telemedicine Informed Consent
Telemedicine Informed Consent and Patient
(the “Agreement” and “Consent”)
Brain Initiative Corp
616 S. Catalina Ave.
Redondo Beach, CA 90277
Your Physicians provide lifestyle medicine. For more information on BHI and its providers’ services, please visit Our website at
www.brainhealthinstitute.com (collectively, the “Site”),
https://brainhealthinstitute.com/meet-the-doctors/, or contact us at the above information.
We believe it is important for every patient to have a local primary care doctor. You should not consider any provider at BHI to be Your primary care provider (“PCP”). We strongly encourage You to establish a relationship with a local PCP in Your area. Please understand, the Physician Services, as defined below, are in addition or supplementation to, and do not replace, the medical care provided by Your local PCP. The ultimate responsibility for Your overall medical care should remain with Your local PCP.
Telemedicine is the provision of healthcare services over telecommunication systems, enabling healthcare providers at different locations to provide services and share individual patient medical information for the purpose of improving and continuing patient care. By signing below, Patient agrees to become a patient of the Physicians. As used in this Agreement, “Physician Services” applies to all telemedicine and other professional services provided to You by Your Physician, and includes but is not limited to telemedicine services consisting in any combination of the following: remote evaluation, diagnosis, chart review, prescribing, treatment, follow-up or related patient education, and may include but is not limited to:
- Electronic transmission of medical records, test results, photo images, personal health information, synchronous or asynchronous communications, or other data between Patient and healthcare providers;
- Interactions between a patient and healthcare providers via live, two-way audio or video, or data/patient communications;
- Remote evaluation, diagnosis, chart review, prescribing, appointment scheduling, health information sharing, or patient education;
- Interactive audio with store and forward; and
- Use of output data from medical devices, sound, and video files.
All Physician Services will be provided by BHI-affiliated healthcare professionals including Your Physician. The following non-exhaustive list of fees, costs, or services is not part of the care or Physician Services the Physician will provide or BHI will bill for:
- Primary care.
- In-person medical care.
- Emergency or urgent care.
- Vaccinations – BHI does not offer vaccinations as part of its Services. Physician may make reasonable efforts to assist Patient in obtaining necessary or recommended vaccinations.
- In-patient or hospital services.
- Obstetric or gynecologic services.
- Invasive or non-invasive surgical procedures.
- Durable medical equipment or supplies.
Patient understands and agrees BHI is not a medical organization or healthcare clinic, provider, or practitioner. BHI is not licensed in, and cannot individually practice medicine. Instead, BHI will provide the following non-exhaustive list of services to facilitate Physician’s care for Patient (the “BHI Services”):
- providing individuals with information on healthcare and wellness (“Content”);
- connecting individuals with pharmacy services;
- providing individuals with access to technology-oriented tools for smoking cessation;
- development and gathering of healthcare records and healthcare information with retention of the same for use in healthcare provider appointments, communications, and related services;
- administrative support in connection with scheduling, payment for Physician Services, and related services; and
- telecommunications support for using the Physician Services, including for communication, consultations, assessments, and treatment by such healthcare organizations and their providers.
Telemedicine is NOT an appropriate method of care in an emergency. IN CASE OF AN EMERGENCY, YOU SHOULD SEEK IMMEDIATE MEDICAL ATTENTION OR EMERGENCY CARE BY IMMEDIATELY GOING TO AN EMERGENCY ROOM OR BY CALLING 911.
By entering into this Agreement and Consent, neither Physician, nor BHI warrant or promise to Patient any specific outcome or guarantee regarding the efficacy or success of the Physician Services or BHI Services. Physician and BHI additionally cannot guarantee that the Patient will not need future services that are not within the scope of this Agreement or the Physician’s skill or expertise, such as care from other specialists, or emergency or urgent care.
