AMG Medical Group (DE), P.A. Informed Consent for Telehealth Services

Last Updated: [11/21/20]

Telehealth involves the use of secure electronic communications, information technology, or other means to enable a healthcare provider and a patient at different locations to communicate and share individual patient health information for the purpose of rendering clinical care.  This “Telehealth Informed Consent” informs the patient (“patient,” “you,” or “your”) concerning the treatment methods, risks, and limitations of using a telehealth platform as well as some of the means by which the healthcare provider and affiliates may communicate with you.  

Services Provided:

Telehealth services offered by AMG Medical Group (DE), P.A, and its affiliated medical groups (collectively “Group”), and the Group’s engaged providers (our “Providers” or your “Provider”) may include a patient consultation, diagnosis, treatment recommendation, prescription, and/or a referral to in-person care, as determined clinically appropriate (the “Services”).  Your Provider will be licensed in the state where you are located at the time of your consultation, or otherwise meet a professional licensure exception under applicable state law, and will establish a provider-patient relationship in accordance with the laws and rules in the applicable state.

DNA Ally, Inc. (“DNA Ally”) does not provide the Services; it performs administrative, payment, and other supportive activities for Group and our Providers.

Electronic Transmissions:

The types of electronic transmissions that may occur using the telehealth platform include, but are not limited to:

• Appointment scheduling; 
• Completion, exchange, and review of medical intake forms and other clinically relevant information (for example: health records; images; output data from medical devices; sound and video files; diagnostic and/or lab test results) between you and your Provider via: 
  • asynchronous communications; 
  • two-way interactive audio in combination with store-and-forward communications; and/or 
  • two-way interactive audio and video interaction;
• Treatment recommendations by your Provider based upon such review and exchange of clinical information;
• Delivery of a consultation report with a diagnosis, treatment and/or prescription recommendations, as deemed clinically relevant;and/or 
• Other electronic transmissions for the purpose of rendering clinical care to you.

Expected Benefits:

• Improved access to care by enabling you to remain in your preferred location while your Provider consults with you.  Our telehealth services are available [24] hours a day, [7] days a week.
• More efficient care evaluation and management. 

Service Limitations: 

• The primary difference between telehealth and direct in-person service delivery is the inability to have direct, physical contact with the patient. Accordingly, some clinical needs may not be appropriate for a telehealth visit and your Provider will make that determination.
• Our providers do not address medical emergencies. If you believe you are experiencing a medical emergency, You should dial 9-1-1 and/or go to the nearest emergency room.  please do not attempt to contact DNA Ally, inc., GROUP, or your Provider.  After receiving emergency healthcare treatment, you should visit your local primary care PROVIDER.
• If you are not experiencing an emergency or do not require immediate or urgent care, you can communicate with Providers through the secure message service in the Platforms. If a technical failure prevents you from communicating with your Providers through the Platforms, please email us immediately at yourfriends@DNAAlly.com.
• Our Providers are an addition to, and not a replacement for, your local primary care provider.  Responsibility for your overall medical care should remain with your local primary care provider, if you have one, and we strongly encourage you to locate one if you do not.
• Group does not have any in-person clinic locations. 

Security Measures:

The electronic communication systems we use will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.  All the Services delivered to the patient through telehealth will be delivered over a secure connection that complies with the requirements of the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”). 

Possible Risks: 

• Delays in evaluation and treatment could occur due to deficiencies or failures of the equipment and technologies, or provider availability.
• In the event of an inability to communicate as a result of a technological or equipment failure, please contact the Group at (844) 362-2559 AND yourfriends@DNAAlly.com. 
• In rare events, your Provider may determine that the transmitted information is of inadequate quality, thus necessitating a rescheduled telehealth consult or an in-person meeting with your local primary care doctor.
• In very rare events, security protocols could fail, causing a breach of privacy of personal medical information.

