Disclaimer and Informed Consent for Telehealth Services
Disclaimer – Bubolo Medical, LLC
Informed Consent – Bubolo Medical Providers
The following telehealth informed consent is provided to you on behalf of Bubolo Medical and your individual Provider. Any liability associated with this informed consent or with any services received shall be the sole and exclusive obligations of Provider, and for the avoidance of doubt Bubolo Medical will have no liability associated therewith.
Telehealth involves the use of electronic communications to enable healthcare providers (and consumers) at different locations to share individual patient medical information for the purpose of improving patient care. Telehealth services offered by your Provider 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 devices and sound and video files.
The electronic communication systems we use 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. Furthermore, Bubolo Medical complies with HIPAA and HITECH requirements.
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.
- Improved access to care by enabling you to remain in your home while the Provider consults and obtains results at distant or other sites.
- More efficient care evaluation and management.
- Obtaining expertise of a specialist as appropriate.
- 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.
- In very rare events, security protocols could fail, causing a breach of privacy of personal health information.
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 your Provider at 770-975-1299 or email@example.com
By checking the box associated with "Informed Consent" you acknowledge that you understand and agree with the following:
- This service is provided by technology (including but not limited to video, phone, text, and email) and may not involve direct, face to face, communication. There are benefits and limitations to this service. I will need access to, and familiarity with, the appropriate technology to participate in the service provided. Exchange of information will not be direct and any paperwork exchanged will likely be exchanged through electronic means or through postal delivery. I hereby consent to receiving telehealth services via telehealth technologies.
- I understand that my Provider offers telehealth-based services, but that these services do not replace the relationship between me and my primary care doctor. I also understand it is up to my Provider to determine whether or not my specific clinical needs are appropriate for a telehealth encounter.
- The laws that protect the confidentiality of my medical and mental health information also apply to online mental health encounters. As such, I understand that the information disclosed by me during the course of my therapy is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, including, but not limited to reporting child, elder, and dependent adult abuse; expressed threats of violence towards self and/or an ascertainable victim; and where I make my mental or emotional state an issue in a legal proceeding.
- I understand that federal and state law requires health care providers to protect the privacy and the security of health information. I understand that my Provider will take steps to make sure that my identifiable health information is not seen by anyone who should not see it. I understand that telehealth may involve electronic communication of my personal mental health 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 my Provider and Bubolo Medical. I agree to hold harmless my Provider and Bubolo Medical 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 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. I understand that online mental health based services and care may not be as complete as face-to-face services. I also understand that if my Provider believes I would be better served by another form of delivery of healthcare services (e.g. face-to-face services) I may be referred to a provider who can provide such services in my area. Finally, I understand that there are potential risks and benefits associated with any form of telehealth, and that despite my efforts and the efforts of my Provider, my condition may not improve, and in some cases may even get worse.
- 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 health care information may be shared with other individuals for scheduling and billing purposes. Persons may be present during the consultation other than 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 health history/examination that are personally sensitive to me; (2) ask non-essential 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 health records which will be provided to me at reasonable cost of preparation, shipping and delivery, in accordance with applicable state law.
- I understand that the inability to have direct, physical contact with the provider is a primary difference between telehealth and direct in-person service.
- I have been informed of alternate forms of communication between me and a Provider for urgent matters.
- I have had a conversation with my Provider, during which I had the opportunity to ask questions in regard to this practice. My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language in which I understand.
Additional State-Specific Consents: The following consents apply to users accessing the platform for the purposes of participating in a telehealth consultation as required by the states listed below:
California: NOTICE TO CONSUMERS: The Department of Consumer Affair’s Board of Psychology receives and responds to questions and complaints regarding the practice of psychology. If you have questions or complaints, you may contact the board on the Internet at www.psychboard.ca.gov, by calling 1-866-503-3221, or by writing to the following address: Board of Psychology, 2005 Evergreen Street, Suite 1400, Sacramento, California, 95815-3894.
Kentucky: I understand that I have the right to be informed of any party who will be present at the site during the telehealth consult and I have the right to exclude anyone from being present. I also understand that I have the right to object to the videotaping of the telehealth consultation. KY Admin. Regs. Tit. 907, 3:170.
Maryland: I understand that I cannot request telehealth services to be conducted via correspondence only. Code of MD Reg. 10.41.06.04.
Nebraska: I understand that I have the right to be informed of any party who will be present at the site during the telehealth consult and I have the right to exclude anyone from being present. I understand that any dissemination of identifiable images or information from a consult requires my express permission. I understand that I have the right to request an in-person consult immediately after the telehealth consult and I will be informed if such consult is not available. NE Revised Stat. 71-8505; NE Admin. Code Tit. 471, Ch. 1.
New Jersey: I understand I have the right to request a copy of my medical information and I understand my medical information may be forwarded directly to my primary care provider or health care provider of record, or upon my request, to other health care providers. (NJ Rev. Stat. § 45:1-62).
I understand I have the right to know and must consent to any videotaping, audio recording, or permitting third-party observation of psychotherapy interactions. (N.J.A.C §13:34-7.2)
New York: I understand if I am denied access to my records, I may appeal that decision to the New York State Department of Health.
I understand that I may verify my Provider’s credentials at the following location(s):
Nevada: I understand that the transmission of any confidential medical information while engaged in telemedicine is subject to all applicable federal and state laws with respect to the protection of and access to confidential medical information. NV Rev. Stat. Ann. § 633.0165.
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).
I understand I have the right to know my Provider’s name location, telephone number, fee schedule, educational training, and areas of specialization. (S.C. Code 1976 § 40-63-270)
I understand I have the right to know and must consent to any videotaping, audio recording, or permitting third-party observation of psychotherapy interactions. (S.C. Code 1976 §110-20)
Tennessee: I understand that I may request an in-person assessment before receiving a telehealth assessment.
Texas: I understand that upon request my medical records may be sent to my primary care physician. (V.T.C.A., Occupations Code § 111.005).
Virginia: I understand that I have the right to information regarding the implications of diagnosis, intended use of tests and reports, and fees of my Provider. (18 V.A.C. § 115-20-10)
I understand that I must notify my Provider if I am receiving services from another mental health service provider. (18 V.A.C. § 115-20-10)
I understand I have the right to know and must consent to any videotaping, audio recording, permitting third-party observation of psychotherapy interactions, or using identifiable client records and clinical materials in teaching, writing or public presentations. (18 V.A.C. § 115-20-10)
I have read this document carefully, and understand the risks and benefits of the telehealth consultation and have had my questions regarding the procedure explained and I hereby give my informed consent to participate in a telehealth consultation under the terms described herein.
By checking the Box containing "INFORMED CONSENT FOR TELEHEALTH SERVICES" I hereby state that I have read, understood, and agree to the terms of this document.