NEITHER BHI NOR ANY OF BHI’S AFFILIATED HEALTHCARE PROVIDERS, INCLUDING PHYSICIAN, PARTICIPATE IN OR BILL THROUGH INSURANCE FOR ANY OF THE SERVICES. BHI AND ITS AFFILIATED HEALTHCARE PROVIDERS DO NOT ACCEPT ANY PRIVATE INSURANCE, MEDICARE, MEDICAID, MEDIGAP, TRICARE, OR ANY SUPPLEMENTAL INSURANCE PLAN IN RELATION TO BILLING FOR THE BHI SERVICES OR THE PHYSICIAN SERVICES. You expressly acknowledge and understand that a private or public insurance entity may not reimburse You for the BHI Services or the Physician Services, and You will be liable for all incurred charges that are not covered by insurance. Medicare, Medicaid, and other non-private insurance agencies will not assist You in paying for the BHI Services or the Physician Services or billings You incur through either of them. Upon request, We may provide You with a superbill for You to seek reimbursement from Your private insurance company. We are in no way liable for, however, and do not in any way guarantee any such reimbursement will occur. You further agree not to bill or attempt to bill any Medicare, Medicaid or any other government or non-private insurance company or entity for any of the BHI Services or the Physician Services. You expressly acknowledge and understand You have the right to seek out care or similar services from physicians and entities who do accept Medicare or other private, government, or supplemental insurance plans. You further acknowledge and understand neither BHI, Our affiliated healthcare providers are limited in the amount they may charge for the Services.
Special Notice regarding Non-Participation in Insurance or Medicare.
This section specifically applies to all Medicare beneficiaries. As used in this Section, “Patient,” “You,” and “Your” apply to such Medicare recipients, and not generally to all patients, as is true through the rest of this Agreement.
Many of Our affiliated healthcare providers have made the individual choice to “opt out” of Medicare pursuant to Medicare’s requirements to do so (an “Opted-Out Provider”). By signing and agreeing to receive services from Physician, You understand, acknowledge, and agree:
- An Opted-Out Provider has opted out of participation in Medicare.
- An Opted-Out Provider does not bill through or accept payments from Medicare.
- Medicare payment limits do not apply to what an Opted-Out Provider may charge patients for items or services.
- You agree to give up all potential reimbursement for Medicare-covered services as part of this Agreement.
- You, as a Medicare beneficiary, and Your legal representative, if applicable, agree not to submit any claim to Medicare or to ask BHI or Our Opted-Out Providers to submit a claim to Medicare on Your behalf.
- Medicare payment will not be made for any items or services provided by an Opted-Out Provider that would otherwise have been covered by Medicare.
- You will be liable for all incurred charges without Medicare balance billing limitations or assistance from Medigap or other supplemental insurance.
- You have the right to obtain Medicare items and services from other physicians or providers who have not opted out of Medicare participation.
- This Agreement and Consent constitutes a private contract for services that include Medicare-covered services.
- You are not required to enter into private contracts for Medicare-covered services provided by other physicians or providers who have not opted out of Medicare.
- Medigap plans do not, and other supplemental plans may elect not to, make payments for items and services not paid for by Medicare.
- The expected effective and expiration dates of any opt out period will vary by provider. Please see below for a current list of Opted-Out Providers, which may include Your Physician.
Our current Opted-Out Providers include the following (with effective and anticipated expiration dates of the opt out):
- Dean Sherzai, MD, PhD, MPH, MAS, LLC (3/31/20 – 3/31/22).
If Patient is concerned or has questions about any of these issues, Patient agrees to inquire about them with Physician or BHI prior to obtaining any care from Physician. By signing and agreeing to receive services from Physician, Patient further affirmatively agrees to inform Physician and BHI of the fact Patient is a Medicare recipient prior to receiving any care through the Physician Services.
This Agreement is not health insurance. PHYSICIAN AND BHI ARE NOT health insurance or health maintenance organizationS. This Agreement is not a contract for the provision of health insurance, and in isolation, does not meet federal or state requirements for Patient’s maintenance of health insurance. This Agreement is not intended to replace any existing or future health insurance or health plan coverage that Patient may carry now or in the future. Patient acknowledges and understands this Agreement is not a substitute for health insurance or other health plan coverage (such as membership in an HMO). This Agreement will not cover hospital services or any other services or treatment BHI AND PHYSICIAN do not provide. BHI and Physician advise Patient to obtain or keep in full force all health insurance policies or plans necessary to cover Patient for Patient’s healthcare costs, services, or treatment.
BHI and each Physician reserve the right, in their sole discretion, to accept or decline patients based on any reason they deem fit. This may include but is not limited to a declination because a Physician’s practice is at capacity or because Patient needs medical care outside of the scope of the offered Physician Services or BHI Services.
Your participation in telemedicine treatment is at all times voluntary. You have the exclusive right to choose whether to remain in or terminate a treatment relationship at any time, although in this setting, any fees or costs You incur or incurred on Your behalf prior to termination will remain Your responsibility. Upon the cessation of any treatment or services, You also have the right to ask about and understand the consequences of stopping treatment.