Patient Acknowledgments:

I further acknowledge, understand, and agree to the following:

1. I am at least eighteen (18) years of age. 
2. I am the individual who will provide the sample for the Test(s) that I am requesting.
3. A Group physician will determine whether or not Test(s) and Services are appropriate for me.
4. My health information and results may be shared with other health care professionals including, but not limited to, physicians and counselors for purposes of providing Services.
5. I have read and understand the information provided about the Test(s). For COVID-19 testing, additional information is also available at the CDC website https://www.cdc.gov/coronavirus/2019-ncov.
6. The information I have provided in connection with Services is correct to the best of my knowledge. I will not hold DNA ALLY, Group or its health care providers responsible for any errors or omissions that I may have made in providing such information.
7. Services do not constitute treatment of any condition, disease or illness.
8. While DNA ALLY Group, and the laboratories implement safeguards to avoid errors, as with all laboratory tests, there is a chance of a false positive or false negative result.  
9. I understand that after receiving my Results, I will have the opportunity for a Telemedicine Consult with a Group physician or other licensed healthcare provider to answer any questions I may have.
10. I will not make medical decisions without consulting my primary care or disregard medical advice from my primary care or delay seeking such advice based on information as a result of the use of the Services.
11. The scope of Services will be at the sole discretion of the healthcare provider conducting the Telemedicine Services, with no treatment or prescription. The healthcare provider will determine whether or not the Services being rendered are appropriate for a telehealth encounter.
12. Healthcare services provided by Group may include physician oversight of laboratory testing for lab tests such as genetic tests and COVID-19 (the “Test”), including, without limitation, evaluation of the test request, ordering of a Test (if appropriate), receipt of Test results (“Results”), consultations by healthcare providers via telemedicine (“Consults”), customer support and any other related services. DNA ALLY and Group  are not responsible for the laboratory services, the provision of the Test or other services provided by the company from which you requested the Test (“Test Provider”) or through or in connection with Test Provider’s website. 

13. Prior to the telehealth visit, I will be given an opportunity to select a provider as appropriate, including a review of the provider’s credentials, or I have elected to visit with the next available provider from Group, and have been given my Provider’s credentials.

14. If I am experiencing a medical emergency, I will be directed to dial 9-1-1 immediately and my Provider is not able to connect me directly to any local emergency services.

15. I may elect to seek services from a medical group with in-person clinics as an alternative to receiving telehealth services.

16. I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time without affecting my right to future care or treatment.

17. Federal and state law requires health care providers to protect the privacy and the security of health information.  I am entitled to all confidentiality protections under applicable federal and state laws.  I understand all medical reports resulting from the telehealth visit are part of my medical record.  

18. Group will take steps to make sure that my health information is not seen by anyone who should not see it. Telehealth may involve electronic communication of my personal health information to other health practitioners who may be located in other areas, including out of state.

19. Dissemination of any patient identifiable images or information from the telehealth visit to researchers or other educational entities will not occur without my affirmative consent.

20. There is a risk of technical failures during the telehealth visit beyond the control of Group.  I AGREE TO HOLD HARMLESS GROUP AND ITS EMPLOYEES, CONTRACTORS, AGENTS, DIRECTORS, MEMBERS, MANAGERS, SHAREHOLDERS, OFFICERS, REPRESENTATIVES, ASSIGNS, PARENTS, PREDECESSORS, AND SUCCESSORS for delays in evaluation or for information lost due to such technical failures.

21. In choosing to participate in a telehealth visit, I understand that some parts of the Services involving tests (e.g., labs or bloodwork) may be conducted at another location such as a testing facility, at the direction of my Provider.

22. Persons may be present during the telehealth visit other than my Provider in order to operate the telehealth technologies. If another person is present during the telehealth visit, I will be informed of the individual’s presence and his/her role and I have the right to request the following: (i) omit specific details of my medical history/examination that are personally sensitive to me; (ii) ask non-medical personnel to leave the telehealth consultation; and/or (iii) terminate the consultation at any time.

23. My Provider will explain my diagnosis and its evidentiary basis, and the risks and benefits of various treatment options.

24. I am responsible for checking for results notification and logging on to my account to view my results when available. 
25. I am responsible for downloading and forwarding any results or records to my primary care or other personal physician and for initiating follow up, without delay, with such physician for care, diagnosis or medical treatment. I should not make medical decisions without consulting my personal physician. 

26. I have the right to request a copy of my medical records.  I can request to obtain or send a copy of my medical records to my primary care or other designated health care provider by contacting Group at: yourfriends@dnaally.com.  A copy will be provided to me at reasonable cost of preparation, shipping and delivery.  

