Telehealth Consent

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

If you are experiencing a medical emergency or any life-threatening situation such as contemplating suicide, CALL 911 OR THE 988 SUICIDE & CRISIS LIFELINE AT 988.

I understand and agree to the following:

  1. I understand that Forecast Care Serivces, LLC 1201 North Market Street, Suite 111 Wilmington, DE 19801 (302)-365-0174 ( “Admired”) is a healthcare platform that contracts with Openloop Healthcare Partners 317 6th Avenue, Suite 400, Des Moines, Iowa 50309 ("Telehealth Providers"), which render telehealth services, engage licensed practitioners, and ensure compliance with applicable telehealth law.
  2. I understand that Admired is not a healthcare provider, and engaging with Admired does NOT create a provider-patient relationship. I understand that Admired is a digital platform that coordinates and facilitates clients by connecting them with experienced licensed healthcare professionals to manage different aspects of their healthcare and wellness experience via the Telehealth Providers.
  3. I understand that prescription products require an online consultation with the Telehealth Providers who will determine if a prescription is appropriate.
  4. I understand that during the relationship with the Telehealth Providers, I may not receive a prescription if it is medically not appropriate. If a medical provider denies your treatment, we will refund the cost of the medication(if applicable).
  5. I understand that consultation fees for the Telehealth Providers to evaluate your treatment are non-refundable.
  6. I understand that telehealth services are conducted through videoconferencing, telephonic, and asynchronous technology and I'm aware that the Telehealth Providers will not be present in the room with me. 
  7. 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.
  8. I understand that I could seek an in-office visit elsewhere rather than obtain care from Telehealth Provider, and I am choosing to participate in a Telehealth consultation through Admired, a business associate of Openloop Healthcare Partners, PC, Openloop Healthcare Partners, PC, Openloop Healthcare Partners California, PC, Openloop Healthcare Partners Colorado, PC, Openloop Healthcare Partners New Jersey, PC, Openloop Healthcare Partners Wisconsin SC, Reliant.MD Medical Associates, PLLC, Reliant.MD Medical Associates California, PC, Reliant.MD Medical Associates Colorado, PC, Reliant.MD Medical Associates New Jersey, PC, Reliant.MD Medical Associates Wisconsin, SC, MECNB Physician Services, PC, MECNB Physician Services California, PC, MECNB Physician Services Colorado, PC, MECNB Physician Services New Jersey, PC, and MECNB Physician Services, SC collectively referred to as "Telehealth Providers".
  9. 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.
  10. I understand that I am responsible for payment of any amounts due and owing resulting from my Telehealth visit.
  11. 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.
  12. I understand that I am free to obtain my medical examination from another healthcare provider that is not associated with Admired
  13. I understand that Admired also has a commercial relationship with GoGomeds LLC ( 525 Alexandria Pike Suite 100 Southgate,KY 41071 (888)-795-5826 ("Pharmacy Partners") and will use them as pharmacy partners to fulfill my order directly to my door. I am free to obtain my prescription from any pharmacy of my choice by contacting our support team via the member portal.
  14. I understand that prescriptions may be filled by and transferred between the Pharmacy Partners on my behalf. I must pay the full amount of the costs associated with the use of the Service, including any prescription I may receive, and will not attempt to submit a claim to Medicare, any other federal payor, or any state or private insurer.

I certify:

  1. That I have read, accepted and agreed to the above and/or had it explained to me and hereby grant agency authority to any party who clicks on either a checkmark, any "I agree" form entry option or otherwise indicates acceptance to this consent by me or someone on my behalf.
  2. That I understand the risks and benefits of a Telehealth appointment
  3. That I have been given the opportunity to ask questions and that such questions have been answered to my satisfaction.

CONSENT TO TEXT OR EMAIL USAGE FOR APPOINTMENT REMINDERS AND OTHER HEALTHCARE REMINDERS

By proceeding forward with your online consultation,  I consent to receive text messages from Admired, Telehealth Providers or Pharmacy Partners mentioned above at my phone number or email to receive communication related to treatment, orders, subscriptions, medications, prescriptions, appointment reminders, general health reminders/alerts, automated system messages, or any type of communication related to the user experience of either Admired, Telehealth Providers or Pharmacy Partners. I understand that this request is to receive emails and/or text messages which will apply to all future communication unless I request a change in writing. I also acknowledge this means of communication is not considered secure for the transmission of private information.