Telemedicine can have benefits and risks. As with most other forms of treatment, results cannot be and are not guaranteed.
Benefits of Telemedicine:
- Improved access to care by enabling You to remain in Your home, office, or other convenient location while Your BHI-affiliated provider consults with You from a distant site.
- More efficient care, evaluation, and health management.
- Receiving the expertise of a BHI-affiliated lifestyle medicine specialist as appropriate.
Risks and Disadvantages of Telemedicine:
- Not all visual or physical cues of a face-to-face meeting are available. Interactions are subject to the quality of video or phone conferencing systems.
- A physician may not use direct touch to assist in diagnosis or treatment. This may prevent a physician from coming to certain diagnoses or recommending certain treatments. It also forces the physician to be more dependent on the accuracy of patient historical information when formulating diagnoses or treatment plans.
- Delays or interruptions in evaluation and treatment could occur due to deficiencies or failures of communication equipment or technologies.
- In rare events, a provider may determine transmitted information is inadequate as to quality, and may recommend a rescheduled Telemedicine consultation or a meeting with Your local PCP.
- In very rare events, security protocols could fail, causing a breach of privacy of personal medical information.
- In rare events, telemedicine and the use of medical records across multiple platforms could cause a lack of access to a patient’s complete medical records or chart, thereby resulting in an adverse drug interaction, or allergic reaction, or other unforeseen or unfortunate outcome, including even death.
To reduce the risk to You of the above risks, We strongly encourage you to provide all relevant information and discuss any and all diagnoses and treatment options with a separate healthcare provider. Moreover, Your Physician may be limited by state law or licensure in prescribing certain medications to You without first conducting an in-person physical examination. By deciding to engage the PHYSICIAN SERVICES OR BHI Services, AS DEFINED BELOW, you acknowledge and agree that You are aware of these limitations and agree to assume the risk of these limitations. Furthermore, you agree and accept all of the following:
- any diagnosis you may receive is limited and, in some cases, provisional;
- the healthcare services are not intended, in all cases, to replace a full medical evaluation or an in-person visit with a healthcare provider, including with Your PCP;
- a healthcare provider may not always have important information that is usually obtained through a “hands-on” physical examination;
- the absence of a physical examination may affect the healthcare provider’s ability to diagnose any potential condition, disease or injury;
- the Physician Services may be limited by training, experience, equipment, or supplies; and
- each Physician will make a determination about the scope of the services offered to Patient according to Patient’s reasonable requests, the offered Physician Services, BHI’s Services, as defined below, Physician’s independent medical training, expertise, and decision making, Patient’s condition, or Patient’s needs.
As an alternative to telemedicine, You may conduct in-person visits with appropriate medical professionals, including Your PCP. You may also seek telemedicine services from those same medical professionals. You are entitled to a second or multiple opinions. If You have unanswered questions about any aspect of Your treatment, involved risks, the BHI Services or the Physician Services, the Physician’s expertise, or about Your treatment plan, please ask and We will thoroughly discuss these items with You. You also have the right to ask about other treatments for Your situation and health and the risks and benefits of them, as appropriate. You may inquire of any of these items with separate medical or other professionals, as You deem appropriate.
Prior to Our telemedicine sessions, please be sure to exit out of any programs that take up a large amount of bandwidth or computer memory. Quit (don’t just minimize) Skype, Carbonite, Google Drive, any other cloud-based service, and any other programs You are not using. Please ensure that no one in Your home is streaming video or playing graphic heavy online video games as this will decrease Our internet connection. Tech issues are usually easy to solve. Turning things off and back on again typically fixes most issues. We will never intentionally hang up or leave a session regardless of what is said. Due to telemedicine’s reliance on technology, there is unfortunately always a possibility of technology failure during a session. If You need to receive follow-up care, assistance in the event of a non-emergent adverse reaction to treatment, or in the event of an inability to communicate as a result of a technological or equipment failure, please contact Us using the contact link in Your individual patient portal at www.brainhealthinstitute.com. 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.
We use secure and encrypted video software for Our sessions through a third-party provider, Athenahealth telehealth. We also use secure email, phone, and faxing systems. Please be aware, however, if You do not also use secure/encrypted programs on Your side of the communication, the communication may not be completely secure. We also regularly check the security of Our methods of communication, but swift advances in technology may preclude Our ability to always be certain of Our privacy and security. Please ensure You are also adequately protecting Your privacy by considering where You are located while You participate in care (e.g., in a private office or in a public coffee shop), and who has access to Your internet passwords, computers, email, text messages, and other accounts or information. Please always be sure to fully exit any telemedicine sessions before leaving Your computer.