27. There is no guarantee that I will be issued a prescription and that the decision of whether a prescription is appropriate will be made in the professional judgement of my Provider.  If my Provider issues a prescription, I have the right to select the pharmacy of my choice. I understand that I will not be prescribed any controlled substances.

28. There is no guarantee that I will be treated by a Group provider. My Provider reserves the right to deny care for potential misuse of the Services or for any other reason if, in the professional judgment of my Provider, the provision of the Services is not medically or ethically appropriate.  

29. I agree to receive invitations, notifications, reminders and other communications from my Provider and DNA Ally, Inc. (“DNA Ally”) and any of its affiliates or agents) through the DNA Ally websites or mobile application (the “Platform” or “DNA Ally App”), or by email, text message (including any short message service), fax, phone or other method of communication. I agree and authorize my Provider and DNA Ally to make such communications through use of an automatic telephone dialing system and/or an artificial or prerecorded voice message system (“Automated Messages”) at any of the contact information provided to DNA Ally or my Provider or to other service providers who are working with DNA Ally or the Group. I will immediately notify my Provider if there are any changes to my mobile phone or other contact information.

30. I understand that Automated Messages may include (without limitation) an invitation to download and use the DNA Ally App. I understand that I may receive multiple messages per day, and that I am responsible for any message and data rates charged by my mobile carrier. These communications may not be secure (not encrypted). Unsecured communications may pose a risk to the confidentiality and privacy of the information being sent because they might be intercepted by a third party. I also understand that my consent to receive Automated Messages is optional and is not a condition to getting treatment or to my ability to use the DNA Ally App. I can opt out of receiving Automated Messages at any time, including y contacting DNA Ally or the AMG Medical Group at yourfriends@DNA Ally.com or replying “STOP” to an automated text message.

Additional State-Specific Consents: The following consents apply to patients accessing Group’s website for the purposes of participating in a telehealth consultation as required by the states listed below:

Iowa: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here:

https://medicalboard.iowa.gov/consumers/filing-complaint   

Idaho:  I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here:

https://bom.idaho.gov/BOMPortal/AgencyAdditional.aspx?Agency=425&AgencyLinkID=650  

Indiana:  I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here:

https://www.in.gov/attorneygeneral/2434.htm 

Kentucky: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here:

https://kbml.ky.gov/grievances/Pages/default.aspx 

Maine:  I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here:

https://www.maine.gov/md/discipline/file-complaint.html

Oklahoma: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here:

Oklahoma Board of Medical Licensure and Supervision:

http://www.okmedicalboard.org/complaint; 

Oklahoma Board of Osteopathic Examiners:

https://www.ok.gov/osboe/faqs.html. 

Texas: I have been informed of the following notice:

NOTICE CONCERNING COMPLAINTS -Complaints about physicians, as well as other licensees and registrants of the Texas Medical Board, including physician assistants, acupuncturists, and surgical assistants may be reported for investigation at the following address: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018, Assistance in filing a complaint is available by calling the following telephone number: 1-800-201-9353, For more information, please visit our website at www.tmb.state.tx.us.  

AVISO SOBRE LAS QUEJAS- Las quejas sobre médicos, asi como sobre otros profesionales acreditados e inscritos del Consejo Médico de Tejas, incluyendo asistentes de médicos, practicantes de acupuntura y asistentes de cirugia, se pueden presentar en la siguiente dirección para ser investigadas: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018, Si necesita ayuda para presentar una queja, llame al: 1-800-201-9353, Para obtener más información, visite nuestro sitio web en www.tmb.state.tx.us   

Vermont: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here:

Vermont Board of Medical Practice:

http://www.healthvermont.gov/health-professionals-systems/board-medical-practice/file-complaint  

Vermont Board of Osteopathic Examiners: 

PATIENT CONSENT

I have read this document carefully and understand the risks and benefits of the telehealth consultation and have had my questions regarding the procedure explained and I hereby give my informed consent to participate in a telehealth consultation and communicate/receive communications under the terms described herein.

By checking the Box containing “INFORMED CONSENT FOR TELEHEALTH SERVICES” I hereby state that I have read, understood, and agree to the terms of this document.