Telehealth Informed Consent

BY CLICKING “I AGREE,” CHECKING A BOX TO SIGNIFY ACCEPTANCE, USING ANY OTHER ACCEPTANCE PROTOCOL PRESENTED THROUGH THE SERVICE OR OTHERWISE AFFIRMATIVELY ACCEPTING THIS CONSENT, YOU ACKNOWLEDGE THAT YOU HAVE READ, ACCEPTED, AND AGREED TO BE BOUND BY THIS CONSENT. IF YOU DO NOT AGREE TO THIS CONSENT, DO NOT CREATE AN ACCOUNT OR USE THE SERVICE. YOU HEREBY AUTHORIZE ANY PARTY WHO CLICKS “I AGREE” OR INDICATES ACCEPTANCE TO THIS CONSENT ON YOUR BEHALF.

IF YOU ARE EXPERIENCING A LIFE-THREATENING SITUATION SUCH AS CONTEMPLATING SUICIDE, CALL 911 OR THE 988 SUICIDE & CRISIS LIFELINE AT 988.

Purpose.The purpose of this consent form (“Consent”) is to provide you with information about telehealth and to obtain your informed consent to the use of telehealth in the delivery of healthcare services to you by physicians, physician assistants, and/or nurse practitioners (“Providers”) using the online platforms owned and operated by Optimize (the “Service”). In this Consent, the terms “you” and “your” refer to the person using the Service.

Use of Telehealth. Telehealth involves delivering healthcare services using electronic communication, information technology, or other means between a healthcare provider and a patient who are not in the same physical location. Telehealth may be used for diagnosis, treatment, follow-up, or patient education. It may include, but is not limited to: electronic transmission of medical records, photo images, personal health information, or other data between you and a provider; interactions via audio, video and/or data communications (such as messaging or email); and use of output data from medical devices or sound and video files.

Anticipated Benefits. Potential benefits of telehealth include easier access to medical care, efficient delivery of services, convenience of receiving care at home, and increased ability to interact with Providers without a physical office visit. For example, telehealth may allow you to consult with healthcare providers at times and places that are more convenient for you, and may improve coordination of care.

Potential Risks. The use of telehealth also poses potential risks. These include, but are not limited to:

• Technical Risks:The quality, accuracy or effectiveness of the services may be limited by technical factors. Technology (including the Service) may contain bugs, errors or may fail, causing parts of the system to be unavailable or to produce incorrect information. Failures may impact your Provider’s ability to diagnose or treat.
• Quality Risks:Some tests or assessments (like physical exams or vital signs measurements) cannot be performed remotely, which may limit the Provider’s ability to diagnose or treat your condition or determine the need for in-person emergency care. You understand that your Provider may not be able to provide treatment for every condition via telehealth, and you may be referred to in-person care if necessary.
• Privacy and Security Risks: Although we use encryption and other security protocols, there is a risk of a breach of privacy when transmitting medical information electronically. Communications or files (e.g., emails, video streams, photos) may be accessed by unauthorized parties despite precautions.
• Other Risks: Delays in evaluation or treatment could occur due to unavailability of your Provider or technical failures. There may be conditions for which telehealth is inappropriate.

By using telehealth, you acknowledge that you understand these risks and that your Provider will discuss them with you.

Medical Record and Confidentiality. Any information that you provide during a telehealth session will be kept confidential to the extent required by law. Your Provider will document the session in your medical record. No recordings of your telehealth sessions will be made by the Provider without your consent. Please note that Optimize is not a covered entity under HIPAA, but providers and medical groups are subject to HIPAA. Nevertheless, Optimize has contractual obligations to protect your information. Communications and information transmitted via electronic means may not be fully confidential or secure.

Voluntary Participation; Alternatives. Participation in telehealth is entirely voluntary. You may withdraw your consent at any time by notifying your Provider. Alternatives to telehealth include traditional in-person visits. You should discuss any questions about alternatives with your Provider.

No Guarantee of Outcomes. Optimize does not guarantee any specific results from telehealth services. The outcome of each session depends on your cooperation, the quality of the technology, and other factors beyond our control.

By clicking “I Agree” or otherwise accepting this Consent, you acknowledge that you have read, understood, and agree to this Telehealth Informed Consent. You acknowledge that all your questions have been answered and that you agree to the use of telehealth under these terms.