Pursuant to federal and state law, We will maintain a copy of Your records for seven years from the date of any termination of services or on the last date of contact with the patient, whichever is later.
BHI-affiliated physicians are currently licensed in 10 states, but each independent physician may not be individually licensed in all 50 states. Due to certain legal constraints, Your Physician will only provide telemedicine while You are physically located in one of the states in which the Physician is licensed to practice medicine, consistent with the Physician’s licensure.
During times of significant or nationwide health crises, such as the recent COVID-19 outbreak, many states permit limited telehealth services from out-of-state providers to their residents. This is a complicated and often nuanced issue. We may provide telehealth services consistent with those permissions, even where BHI-affiliated providers are not licensed in a particular state, and pursuant to applicable state-based, legal waivers.
We will notify You of the states in which the Physician is licensed to practice. You agree to notify the treating Physician of Your location at the outset of every interaction so the Physician may verify his or her licensure requirements prior to providing care to You. If You intend to be out-of-town, or if You cannot be present in one of those states for a particular telemedicine session, You agree to notify BHI as soon as is practicable of those facts, or at the latest, at the beginning of any such Telemedicine session. The Physician will not provide You telemedicine care while You are not within one of the states of the Physician’s licensure.
By signing below, You acknowledge and agree You are voluntarily participating in telemedicine treatment, and that YOU MAY–AT ANY TIME–DECLINE TO PARTICIPATE IN TREATMENT OR ANY PART OF IT. You acknowledge You are fully aware of the risks, benefits, and alternatives involved in treatment. You understand the risks detailed in this CONSENT AND AGREEMENT MAY not BE complete. Neither BHI or Your Physician, individually, assume any risk, responsibility, or liability for any injury to You or Your property, regardless of whether that risk was foreseeable or unforeseeable in relation to telemedicine. By signing below, You agree, understand, and VOLUNTARILY, SOLELY, AND EXCLUSIVELY ASSUME ALL RESPONSIBILITY FOR ANY AND ALL RISKS AND LIABILITIES TO YOU OR YOUR PROPERTY IN ANY WAY ASSOCIATED WITH TREATMENT, INCLUDING VIA TELEMEDICINE, IF APPLICABLE AND AS DISCUSSED BELOW. YOU FURTHER IRREVOCABLY AND UNCONDITIONALLY RELEASE, WAIVE, FOREVER DISCHARGE, HOLD HARMLESS, AND AGREE NOT TO SUE BHI, ITS AFFILIATED PROVIDERS, SUCCESSORS, ASSIGNS, AFFILIATES, OFFICERS, MEMBERS, OWNERS, PARTNERS, AGENTS, CONTRACTORS, EMPLOYEES, VOLUNTEERS, AND ANY OTHER REPRESENTATIVES, OR THE PHYSICIAN FOR ANY AND ALL CLAIMS, DEMANDS, ACTIONS, CAUSES OF ACTION, OR LOSSES OF ANY KIND (WHETHER EXEMPLARY, DIRECT, INDIRECT, INCIDENTAL, SPECIAL, CONSEQUENTIAL, PUNITIVE, OR OTHER) IN ANY WAY RELATED TO OR WHICH COULD BE ASSERTED FOR YOUR PARTICIPATION IN TREATMENT, OR RELATED EVENTS, REGARDLESS OF WHO CAUSED SUCH LIABILITIES OR WHETHER THE LIABILITY ARISES IN NEGLIGENCE, TORT, CONTRACT, STRICT LIABILITY, OR ANY OTHER LEGAL THEORY. You agree and understand this waiver, including any representations and warnings within it, supersede any prior communications or representations on these subjects.
THE FOREGOING SECTIONS TITLED “ASSUMPTION OF RISK; WAIVER; RELEASE IS INTENDED TO BE USED ONLY AS PERMITTED BY LAW. IF ANY PORTION OF THESE SECTIONS IS HELD TO BE INVALID UNDER THE LAWS OF ANY APPLICABLE STATE, THE REMAINING PORTION SHALL BE ENFORCED TO THE MAXIMUM EXTENT PERMISSIBLE UNDER APPLICABLE LAW, AND THE INVALIDITY OF SUCH PORTION SHALL NOT AFFECT THE VALIDITY OF THE REMAINING PORTIONS OF THE APPLICABLE SECTIONS.
