. Providers may include primary care practitioners, specialists, and/or subspecialists. The information may be used for diagnosis, therapy, follow-up and/or education, and may include any of the following:

● Patient medical records

● Medical images

● Live two-way audio and video

● Output data from medical devices and sound and video files

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.

Responsibility for the patient care should remain with the patient’s local clinician, if you have one, as does the patient’s medical record.

Expected Benefits:

● Improved access to medical care by enabling a patient to remain in his/her local healthcare site (i.e. home) while the physician consults and obtains test results at distant/other sites.

● More efficient medical evaluation and management.

● Obtaining expertise of a specialist.

Possible Risks:

As with any medical procedure, 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, or at least a rescheduled video consult;

● 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;

● 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 “Video Limitations”, You acknowledge that you understand and agree with the following:

1. I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine, and that no information obtained in the use of telemedicine, which identifies me, will be disclosed to researchers or other entities without my written consent.

2. 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.

3. 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 some parts of the exam involving physical tests may be conducted by individuals at my location, or at a testing facility, at the direction of the consulting healthcare provider.

4. 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.

5. 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.

6. I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. Others may also be present during the consultation other than my healthcare provider and consulting healthcare provider in order to operate the video equipment. The above mentioned people will all 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) terminate the consultation at any time.

Patient Consent To The Use of Telemedicine

I have read and understand the information provided above regarding telemedicine, have discussed it with my physician or such assistants as may be designated, and all of my questions have been answered to my satisfaction.

I have read this document carefully, and understand the risks and benefits of the teleconferencing consultation and have had my questions regarding the procedure explained and I hereby give my informed consent to participate in a telemedicine visit under the terms described herein.

By checking the Box containing “I UNDERSTAND THE LIMITATIONS OF A VIDEO VISIT” I hereby state that I have read, understood, and agree to the terms of this document.

Legal Disclosures

Web and Mobile Terms and Conditions

Notice of Patient Privacy Policies

Web and Mobile Privacy Policy

Informed Consent for Limitations of a Video Consultation

Address

Contacts

Links