Informed Consent for Services Provided by BDL Network Physicians
By requesting a telehealth and/or telemedicine consultation, you are requesting to enter into a doctor/patient relationship with a physician who is independently contracted with Best Docs Live Inc. (“BDL”) to participate as a Network Physician. The consulting Network Physician shall be the actual provider of the professional medical services to you. While BDL provides certain technology and administrative services to you and the Network Physicians, BDL does not itself provide the professional medical services to you. Therefore, you agree to pay BDL on behalf of the Network Physician for the telehealth and/or telemedicine consultations at the time they are requested, unless payment arrangements have been established through your employer, association, or other entity.
As a requirement of the Network Physicians, you agree to complete a medical history form that BDL will store electronically and make available to each Network Physician who performs a telehealth and/or telemedicine consultation for you.
You acknowledge that, if you have a primary care physician, that relationship is not replaced by a Network Physician. Furthermore, you agree that, by requesting a telehealth and/or telemedicine consultation from a Network Physician, you are designating the Network Physician as your physician because your primary care (or other) physician, as applicable, is not available.
You acknowledge that Network Physicians will not prescribe any Drug Enforcement Agency controlled substances nor do they guarantee that a prescription will be issued. There is further no guarantee that you will be treated as a patient by a Network Physician if, for example, a Network Physician determines that your medical condition cannot be properly treated by him/her.
If you are treated by a Network Physician, you have a right to your medical records in accordance with applicable law.
The telehealth and/or telemedicine services provided by the Network Physicians (and the technology and non-medical operational and administrative services provided by BDL that are attendant thereto) may involve the use of electronic communications to enable the Network Physicians at distant locations to access your patient medical information for the purpose of providing you patient care. The information may be used for diagnosis, treatment, follow-up and/or education, and may include any of the following:
- Patient medical records
- Medical images
- Live two-way audio and/or 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.
- Improved access to medical care by enabling a patient to remain in his/her local healthcare site (e.g., home) while the physician consults from a distant site.
- More efficient medical evaluation and management.
As with any medical procedure, there are potential risks associated with the use of telehealth and/or 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, necessitating that the patient obtain an in-office, face-to-face evaluation with a physician, or reschedule a web video consultation;
- 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 “Informed Consent”, You acknowledge that you understand and agree with the following:
- I understand that the laws that protect privacy and the confidentiality of medical information also apply to telehealth and/or telemedicine, and that no information obtained through the use of telehealth and/or telemedicine, which identifies me, will be disclosed to researchers or other entities without my written consent.
- I understand that I have the right to withhold or withdraw my consent to the use of telehealth and/or telemedicine in the course of my care at any time, without affecting my right to future care or treatment.
- I understand the alternatives to telehealth and/or telemedicine consultation as they have been explained to me, and in choosing to participate in a telehealth and/or 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.
- I understand that telehealth and/or telemedicine may involve electronic communication of my personal medical information to medical practitioners who may be located in other areas, including out of state.
- 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.
- 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 the 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 telehealth and/or telemedicine examination room; and/or (3) terminate the consultation at any time.
Patient Consent To The Use of Telehealth and/or Telemedicine
I have read this Informed Consent form carefully (or have had it read carefully to me), and I understand the information provided in it. I understand the risks and benefits of telehealth and/or telemedicine, and that I will have the opportunity to ask any questions I may have regarding it with the consulting physician at the onset of and during my consultation, and I can end the consultation at any time should any of my questions not be answered to my satisfaction.
I hereby give my informed consent to participate in a telehealth and/or telemedicine visit under the terms described in this consent form.
By clicking ‘Sign up’, I hereby state that I have read this Informed Consent form carefully (or have had it read carefully to me), I agree to its terms, and wish to proceed with my consultation.