By choosing to participate in BHI’s offerings, BHI’s Services, and the Physician Services, you agree to indemnify, defend, and hold harmless, BHI, ITS EMPLOYEES, AGENTS, DIRECTORS, MEMBERS, MANAGERS, SHAREHOLDERS, OFFICERS, REPRESENTATIVES, ASSIGNS, PARENTS, PREDECESSORS, AND SUCCESSORS, and THE PHYSICIAN, FROM AND against any and all claims, actions, suits, demands, assessments, or judgments asserted, and any and all losses, liabilities, damages, costs, and expenses, including, without limitation, attorney fees (collectively, “Claims”), alleged or incurred arising out of or in any way relating to ANY FAILURE OF TECHNOLOGY OR EQUIPMENT IN CONNECTION WITH THE PROVISION OF THE BHI services or the physician SERVICES, WHETHER OR NOT ANY SUCH CLAIM ARISES FROM OR RELATES TO THE PROVIDER’S NEGLIGENCE, AND regardless of who asserts the Claim, or the legal or factual basis for IT.
By agreeing to and signing this Agreement and Consent, You acknowledge, understand, and agree:
- You are at least eighteen (18) years of age and possess the legal right and ability, on behalf of Yourself or a minor child of whom you are a parent or legal guardian, to voluntarily and unequivocally agree to this Agreement and Consent;
- You will fully, accurately, and truthfully create and maintain Your BHI profile;
- You will prohibit anyone else from using Your BHI profile.
- You will provide accurate, current, and complete patient and payment information about Yourself for Your BHI Profile.
- You will periodically review and update Your BHI profile information as appropriate to keep it accurate, current, and complete.
- You will immediately notify BHI of any actual or suspected unauthorized use of Your BHI profile, credentials, or other security concerns of which You become aware.
- Federal and state law requires healthcare providers to protect the privacy and security of health information. BHI will take steps to make sure that my health information is not seen by anyone who should not see it. Telemedicine may involve electronic communication of my personal medical information to other healthcare practitioners who may be located in other areas, including out-of-state.
- There is a risk of technical failures during a telemedicine encounter that may be beyond the control of BHI.
- You have the right to withhold or withdraw consent to the use of telemedicine in the course of care at any time, without affecting Your right to future care or treatment.
- You may suspend or terminate use of telemedicine services at any time and for any reason.
- Telemedicine is inappropriate for emergency care. If You are experiencing a medical emergency, You will seek immediate emergency care by immediately calling 911 or going to the nearest emergency room, as appropriate and available.
- BHI-affiliated providers are not able to connect me directly to any local emergency services.
- Some parts of the BHI Services or the Physician Services may involve tests conducted by individuals at a testing facility and at the direction of a BHI-affiliated provider (e.g., labs or bloodwork).
- No results can be guaranteed or assured as a result of the BHI Services or the Physician Services.
- My healthcare information may be shared with other individuals for scheduling and billing purposes and in compliance with BHI’s Notice of Privacy Practices.
- In order to operate telemedicine technologies, persons other than BHI-affiliated providers may be present during a consultation. You will be informed of any such presence and have the right to decline treatment or request: (a) omission of specific details of Your medical history/examination; (b) non-medical personnel to leave the telemedicine examination; and (c) to terminate the consultation at any time, regardless if the session has already started.
- You will not be prescribed any controlled substances.
- There is no guarantee You will be given any prescription at all.
- You have the right to request a copy of Your medical records or this Agreement and Consent, provided to You at a reasonable cost of preparation, including shipping and delivery.
- You agree to pay all fees or charges to Your account in accordance with the fees, charges, and billing terms in effect at the time a fee or charge is due and payable. You authorize BHI to charge Your credit card or other payment account for all fees and charges due and payable and agree that no additional notice or consent is required. This charge will take place before the start of Your telemedicine visit. All fees are net of any applicable sales tax and if any services or payments for any goods or services are subject to sales tax in any jurisdiction. You will be responsible for payment of such sales tax and any related penalties or interest and indemnify BHI for any liability or expense incurred in connection with such sales taxes (including any use tax and any other tax measured by sales proceeds that BHI is permitted to pass to You) and BHI may automatically charge and withhold such taxes for services to be delivered within any jurisdictions that it deems is required.
