Telehealth Consent
AK Twisted Wellness®
Telehealth Consent
INFORMED CONSENT REGARDING THE USE OF TELEHEALTH
BY CLICKING "I AGREE," CHECKING A RELATED BOX TO SIGNIFY YOUR ACCEPTANCE, USING ANY OTHER ACCEPTANCE PROTOCOL PRESENTED THROUGH THE SERVICE OR OTHERWISE AFFIRMATIVELY ACCEPTING THIS CONSENT, YOU ACKNOWLEDGE THAT YOU HAVE READ, ACCEPTED, AND AGREED TO BE BOUND BY THIS CONSENT. IF YOU DO NOT AGREE TO THIS CONSENT, DO NOT CREATE AN ACCOUNT OR USE THE SERVICE. YOU, AT THIS MOMENT, GRANT AGENCY AUTHORITY TO ANY PARTY WHO CLICKS ON THE "I AGREE" BUTTON OR OTHERWISE INDICATES ACCEPTING THIS CONSENT ON YOUR BEHALF.
IF YOU ARE EXPERIENCING A LIFE-THREATENING SITUATION, SUCH AS CONTEMPLATING SUICIDE, CALL 911 OR THE 988 SUICIDE & CRISIS LIFELINE 988.
PURPOSE The purpose of this consent form ("Consent") is to provide you with information about telehealth and to obtain your informed Consent to the use of telehealth in the delivery of healthcare and mental health services to you by physicians, physician assistants, nurse practitioners, and mental health professionals ("Providers") using the online platforms owned and operated by A.K. twisted Wellness®. and its subsidiaries (the "Service"). In this Consent, the terms "you" and "yours" refer to the person using the Service, or in the case of use of the Service by or on behalf of an individual minor between the ages of thirteen (13) and eighteen (18) or higher age of majority under applicable state law, "you" and "yours" refer to and include (i) the parent or legal guardian who provides Consent to the use of the Service by such minor or uses the Service on behalf of such minor, and (ii) the minor for whom Consent is being provided or on whose behalf the Service is being utilized.
USE OF TELEHEALTH Telehealth involves the delivery of healthcare and mental health services using electronic communications, information technology, or other means between a healthcare or mental health provider and a patient not in the exact physical location. Telehealth may be used for diagnosis, treatment, follow-up, and patient education and may include, but is not limited to, one or more of the following: electronic transmission of medical records, photo images, personal health information, or other data between a patient and a provider; interactions between a patient and Provider via audio, video and data communications (such as messaging or email communications); use of output data from medical devices, sound, and video files. Alternative methods of care may be available to you, such as in-person services,
and you may choose an alternative at any time. Always discuss alternative options with your Provider.
ANTICIPATED BENEFITS The use of telehealth may have the following possible benefits
- making it easier and more efficient for you to access medical care or other services and treatment for the conditions treated by your Provider (s),
- Allowing you to obtain medical care or other services and treatment by Provider (s) at times that are convenient for you and
- I enable you to interact with Provider (s) without an in-office appointment.
POTENTIAL RISKS While telehealth in care delivery can provide potential benefits, there are risks associated with telehealth and other technology. These risks include, but may not be limited to the following: the quality, accuracy or effectiveness of the services you receive from your Provider could be determined; technology, including the Service, may contain bugs or other errors, including ones which may limit functionality, produce erroneous results, render part or all of such technology, including the Service, unavailable or inoperable, make incorrect records, transmissions, data or content, or cause documents, messages, data or content to be corrupted or lost; failures of technology may also impact your Provider (s) ability to correctly diagnose or treat your condition; the inability of your Provider (s) to conduct specific 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 medical care or treatment for you; your Provider (s) may not able to provide treatment for your particular condition and you may be required to seek alternative healthcare or emergency care services; delays in medical evaluation/treatment could occur due to unavailability of your Provider (s) or deficiencies or failures of the technology or electronic equipment used; the electronic systems or other security protocols or safeguards used could fail, causing a breach of privacy of your medical or other information; data stored and communicated electronically, for example, through email communications, may be more susceptible to unintended disclosure of protected health information to third parties; given regulatory requirements in certain jurisdictions, your Provider(s) diagnosis and/or treatment options, especially pertaining to specific prescriptions, may be limited; a lack of access to all of your medical records may result in adverse drug interactions or allergic reactions or other judgment errors.
