DATE OF LAST REVISION: MAY 2022
This Consent is provided by Shakespeare Digital Health and its affiliates, including 4Romeo and 4Juliet entities, (collectively, “SDH,” “we,” “our,” or “us”)
The purpose of this form is to provide you with information about telemedicine / e-visit and to obtain your informed consent to participate in a telemedicine / e-visit health service as part of your medical care.
Nature of telemedicine / e-visit
Telemedicine / e-visit involves the use of electronic communications to enable a health care provider and a patient at different locations to share medical information for the purpose of evaluation, diagnosis, consultation, or treatment of the patient. The delivery of healthcare via telemedicine / e-visit allows the patient and provider to establish a relationship, much as they would during a traditional face-to-face appointment. For example, your telemedicine / e-visit encounter may include interaction through and with the use of the internet, recorded audio communications, physical examinations, medical imaging, medical tests, and diagnoses, as well as related technologies known as “store-and- forward.”
The benefits of telemedicine / e-visit include improved access to medical services and care, including the expertise of specialists and consultants that may not otherwise be available to you. Telemedicine / e-visit also permits increased efficiency in evaluations, diagnoses, consultations, and treatment.
The potential risks associated with the use of telemedicine / e-visit are rare, but include delays in medical evaluation and treatment due to equipment failures or information transmission deficiencies (such as poor image resolution); breach of privacy of protected health information due to security breaches or failures; and adverse drug interactions, allergic reactions, complications, or other errors due to patient’s failure to provide complete medical information or records.
YOU AGREE TO INDEMNIFY AND HOLD HARMLESS SDH, ITS EMPLOYEES, AGENTS, DIRECTORS, MEMBERS, MANAGERS, SHAREHOLDERS, OFFICERS, REPRESENTATIVES, ASSIGNS, PARENTS, PREDECESSORS, AND SUCCESSORS FROM AND AGAINST ANY AND ALL LOSS, DAMAGE, EXPENSE, LIABILITY, CLAIM, OR DEMAND WHATSOEVER, ARISING OUT OF OR RELATED TO ANY FAILURE OF TECHNOLOGY OR EQUIPMENT IN CONNECTION WITH THE PROVISION OF TELEMEDICINE / E-VISIT WHETHER OR NOT ANY SUCH LOSS, DAMAGE, EXPENSE, LIABILITY, CLAIM, OR DEMAND ARISES FROM OR RELATES TO SDH NEGLIGENCE.
Alternative methods of care may be available to you, such as in-person services. Your provider will explain any such options to you, and you may choose an alternative at any time.
Follow-up Care & Emergency Situations
In some situations, telemedicine / e-visit is not an appropriate method of care. If there is an urgent situation, if you have an adverse reaction, if a technical failure prevents you from communicating with your telemedicine provider, or if you believe telemedicine / e-visit will not provide sufficient safety and quality, you should contact SDH at 800-715-7010 (Mon-Fri 8:30am to 5:30pm CST). If the contacts listed below are unavailable, you must seek care at an emergency room facility or other provider equipped to deliver urgent or emergent care. If the situation is an emergency, call 911.
Your Privacy Rights
SDH uses network and software security protocols to protect the confidentiality of your patient health information, including for example your medical record, EMR, imaging, and personal financial data. These protocols are designed to safeguard the data and to ensure its integrity against corruption. Personal information that identifies you or contains protected health information will not be disclosed to any third party without your consent, except as authorized by law for the purposes of consultation, treatment, payment/billing, and certain administrative purposes, or as otherwise set forth in SDH’s Notice of Privacy Practices.
By signing this form, I agree to the following
Telemedicine / e-visit is the use of electronic information and communication technologies by a health care provider to deliver services to an individual when he/she is located at a different site than the provider. I understand that I need to provide a full and accurate medical history, including any pre-existing conditions, to my telemedicine / e-visit provider so that my provider can accurately determine what services I need. I further understand that my provider will determine whether telemedicine / e-visit is appropriate for me at this time, based on the condition being diagnosed and/or treated. I understand that I may benefit from telemedicine / e-visit, but that results cannot be guaranteed.
My provider will inform me who will be present at the provider’s location during the telemedicine / e-visit service and I have the right to exclude anyone from being present, if I so choose. I further understand that I have the right to object to the use of a telemedicine / e-visit service without prejudice to any future care or treatment and without risking the loss or withdrawal of any health benefits to which I am entitled. If there are costs to me associated with my telemedicine / e-visit encounter, a health care professional will discuss those costs with me prior to the start of my session.
Further, I understand and agree that I must pay the full amount of the costs associated with this telemedicine / e-visit service, including any prescription I may receive, and I will not attempt to submit a claim to Medicare, any other federal payor, or any state or private insurer. I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine / e-visit and I agree that Shakespeare Digital Health may provide my confidential personal health information to other medical providers who may be located in other areas, including on rare occasions to providers outside the State, as necessary. I have the right to inspect and obtain copies of all information received and recorded during any telemedicine / e-visit session, subject to the policies of the physicians, physician assistants, nurse practitioners and facilities involved in my care. I may be charged a fee for copies of my records in accordance with applicable State rules. I have read and understand the information above, and all of my questions have been answered to my satisfaction.
All photos and images used are licensed images and not actual patients unless expressed otherwise.
If you have a concern about a medical professional, you may contact the Medical Board in your state regarding your concerns.
I consent to a SDH contracted physician, physician assistant, or nurse practitioner to provide services to me via telemedicine / e-visit.
By clicking “I Agree”, I understand and consent to the foregoing acknowledgements and disclosures including SDH Terms of Service and Notice of Privacy Practices.
When medically necessary, pharmacy services are provided by TeleCare Pharmacy located at 324 Peterson Rd. Libertyville, IL 60048 – Tel: 866-396-0288. However, the providers are always able to issue a prescription order to any pharmacy of your choice. You are free to obtain your medical examination from another healthcare provider that is not associated with SDH.
SDH will use its contracted pharmacy to fulfill your order directly to your door. You are free to obtain your prescription from any pharmacy of your choice by contacting our support team. Further, for purposes of this informed consent, MY ACT OF CLICKING “I Agree” SHALL CONSTITUTE AND IS MY ELECTRONIC SIGNATURE.