Consent to Treat & Telehealth Services
“Provider(s)” means the medical professionals contracted or employed by independently owned professional practices that contract with Calibrate to provide certain healthcare services on behalf of Calibrate, including Calibrate Health Medical P.C., Medical Services of North Madison Square Park, P.C., Calibrate Health and Medical of California, P.C., Calibrate Health Medical of New Jersey, P.C., Calibrate Health Medical of Texas, P.A., Calibrate Health Medical of Kansas, P.A., Calibrate Health Medical of Hawaii Professional Corp, and Calibrate Health Medical of Alaska. Because Calibrate providers function as a Clinical Team to provide healthcare services, the term “Provider” or “my Provider” as used herein refers to the Calibrate Clinical Team as a whole.
“Telehealth” means the use of electronic information and communication technologies by Providers to deliver health care services to patients not at the same physical location, which may include the assessment, diagnosis, consultation, treatment, education, care management and/or self-management of a patient. Such communication can include electronic transfer of medical records, images/photographs, health information, or other Personal Information between you and the Providers, live conversations or other interactions between you and the Providers via audio, video, and/or media, and use and analysis of output data from medical or wearable devices, sound, video, and other related files.
Although the provision of healthcare services using telehealth may offer potential benefits, there are potential risks associated with the use of telehealth. These risks are described in more detail below. Telehealth services may not be a substitute for in-person health care in all cases.
The telehealth services provided by Calibrate include a metabolic health assessment by a Provider as well as virtual nutrition and wellness coaching and consultations with Coaches. Calibrate’s telehealth services may provide an easier and more efficient way for you to obtain these healthcare services at a time and place most convenient for you and you can interact with the Providers without needing an in-office appointment. Your Provider will interact with you by video over the computer or smartphone instead of in person. You will be able to speak with the Provider and ask any questions during your visit. The Provider will be able to assess your medical condition, provide medical advice, and prescribe treatment (including medication), as appropriate.
Just as with an in-person encounter, there are potential risks associated with the use of telehealth. These risks may include, but are not limited to:
- Limitations on the availability and/or appropriateness of specific health services as a result of the Services being offered remotely (e.g., information transmitted to the Providers may not be sufficient to allow for appropriate medical decision making by the Providers and the inability of your Providers to conduct certain tests or assess vital functions and signs in-person may prevent the Providers from providing a diagnosis or treatment)
- Risks to the confidentiality and security of your health information, including Personal Information, related to your use of potentially unsecure electronic and telecommunication technologies (see below)
- Technology issues that may occur during your telehealth visit (however, alternative communication methods may be available if you having connectivity issues)
- Limitations in treatment options due to regulatory restrictions in certain jurisdictions
In order to participate in Calibrate’s Program, you must review and agree to this Consent. By accepting this Consent, you acknowledge your understanding and agree to the following:
- I have read the above information and have had an opportunity to ask questions.
- I understand the benefits and risks of receiving telehealth services.
- I voluntarily request and consent to medical care and treatment by Calibrate Providers and give my informed consent to the use of telehealth by my Provider.
- My Provider may retrieve my medication history for treatment related purposes.
- My Provider will only prescribe medication as they deem medically appropriate.
- I have the right to refuse any treatment recommended by my Provider.
- I have the right to discuss all medical treatment with my Provider.
- I understand that my Provider may determine, in their sole discretion, that: 1) my participation in the Calibrate program is not medically appropriate; 2) my condition is not suitable for treatment using telehealth; and/or 3) that I may need to seek medical care and treatment in-person or from an alternative source.
- I understand that I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time by emailing email@example.com with such instruction; otherwise, this consent will remain in effect for as long as I receive Services from Calibrate and will be considered renewed upon each telehealth encounter with my Provider.
- I understand that while the use of telehealth may provide potential benefits to me, as with any medical care service no such benefits or specific results can be guaranteed.
- I understand that I have the right to access my health and wellness information pertaining to the Services delivered via telehealth in accordance with applicable laws and regulations.
- My Provider may share information regarding my telehealth exam and the Services I received from my Provider with other individuals, my health insurance carrier, pharmacy and Calibrate for treatment, payment, and health care operations purposes as described in Calibrate’s Notice of Privacy Practices.
- Calibrate may contact me via text message/SMS and/or email for treatment/program related purposes.