Patient Consent to Use of Telehealth Technology

RW Health FL, PC and its related medical groups (collectively “Group” or “RW Health”) offer certain health care services that are delivered to you by their health care providers using electronic communications technologies (“Telehealth Technology”). If you have questions about use of the Telehealth Technology itself and whether it is appropriate for your medical condition, the risks associated with using the Telehealth Technology, or the provider’s credentials and professional background, please ask your Group provider. In exchange for your use of the Telehealth Technology to receive medical treatment, you acknowledge and agree to the following terms and conditions of this Consent (this “Consent”):

1. Use of Telehealth Technology. You understand and agree that:

• The Group provider will decide, in his or her sole discretion, whether it is appropriate to treat your condition using the Telehealth Technology.

• You or the Group provider may require an in-person examination prior to or after diagnosing or prescribing a treatment plan.

• The anticipated response time for electronic communications submitted through the Telehealth Technology varies and you accept any risk associated with the response time, including a delay in obtaining medical care.

• No warranty or guarantee has been made to you concerning any particular result related to your condition or diagnosis.

2. Risks Associated with Use of Telehealth Technology. You understand that use of the Telehealth Technology has risks associated with it, such as (1) information that you transmit through the Telehealth Technology may be insufficient to allow for appropriate medical decision-making by the Group provider (e.g., poor resolution of transmitted images); (2) failures of equipment (e.g., servers, devices) or infrastructure (e.g., communications lines, power supply) may cause delays in medical evaluation and treatment, or loss of information; and (3) unauthorized access to your medical information. You acknowledge that, although Group and its telehealth technology vendor strive to prevent unauthorized access to information about me through encryption of information transmitted by the Telehealth Technology and other security measures, Group and its vendor cannot guarantee that your use of the Telehealth Technology and the information will be private or secure, and you consent to this risk.
You understand and consent to the risks associated with your use of the Telehealth Technology.

3. Accuracy of Information Submitted to the Group Provider. You acknowledge and agree that you are solely responsible for ensuring that the information provided by you through the Telehealth Technology is accurate, complete and current. You understand that the Group provider will rely on this information to diagnose and prepare a treatment plan for your medical condition and your failure to provide accurate, complete and current information may lead to a delay in your treatment or a misdiagnosis.

4. Privacy and Security of Data. You understand that the laws that protect privacy and the confidentiality of medical information also apply to care delivered through Telehealth Technologies, and that our use of your personal information will be governed by such laws and our Notice of Privacy Practices.

5. Release and Waiver. You acknowledge and agree to limit, disclaim, and release Group from liability in connection with the Telehealth Technology’s use.

6. Expenses. Depending on our agreement with your employer or health plan, you understand and agree that may be are responsible for the cost of all professional fees associated with your use of the Telehealth Technology, which may change from time to time. You understand that you will be responsible for cost of any medications or supplies prescribed by the Group provider, if applicable, to the extent required under your current health plan coverage.

7. Other Legal Terms. This Consent will may not be amended except in writing by mutual agreement of Group and you. If any provision is or becomes unenforceable or invalid, the other provisions will continue with the same effect.

8. Right to Revoke. You understand that you can revoke this Consent by sending written notice using certified mail to Group at: Rightway Healthcare, Inc (“Revocation”). You agree that your Revocation must contain your name and your address. You also understand that your Revocation means that you are not permitted to receive care using Telehealth Technology. Your Revocation will be effective upon Group’s receipt of your written notice, except that your Revocation will not have any effect on any action taken by the Group provider in reliance on this Consent before it received your written notice of Revocation.