Note from Apostrophe: Our goal is to make it as easy as possible to access great skincare from a licensed healthcare provider by using our platform. Telehealth involves the delivery of healthcare using technology, when a patient is in one location and a provider is in another location. Providing healthcare through technology is called "telehealth." Below we outline the potential benefits and risks of telehealth and ask you to consent to its use as part of your Apostrophe experience. We want to provide you with information around the benefits and the risks, however we want you to make an informed decision about your care. Please read the form below carefully and feel free to reach out to us if you have any questions: email@example.com
In using the Apostrophe platform, you will be consulting with a licensed healthcare provider ("Provider") solely via the use of "telehealth." Telehealth involves the delivery of healthcare services using electronic communications, 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 and/or patient education, and may include, but is not limited to:
Electronic transmission of medical records, photo images, personal health information, or other data between a patient and a healthcare provider
Interactions between a patient and healthcare provider via audio, video, and/or data communications
Use of output data from medical devices, sound, and video files
Provider(s) using the Apostrophe platform will be interacting with you solely via use of the Apostrophe platform. As a result, all of the medical care and treatment you receive from such Providers will be provided via telehealth, and you will not be able to meet with your Provider in the same physical location.
The electronics system used in the Apostrophe platform will incorporate network and software security protocols to protect the privacy and security of health information and imaging data, and will include measures to safeguard the data to ensure its integrity against intentional or unintentional corruption.
The use of telehealth by Providers through the Apostrophe platform may have the following benefits:
Making it easier and more efficient for you to access the medical care for the conditions treated by Providers
Reducing wait times for diagnosis, treatment, and appropriate prescriptions
Allowing you to obtain medical care and treatment by Providers at times that are convenient for you
Avoiding unnecessary travel and allowing you to obtain medical care from the comfort and privacy of your home
Enabling ongoing care and follow-up communication with your Providers on your terms without travel or missed work or school
While the use of telehealth may provide numerous benefits, there are also potential risks. These risks include, but may not be limited to, the following:
The information transmitted to your Provider(s) may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision-making by the Provider(s)
The inability of your Provider(s) to conduct certain tests or assess vital signs in-person may in some cases prevent the Provider(s) from providing a diagnosis or treatment or from identifying the need for emergency care
Your Provider may not be able to provide medical treatment for a particular condition, and you may be required to seek alternative health care or emergency care services
Delays in medical evaluation or treatment could occur due to unavailability of Providers or the possibility of deficiencies or failures of the technology or electronic equipment used
In rare instances, security protocols or safeguards could fail, causing a breach of privacy
Given regulatory requirements in certain jurisdictions, your Provider(s) treatment options, especially pertaining to certain prescriptions, may be limited
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
BY CONSENTING TO THE FORM, I UNDERSTAND AND AGREE TO THE FOLLOWING:
- All medical care and treatment I receive from Providers using the Apostrophe platform will be provided using telehealth and Providers will not be able to provide any medical care and treatment to me without the use of telehealth.
- In some cases, I understand that treating Provider(s) may be a nurse practitioner or physician assistant, and not a physician. By deciding to seek care via the Apostrophe platform, I consent to treatment by a non-physician Provider if applicable.
- The delivery of healthcare services via telehealth is an evolving field and the use of telehealth in my medical care and treatment from Providers may include uses of technology not specifically described in this Patient Consent.
- While the use of telehealth may provide potential benefits to me, as with any medical care service (in-person or using telehealth technology) no such benefits or specific results can be guaranteed. My condition may not be cured or improved, and in some cases, may get worse.
- There are certain risks to me in the use of telehealth, including but not limited to the risks described in the Patient Consent.
- I have the right to withhold or withdraw my consent to the use of telehealth at any time by terminating my use of the Apostrophe platform.
- The use of telehealth involves electronic communication of my personal information to Providers who may be located in other areas, including outside of the state in which I reside.
- My medical information may be shared with additional Provider(s) to facilitate my care and treatment.
- It is my duty to provide each Provider providing services on the Apostrophe platform all information relevant to my medical care, including all information regarding care that I may have received or may be receiving from other healthcare providers outside of the Apostrophe platform.
- Provider(s), after assessing my medical condition, may determine in their sole discretion that it is medically appropriate to diagnose and/or treat my condition via telehealth. By continuing to use the Apostrophe platform, I concur with such Provider’s medical assessment, and agree to receive a diagnosis and/or treatment via telehealth technology.
- Provider(s) may determine in his or her sole discretion that my condition is not suitable for treatment using the Apostrophe platform and that I may need to seek medical care and treatment from a specialist or other healthcare provider outside of the Apostrophe platform.
- My care at Apostrophe is limited to the diagnosis and treatment of the Services offered and related disorders and not for the diagnosis or treatment of any other medical or dermatological conditions, including skin cancer. I understand that the Website is not a substitute for the in-person treatment or advice of my local dermatologist, primary care physician, or any other qualified healthcare professional. I understand that I should never delay seeking advice from my local dermatologist, primary care physician, or any other health professionals if advised to do so by my Apostrophe healthcare Provider, or if I have any concerns.
- I understand that if I have an emergency health issue of any nature, I should call my local emergency medical number or take such other action as I deem necessary. If the situation is an emergency, call 911.
- I am fully responsible for payment for all services provided by Providers or through use of the Apostrophe platform.
OPEN PAYMENTS NOTICE
For informational purposes only, a link to the federal Centers for Medicare and Medicaid Services Open Payments web page is provided here. The federal Physician Payments Sunshine Act requires that detailed information about payment and other payments of value worth over ten dollars ($10) from manufacturers of drugs, medical device, and biologics to physicians and teaching hospitals be made available to the public. The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. It can be found at https://openpaymentsdata.cms.gov.
BY CONTINUING, I HEREBY:
- Represent that I have read this Patient Consent carefully, and that I understand the benefits and risks of the use of telehealth in the medical care provided to me by Providers using the Apostrophe platform;
- Give my informed consent to the use of telehealth by Providers using the Apostrophe platform under the terms described in this Patient Consent; and
- Further, I acknowledge I have received information about the federal Open Payments database.