Informed consent of Telehealth Services

I understand that Telehealth is a mode of delivering health care services via communication technologies (e.g., internet or cell phone) to facilitate diagnosis, consultation, treatment, education, care management, and self-management of a patient’s health care.

By acknowledging my consent below, I understand and agree to the following:

1. I understand that Jetson and affiliate Openloop Healthcare Partners, PC offer Telehealth consultations, which are conducted through videoconferencing, telephonic, and asynchronous technology and my Telehealth provider will not be present in the room with me. 
2. I understand there are potential risks to the use of Telehealth technology, including but not limited to, interruptions, delays, unauthorized access, and or other technical difficulties.  I understand that either my Telehealth provider or I can discontinue the Telehealth appointment if the technical connections are not adequate for my visit.
3. I understand that I could seek an in-office visit rather than obtain care from a Telehealth provider, and I am choosing to participate in a Telehealth consultation with Jetson, an affiliate of Openloop Healthcare Partners, PC provider.
4. To protect the confidentiality of my health information, I agree to undertake my Telehealth consultation in a private location, and I understand that my Telehealth provider will similarly be in a private location.
5. I understand that I am responsible for payment of any amounts due and owing resulting from my Telehealth visit.
6. In an emergent situation, I understand that the responsibility of my Telehealth provider may be to direct me to emergency medical services, such as an emergency room.

By clicking “I accept”, I certify:

• that I have read this form and/or had it explained to me
• that I understand the risks and benefits of a Telehealth appointment
• That I have been given the opportunity to ask questions and that such questions have been answered to my satisfaction.

 

Consent to test or email usage for appointment reminders and other healthcare reminders

By clicking “I accept”, I consent to receive text messages from the practice at my phone number or email to receive appointment reminders and general health reminders of information. I understand that this request is to receive emails and/or text messages will apply to all future appointment reminders/feedback/health information unless I request a change in writing. I also acknowledge this means of communication is not considered secure for the transmission of private information.

 

Informed consent of Pharmacy Services

This is a legal and binding document between you and Truepill on behalf of itself, its subsidiaries, and affiliated professional entities (collectively, “We,” “Our”, or “Us”). Read it carefully before clicking “I accept”. By clicking “I accept”, you hereby consent to receive clinical services from health care providers contracted with Truepill or Truepill-affiliated professional entities (in either case, “Truepill-affiliated Providers”) who are located at sites remote from you to provide consultative services to you. The receipt of clinical services from a Truepill-affiliated Provider (the “Services”) is a type of “telemedicine” or “telehealth” service. 

Agreement to Contract Pharmacy Relationship. Jetson is not a pharmacy. We partner with Truepill, Inc.’s network of affiliated pharmacies for quality pharmacy services, but you always have the right to have your prescription filled by any pharmacy of your choice. By choosing Truepill, Inc.’s affiliated pharmacy network, you acknowledge that in some cases, when allowed by law, one or more pharmacies may be involved in the processing and dispensing of your prescription. If 

necessary, by law, Truepill, Inc.’s affiliate pharmacy may need to transfer or forward your prescription to another pharmacy. If that is necessary, based on the state in which you live, by continuing with this transaction, you authorize Truepill, Inc.’s affiliate pharmacy to transfer the prescription to another pharmacy. You may cancel your prescription order at any time or request to transfer your prescription to another pharmacy by calling 855-910-8606. 

Authorization to Fill Your Prescription Order and Bill Your Insurance Company Anytime you present your prescription(s) and your prescription insurance billing information, you are authorizing Truepill Pharmacy or one of its affiliates to bill the fee for your prescription to your insurance company or its agents, and you agree to pay any out-of-pocket copayment amount assigned by your insurance company. 

Policies and Procedures Payment in full for services, including any copayments assigned by your insurance company, are due at the time services are performed or medications are picked up or delivered. As the patient/guarantor, you are financially responsible for any fees and costs associated with any services or products you receive from our pharmacy. 

By clicking “I accept”, you also represent and warrant the following: 

• Your Truepill-affiliated Provider has discussed the use of telemedicine services with you, including the benefits and risks of such use and the alternatives to the use of the Services, and you have provided consent to your Truepill-affiliated Provider for the use of the Services. 
• You understand that the use of the Services involves electronic communication of your personal medical information to your Truepill-affiliated Providers who may be located in other areas, including outside of the state in which you reside, and that the electronic systems, public networks, or security protocols or safeguards used in the Services could fail, causing a breach of privacy of your medical or other information. 
• You understand that it is your duty to provide your Truepill-affiliated Provider truthful, accurate, and complete information, including all relevant information regarding care that you may have received or may be receiving from other healthcare providers or outside of the Services. 
• You understand that your Truepill-affiliated Provider may determine that your condition is not suitable for diagnosis or treatment using the Services, or may fail to respond promptly or ever to your request for a

telemedicine service, and that you may need to seek medical care and treatment from your Truepill-affiliated Provider, a specialist, or other healthcare provider outside of the Services. 

• You understand the risks and benefits of the Services and its use in the medical care and treatment provided to you by your Truepill-affiliated Provider. 
• No potential benefits from the use of the Services, care provided via the Services, or specific results can be guaranteed. Your condition may not be cured or improved, and in some cases, may get worse. 
• You understand that you can withhold or withdraw this consent at any time by emailing complianceHL@truepill.com with such instruction. Otherwise, this consent will be considered renewed upon each new telemedicine consultation with Truepill-affiliated Providers. 
• You agree and authorize your Truepill-affiliated Provider to share information regarding the telemedicine exam with other individuals for treatment, payment and health care operations purposes. 
• By agreeing to these terms of service, I am attesting that the information above has been communicated with me, I had the opportunity to ask questions, I had the opportunity to have my prescriptions transferred to another pharmacy in lieu of agreeing to have Truepill fulfill the prescription, and I have the opportunity to transfer my prescriptions to another pharmacy at any point in the future regardless of my agreement to the terms of service.

Acknowledgement 

By clicking “I accept”, you (a) further certify that you are the patient, or that you are duly authorized by the patient as the patient’s representative or legal guardian, (b) acknowledge and accept the risks identified above and the terms associated with the receipt of clinical services via the Services, (c) give your informed consent to receive clinical services, service documents and information under the terms described herein electronically (d) agree that you are signing this consent electronically and (e) agree your electronic signature is the legal equivalent of your handwritten signature.