Updated: December 30,2019

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 purpose of this document is to obtain your informed consent to participate in telemedicine services offered by Oak Health LLC and its affiliated physicians and practices (collectively “OAK”). The telehealth services offered by OAK are limited in scope and are not intended to serve as a replacement of your primary care physician. 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 gathered using telemedicine may be used for diagnosis, therapy, remote prescribing, follow-up and/or education and may include any of the following:

Patient medical history, records and test results
Medical images
Realtime and non-real time bidirectional communication
Live two-way audio and video
Audio and video files
Output from medical devices
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.

Expected Benefits:
Improved access to medical care by enabling a patient to not have to travel to a remote site while the physician obtains medical information and test results at distant/remote sites.
More efficient medical evaluation and management.
Obtaining expertise of a distant specialist as needed.

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, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision making by the physician;
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;

In granting your consent to receive telemedicine services from OAK, you agree to the following:
During the telemedicine consultation and/or services:
Details of your medical history, examinations, x-rays, and tests may be discussed with other health professionals and staff using interactive video, audio, and other telecommunication technology.
In certain cases, a physical examination of you at a local clinic may be required before being able to receive certain telemedicine services and/or prescriptions, as applicable.
A non-medical technician may be present in the telemedicine studio to aid in the video or telecommunication transmission.
Video, audio and/or photo recordings may be taken of you during the telemedicine interaction.
You understand that prior to receiving any telemedicine services, a physician must first accept you as a patient and the physician alone can determine if telemedicine is appropriate for you and your specific circumstances. You understand that alternatives to telemedicine exist (such as going to your primary care provider, a local clinic, or specialist) and may be more appropriate for your medical needs.
You have had a chance to select and review an OAK physician and his/her credentials prior to receiving telemedicine services.
You agree to hold OAK harmless for any loss of information or delay in treatment(s) arising out of technical failures or from limitations inherent to telemedicine, software, and/or the internet.
You understand that as in most medical services, no results can be guaranteed, and that use of any medications or treatments can result in experiencing adverse side effects.
In the event of any medical emergencies, you understand that you should directly call 9-1-1 or the appropriate emergency number in your region.
All existing laws regarding access to medical information and copies of your medical records apply to the use of telehealth services. Please note that not all telecommunications are recorded and stored. Your personal and/or health information may be shared with other individuals and certain systems for purposes of billing, customer support, and providing the services.
Reasonable and appropriate efforts have been made to eliminate any confidentiality risks associated with the use of the offered telehealth services and all applicable federal and/or state laws apply to information gathered over the course of the telehealth interaction(s).You may withhold or withdraw consent to telehealth services at any time without affecting your right to future care or treatment.
You have been advised of the potential risks and benefits of telemedicine. You have had the opportunity to ask questions about the information presented in this document and the telemedicine services. All of your questions have been answered and you understand the information provided herein.

Consent to telehealth

Possible Benefits of Telemedicine
Can be easier and more efficient for you to access medical care and treatment. You can obtain medical care and treatment at times that are convenient for you.
You can interact with providers without the necessity of an in-office appointment.

Possible Risks of Telemedicine
Information transmitted to your provider(s) may not be sufficient to allow for appropriate medical decision making by the provider(s).The inability of your provider(s) to conduct certain tests or assess vital signs in-person may in some cases prevent the provider(s) from providing a diagnosis or treatment or from identifying the need for emergency medical care or treatment for you.

Your provider may not able to provide medical treatment for your particular condition via telemedicine and you may be required to seek alternative care.

Delays in medical evaluation/treatment could occur due to failures of the technology.

Security protocols or safeguards could fail causing a breach of privacy.

Given regulatory requirements in certain jurisdictions, your provider(s) treatment options, especially pertaining to certain prescriptions may be limited.

By accepting this Consent to Telehealth, you acknowledge your understanding and agreement to the following:

I have read this special Consent to Telehealth carefully, and understand the risks and benefits of the use of telemedicine in the medical care and treatment provided to me through OAK’s platform by “Providers”.

I give my informed consent to the use of telemedicine by providers affiliated with OAK.I understand that the delivery of healthcare services via telemedicine is an evolving field and that the use of telemedicine in my medical care and treatment may include uses of technology not specifically described in this consent.

I understand that while the use of telemedicine may provide potential benefits to me, as with any medical care service no such benefits or specific results can be guaranteed. My condition may not be cured or improved, and in some cases, may get worse.

I understand that “Providers” may determine in his or her sole discretion that my condition is not suitable for treatment using telemedicine, and that I may need to seek medical care and treatment in-person or from an alternative source.

I understand that the same confidentiality and privacy protections that apply to my other health care services also apply to these telemedicine services.

I understand that I have access to all of my health and wellness information pertaining to the telemedicine services in accordance with applicable laws and regulations.

I understand that I can withhold or withdraw this consent at any time by emailing OAK with such instruction. Otherwise, this consent will be considered renewed upon each new telemedicine consultation with “Providers”.

I agree and authorize my health care provider to share information regarding the telemedicine exam with other individuals for treatment, payment and health care operations purposes

I agree and authorize my health care provider to release information regarding the telemedicine exam to OAK and its affiliates.
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