General consent form explains telemedicine and other major administrative policies.
Telemedicine involves the use of electronic communications to enable health care providers at different locations to share individual patient medical information for the purpose of improving patient care. The information may be used for diagnosis, therapy, follow-up and/or education, and may include any of the following: Patient medical records, medical images, Live two-way audio and video, output data from medical devices and sound/video files. Electronic systems used 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.
Expected Benefits are Improved access to medical care by enabling a patient to initiate a visit to consult with a healthcare practitioner from a remote site, more efficient medical evaluation and management and obtaining expertise of a remote specialist.
Possible Risks: As with any medical procedure, there are potential risks associated with the use of telemedicine. These risks include, but may not be limited to; In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision making by the provider and consultant(s).Delays in medical evaluation and treatment due to deficiencies or failures of the equipment, failure of security protocols causing a breach of privacy of personal medical information, lack of access to complete medical records resulting in adverse drug interactions or allergic reactions, or other judgment errors.
By signing this form, I agree to the following:
1. I understand that the laws (Health Insurance Portability & Accountability Act of 1996 HIPAA) that protect privacy and the confidentiality of medical information also apply to telemedicine, and that no information obtained in the use of telemedicine, which identifies me, will be disclosed to researchers or other entities without my consent.
2. I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment and I have the right to inspect all information obtained and recorded in the course of a telemedicine interaction, and may receive copies of this information for a reasonable fee.
3. I understand that a variety of alternative methods of medical care may be available to me, and that I may choose one or more of these at any time. I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured and telemedical examinations or care may not be as complete as a face to face examination or care.
4. I understand that I cannot record any of the interactions I have with my provider during the session via audio or video methods, and will be held liable for privacy violations if I do and interaction will be private, and at any cost should not involve social media.
5. I understand that when I use electronic communication (fax, text messages, phone or email) there can be unintended disclosure to third parties, and I hold Zohar Health not liable for the same.
Administrative, Financial, Communication, Third Parties and Treatment related
1. I give Zohar Health consent to check my prescription history from I-Stop (NY), Crisp (MD) and PDMP (DC) programs.
2. I understand I have to provide Zohar Health copies of EKG, physical and recent laboratory reports every year and I have to be under the care of a primary care provider.
3. I understand if Zohar Health Provider(s) assigns me for face to face assessment one or two times in a year, it will be based on clinical judgment which includes, but is not limited to being on antipsychotic, stimulants and/or controlled substances, existence of other medical conditions and age. I will make necessary arrangements to see provider(s) at Lynbrook office in New York or Rockville office in Maryland depending on my domicile.
Collaboration and Emergency Contact
Zohar Health is allowed to contact the person who is my designated emergency contact in case of perceived or reported life threatening medical or psychiatric emergencies. Zohar health is allowed to share and receive information from my medical providers and therapist(s) verbally and electronically for treatment purpose.
I agree to receive text messages and secure emails from Zohar Health and the other third party agencies (under HIPAA compliance) with whom Zohar Health contract as business associates. I will be provided a secure email to contact Zohar Health and I am responsible for the protection of my username and password and if I chose non secure platforms to contact Zohar health, it will be at my risk and responsibility.
I acknowledge that I am responsible for co-payment, or deductible or co insurance for health services provided to me towards Zohar Health I am aware that I am responsible for communicating any changes in my insurance and failure to do so can result in denial of my claims and I will be responsible for the full payment of the visit. I understand that Zohar Health will initiate collection process in the event of nonpayment. I give consent to Zohar Maxcare Inc to charge my credit card attached to my file. If the card is declined my visit can be denied and I attest that I will pay the required co-payment and/or deductible to Zohar Maxcare Inc via a secure link provided to me.
Appointments and Cancellations
I understand that I have to provide a 24-hour notice for cancellation, and I will be charged a $75 cancellation fee if the cancellation is after the 24-hour period.
Some medications will require prior authorizations (PA), which may take up to 72-hours and could result in a denial which can affect my care. I allow Covermymeds, a third party provider with BAA to request for PA for me.
Zohar health requires two weeks’ notice to release /prepare documents and need.
Any additional requests for services such as assistance with disability application, letters for court, clearance, or attorney consultations will be prorated based on the full hourly clinical rate (currently $350). These services are not covered by insurance and will be considered out of pocket expenses and must be paid in advance of the service. If representation at the court is required, Zohar Health has a policy which will be available on request.
Termination of Care
My care can be terminated if there is a treatment and policy nonadherence, noncompliance with follow up, absence for three months, two consecutive cancellations without notice and two cancellations in a 4-month period and If I obtain treatment from other providers for the same diagnosis. Abusive or threatening behavior, display of firearms or weapons are reasons for immediate discharge. Zohar Health will try to contact me if I miss my appointment via text and or a phone call once in the first month and in the second month via secure email with a plan to discharge me. I will receive a final discharge notice only via secure email after Zohar health settles financial transactions with the insurance company.
I understand that writing a review on the internet or social media regarding Zohar Health can expose my identity, and I am solely responsible for the ramifications, if any. I also understand that Zohar Health has the right to defend their reputation, and can initiate legal proceedings against me for tarnishing messages on the internet. I will try to resolve any issues related to treatment and/or administrative protocol with Zohar Health, first.
I have read and understand the information provided above regarding telemedicine and in person visits and have discussed it with my provider or designees and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of telemedicine/ telepsychiatry/ in-person visits for my psychiatry and mental health care to Zohar Health Psychiatry and Mental Health (NY, MD, DC).
I here by declare that all the information furnished by me is true to the best of my knowledge, and that I seek this care voluntarily.