Please review this Consent to Telehealth Care form prior to requesting any of the services provided by the Choix Application (the “Application”) and our website at www.mychoix.co (collectively, the “Services”). You will be asked to confirm acceptance of this form at the beginning of each questionnaire.

Consent To Healthcare

Telehealth involves the use of telehealth questionnaires, audio, video, or other electronic communications by your health care provider for the purpose of interacting with you, consulting with you and/or other health professionals responsible for your care, and/or reviewing your medical information for the purpose of diagnosis, therapy, follow-up, and/or education. During your telehealth consultation, details of your medical history and personal health information may be discussed with you or other health professionals through the use of interactive audio, video, or other telecommunications technology. Additionally, a physical examination of you, as well as other treatment steps, may take place, and audio, video, and/or photo recordings may be taken and used during the course of such treatment and/or subsequent treatment.

Electronic systems used during your telehealth encounter will incorporate network and software security protocols to protect the privacy and security of your health information and imaging data, and will include measures to safeguard your data to ensure its integrity against intentional or unintentional corruption.

Anticipated Benefits of Telehealth Care

  • Improved access to health care services, by enabling you, the patient, to remain in your location while the health care provider may provide care to you from a distant site;
  • More efficient medical evaluation and management;
  • The opportunity to obtain expertise from a distantly located specialist;
  • Enabling ongoing care and follow-up communication with a health care provider.

Possible Risks of Telehealth Care

As with any type or form of health care treatment, there are potential risks associated with the use of telehealth. These risks include, but may not be limited to:

Delays in medical evaluation / treatment could occur due to deficiencies or failures of the electronic equipment;

In rare instances, security protocols could fail, causing a breach of privacy of your personal medical information;

In rare cases, a lack of access to all of your medical records may result in adverse drug interactions or allergic reactions or other judgment errors.

NOT FOR EMERGENCIES

I understand that I should never use the Choix Application in an emergency. Further, I understand that, in an emergency, I should dial 911 or go to an emergency department.

By consenting to this form, I, the patient, understand and agree to the following:

  • While I may expect the anticipated benefits from the use of telehealth in my care, no results can be guaranteed.
  • The federal and applicable state laws that protect the privacy and security of my health information apply to telehealth, and no information obtained in the use of telehealth care which identifies me will be disclosed to researchers or other entities without my authorization.
  • I have the right to withhold or withdraw my consent to the use of telehealth care in the ongoing course of my care at any time.
  • I have the right to inspect all information obtained and recorded in the course of a telehealth interaction, and I may receive copies of this information for a reasonable fee.
  • A variety of alternative methods of medical care may be available to me, and I may choose one or more of these at any time. My Choix provider has explained these alternatives to my satisfaction.
  • Telehealth may involve electronic communication of my personal medical information to other health care providers who may be located in other areas, including outside of the state in which I reside.
  • It is my duty to inform my Choix provider of any electronic interactions regarding my care that I may have with other health care providers.
  • I consent to receive protected health information via email or SMS text messaging and I understand that messages shared through these communication channels may not be secure in every instance.
  • You agree to conduct all medical consultations, and in the case of abortion care, take all medications, within the borders of the state you identify when inputting your address during the registration process.

By continuing, I, the patient, hereby:

  • Represent that I have read this Consent to Telehealth carefully, and that I understand the anticipated benefits and risks of the use of telehealth provided to me through the Choix Application.
  • Give my consent to the use of telehealth by providers engaged through the Choix Application.