LIFE-THREATENING AND OTHER EMERGENCY SITUATIONS; FOLLOW-UP CARE
If you are experiencing a life-threatening situation, such as contemplating suicide, call 911 or the 988 Suicide and Crisis Lifeline 988.
If the situation is an emergency, call 911. In some cases, telehealth is not an appropriate method of care. If you require immediate or urgent care, you must seek it.
Care at an emergency room facility or other Provider equipped to deliver urgent or emergent care. Providers may respond slowly to communications you submit through the Service. 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 Service. If a technical failure prevents you from communicating with your Providers through the Service, you should call the following number: Phone:
(520)710-8805 (M-F 9 AM – 5 PM PT).
DATA PRIVACY AND PROTECTION The electronic systems used in the Service will incorporate network and software security protocols to protect the privacy and security of your information. They will include measures to safeguard data against intentional or unintentional corruption. Personal information identifying you or containing protected health information will not be disclosed to any third party without your consent, except as authorized by law for consultation, treatment, payment/billing, and specific administrative purposes or as otherwise outlined in your Provider's Notice of Privacy Practices. Use of the Service may include email communications to and from you that may consist of your protected health information. You understand that A.K. twisted Wellness® does not and cannot guarantee the security or privacy of the services you use to receive communications, including, for example, your email service provider.
LABORATORY PRODUCTS AND SERVICES Certain healthcare services provided to you by Providers via the Service may require that you complete an at-home diagnostic test. Third-party laboratories provide these diagnostic tests, and neither A.K. twisted Wellness®. and its subsidiaries (collectively, "A.K. twisted Wellness®") nor your Provider (s) can guarantee the accuracy or reliability of these tests. These laboratory tests can provide false negative, false positive, or inconclusive results that could impact your provider ('s) ability to diagnose or treat your medical conditions correctly. A failure or defect of these tests could also affect your provider ('s) ability to diagnose or treat your medical needs correctly.
YOUR ACKNOWLEDGMENTS By clicking "I Agree," checking a related box to signify your acceptance, using any other acceptance protocol presented through the Service, or otherwise affirmatively accepting this Consent, you are agreeing and providing your support concerning the following: Healthcare and mental health services provided to you by Providers via the Service will be provided by telehealth. In some cases, your treating Provider may be a nurse practitioner or physician assistant and not a physician, and you agree to be treated by non-physician providers, if applicable, by using the Service. Your treating Provider for therapy services will be a mental health professional, such as a licensed counselor. Specific technology, including the Service, may be used while still in the beta testing and development phase and before such technology is a final and finished product.
Technology used to deliver care, including the Service, may contain bugs or other errors, including ones that may limit functionality, produce erroneous results, render
Part or all of such technology is unavailable or inoperable, produces incorrect records, transmissions, data, or content, or causes documents, messages, data, or content to be corrupted or lost, any or all of which could limit or otherwise impact the quality, accuracy, and effectiveness of the medical care or other services that you receive from your Provider (s). Certain diagnostic testing services, including laboratory products and services offered through the Service, may contain defects, including ones that may limit functionality or produce erroneous results, any or all of which could restrict or otherwise impact the quality, accuracy, and effectiveness of the medical care or other services that you receive from your Provider (s). The delivery of healthcare services via telehealth is an evolving field, and telehealth or other technology in your medical care and treatment from Provider(s) may include uses of technology different from those described in this Consent or not explicitly defined in this Consent. No potential benefits from using telehealth or other technology or specific results can be guaranteed, including any laboratory testing results or related diagnosis or treatment by your Provider (s). Your condition may not be cured or improved, and in some cases, may get worse. There are limitations in providing medical care or other services and treatment via telehealth and technology, including the Service, and you may only be able to receive diagnosis and treatment through telehealth for some conditions for which you seek diagnosis and treatment. There are potential risks to telehealth and other technology, including but not limited to the risks described in this Consent. You have the opportunity to discuss the use of telehealth, including the Service, with your Provider (s), including the benefits and risks of such use and the alternatives to the use of telehealth. Your Provider (s) will assess your medical condition and, in their sole discretion, may determine it is medically appropriate to diagnose and treat your disease via telehealth. By continuing to use the Service, you concur with your Provider's medical assessment and agree to receive a diagnosis and treatment via telehealth technology. You have the right to withdraw your consent to the use of telehealth during your care without prejudice to any future care or treatment and without risking the loss or withdrawal of any health benefits to which you are entitled.