- Unless otherwise agreed to by BHI or Physician in writing, all fees paid are non-refundable.
If for any reason, a court or arbitrator of competent jurisdiction deems any provision of this Agreement and Consent to be legally invalid or unenforceable, that decision shall in no way affect the validity of the remainder of the Agreement and Consent or its terms. The unenforceable or invalid provision shall be modified to the minimum extent necessary to ensure that term’s consistency and enforceability with applicable law and shall thereafter be enforceable in its modified form.
Patient may not assign, sell, or transfer any rights Patient has under this Agreement without first obtaining the express written consent of Physician. All modifications, deletions or additions to this Agreement must be in writing and signed by the Patient, BHI, and Physician. No action of any party, other than in writing and agreed to by the parties, may be construed to waive any provision of this Agreement.
If You are ever dissatisfied with any aspect of the BHI Services or the Physician Services, please do not hesitate to discuss those concerns frankly with Us or Physician. If the parties are unable to resolve their differences, any controversy or claim arising out of or in any way related to this Agreement, the BHI Services, or the Physician Services shall be resolved through final and binding arbitration in Delaware, rather than in a court, pursuant to the Delaware Uniform Arbitration Act and the Rules of the American Arbitration Association except that You may assert individual claims in small claims court, if Your claims qualify. You agree that by entering into this Agreement, You, BHI, and Physician are each waiving the right to a trial by jury or to participate in a class action. You are also waiving Your right to seek punitive damages or appeal any final arbitration award, except as legally permitted in a court of appropriate jurisdiction. Your rights will be determined by a neutral arbitrator, not a judge or jury. The Federal Arbitration Act governs the interpretation and enforcement of any allegations or claims subject to this arbitration provision. Any arbitration shall be conducted by a neutral arbitrator in accordance with the rules and procedures of the American Arbitration Association (“AAA”), as modified by this Agreement. If there is any inconsistency between any term of the AAA Rules and any term of this Agreement, the applicable terms of this Agreement shall control. Payment of all filing, administration, and arbitrator fees (collectively, the “Arbitration Fees”) will be governed by AAA Rules. All aspects of any arbitration proceeding, and any ruling, decision, or award by an arbitrator, will be strictly confidential for the benefit of all parties.
This Agreement shall be governed by and construed in accordance with the laws of the State of Delaware. Subject to the arbitration provision above, Delaware shall have exclusive jurisdiction, including in personam jurisdiction over all matters related to this Agreement, and a Court of appropriate jurisdiction within Delaware shall be the exclusive venue for any and all controversies and claims arising out of or relating to this Agreement.
IF YOU HAVE ANY QUESTIONS AS TO THE INFORMATION contained within this AGREEMENT AND CONSENT, INCLUDING YOUR RIGHTS, OUR POLICIES, THE PROPOSED PATIENT-PHYSICIAN RELATIONSHIP, THE BHI SERVICES, PHYSICIAN SERVICES, TELEMEDICINE, OR ANY OTHER ISSUE, PLEASE ASK US BEFORE SIGNING BELOW. DO NOT SIGN BELOW UNLESS YOU HAVE THOROUGHLY READ, UNDERSTAND, AND AGREE TO ALL OF THE ABOVE INFORMATION.
I have read and fully understand this informed consent, disclosure and Agreement. I have been provided a copy of BHI’s Notice of Privacy Policies. I attest that all information I have provided is accurate to the best of my knowledge or recollection. I am at least 18 years old and have the authority to enter into this agreement.
I consent to receiving the BHI Services and the Physician Services via telemedicine technologies. I understand the BHI Services and Physician Services do not replace the relationship between me and my primary care doctor. I also understand it is up to the BHI-affiliated provider to determine whether or not my specific clinical needs are appropriate for a Telemedicine encounter.
I affirm and swear that if signing on behalf of a minor, I maintain the sole medical and health decision-making rights for the minor at the time of signing and will provide documentation to demonstrate that fact if requested by BHI.
I understand I should not sign this form if all items, including all of my questions, have not been explained or answered to my satisfaction, or if I do not understand any of the terms or words contained in this Agreement and Consent. I give my consent to begin a telemedicine services relationship with BHI and its Physicians, as described above. By signing this form, I understand I am consenting to treatment that includes but is not limited to assessments, evaluation, diagnosis, treatment, and health management. I attest I am of sound body and mind, and willfully and voluntarily agreeing to treatment:
[Digitally Signed at time of Patient Registration]