However, you understand that the Providers who utilize the Service do not offer in-person treatment. Any withdrawal of your Consent will be effective upon receipt of written notice to your Providers, except that such withdrawal will not affect any action taken by A.K. twisted Wellness® or your Provider(s) in reliance on this Consent before it receives your written notice of withdrawal. Any withdrawal of your Consent will not affect any other provision, and you will continue to be bound by this Consent. You understand that using the Service involves electronic communication of your medical information to and from you in connection with the provision of telehealth services, including through email. You understand that you must provide A.K. twisted Wellness® and your Provider (s) truthful, accurate, and complete information, including all relevant information regarding the care you may have received or may be receiving from healthcare and mental health providers. You understand that each of your
The Provider (s) will assess your medical condition and, in their sole discretion, may determine it is medically appropriate to diagnose and treat your disease using telehealth technology, including the Service. By continuing to use the Service, you concur with your Provider's medical assessment and agree to receive a diagnosis and treatment via telehealth technology. You understand that each of your Provider (s) may determine in their sole discretion that your condition is not suitable for diagnosis and treatment using telehealth technology, including the Service, and that you may need to seek care and treatment from a specialist or other healthcare or mental health provider, outside of such telehealth technology. A.K. Twisted Wellness® has a commercial relationship with Tailor Made Compounding and Strive Compounding Pharmacy. A.K. Twisted Wellness® has a financial relationship with the entity that employs or contracts with your Provider. You can obtain your medical examination from another healthcare provider not associated with A.K. twisted Wellness®. A.K. Twisted Wellness® will use its pharmacy partner to fulfill your order directly at your door. You can obtain your prescription from any pharmacy by contacting our support team. You must pay the total amount of the costs associated with using the Service, including any medication you may receive, and you will not attempt to submit a claim to Medicare, any other federal payor, or any state or private insurer.
If you are concerned about a medical professional, you may contact the Medical Board in your state. For applicable contact information, see the list available below.
MEDICAL COMPLAINT INFORMATION
CALIFORNIA
NOTICE TO CONSUMERS
Medical doctors are licensed and regulated by the Medical Board of California. (800) 633-2322
Complaints may be filed online at http://www.mbc.ca.gov/Breeze/Complaints.aspx or submitted in hard copy form. A Consumer Complaint Form, including instructions for completing it, may be found
at http://www.mbc.ca.gov/Consumers/Complaints/Submit_By_Mail.aspx. A hard copy of the Consumer Complaint Form should be submitted to the:
Medical Board of California Central Complaint Unit
2005 Evergreen Street, Suite 1200
Sacrament, CA 95815
The Central Complaint Unit of the Medical Board of California is found by calling 1-800- 633-2322 or 916-263-2382.
INDIANA
To file a consumer complaint, you can request a complaint form by calling 1-800-382- 5516 or 317-232-6330 and file the form with the Attorney General's Office or complete the complaint online. The online complaint form is found
at https://indianaattorneygeneral.secure.force.com/ConsumerComplaintForm.
RHODE ISLAND
Department of Health Complaint Unit
401-222-5200
TEXAS
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 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.
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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
The Vermont Board of Medical Practice investigates complaints of unprofessional conduct. If you are concerned about a medical professional, contact the Board as indicated below. For more information, see the Board's website
here: http://www.healthvermont.gov/health-professionals-systems/board-medical- practice/file-complaint.
VERMONT DEPARTMENT OF HEALTH BOARD OF MEDICAL PRACTICE
108 Cherry Street, P.O. Box 70
Burlington, VT 05402-0070
802-657-4220
Contacting Us
If you have any questions or concerns about this Agreement, please get in touch with us by email
at info@aktw.life. We will attempt to respond to your questions or concerns promptly after receiving them.