GenieMD Medical Group, MO, P.C.
Informed Consent for Telehealth Services

Last revised: September 1, 2019
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Introduction:

‍Telehealth involves the use of electronic communications to enable healthcare providers at different locations to share individual patient medical information for the purpose of improving patient care. Telehealth services offered by GenieMD Medical Group, MO, P.C. and its affiliated entities GenieMD Medical Group, TX, P.A. and David Filsoof M.D., P.C. (collectively “GenieMD”), may also include chart review, remote prescribing, appointment scheduling, health information sharing, and non-clinical services, such as patient education. The information you provide may be used for diagnosis, therapy, follow-up and/or patient education, and may include any combination of the following: (1) health records and test results; (2) images and asynchronous communications; (3) live two-way audio and video; (4) interactive audio with store and forward; and (5) output data from medical devices and sound and video files.

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.
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GenieMD physicians (our “providers”) are an addition to, and not a replacement for, your primary care physician. Responsibility for your overall medical care should remain with your local primary care doctor, if you have one, and we strongly encourage you tolocate one if you do not.

Expected Benefits:

• Improved access to care by enabling you to remain in your home while theGenieMD provider consults and obtains test results at distant/other sites.
• More efficient care evaluation and management.
• Obtaining expertise of a specialist as appropriate.

• Delays in evaluation and treatment could occur due to deficiencies or failures ofthe equipment and technologies.
• In rare events, our provider may determine that the transmitted information is ofinadequate quality, thus necessitating a rescheduled telehealth consult or ameeting with your local primary care doctor.
• In very rare events, security protocols could fail, causing a breach of privacy ofpersonal medical information.
• In rare events, a lack of access to complete medical records may result inadverse drug interactions or allergic reactions or other judgment errors.

If you need to receive follow-up care, assistance in the event of an adverse reaction tothe treatment, or in the event of an inability to communicate as a result of atechnological or equipment failure, please contact GenieMD at 925-460-9191 orCompliance@GenieMD.com.By checking the box associated with "Informed Consent", you acknowledge that youunderstand and agree with the following:

• I hereby consent to receiving GenieMD’s services via telehealth technologies. Iunderstand that GenieMD and its providers offer telehealth-based medicalservices, but that these services do not replace the relationship between me andmy primary care doctor. I also understand it is up to the GenieMD provider todetermine whether or not my specific clinical needs are appropriate for atelehealth encounter.
• I have been given an opportunity to select a provider from GenieMD prior to theconsult, including a review of the provider’s credentials.
• I understand that federal and state law requires health care providers to protectthe privacy and the security of health information. I understand that GenieMDwill take steps to make sure that my health information is not seen by anyonewho should not see it. I understand that telehealth may involve electroniccommunication of my personal medical information to other health practitionerswho may be located in other areas, including out of state.
• I understand there is a risk of technical failures during the telehealth encounterbeyond the control of GenieMD. I agree to hold harmless GenieMD for delays inevaluation or for information lost due to such technical failures.
• I understand that I have the right to withhold or withdraw my consent to the useof telehealth in the course of my care at any time, without affecting my right tofuture care or treatment. I understand that I may suspend or terminate use of thetelehealth services at any time for any reason or for no reason. I understand thatif I am experiencing a medical emergency, that I will be directed to dial 9-1-1immediately and that the GenieMD providers are not able to connect me directlyto any local emergency services.
• I understand that alternatives to telehealth consultation, such as in-personservices are available to me, and in choosing to participate in a telehealthconsultation, I understand that some parts of the services involving tests may beconducted by individuals at my location, or at a testing facility, at the direction ofthe GenieMD provider (e.g. labs or bloodwork).
• I understand that I may expect the anticipated benefits from the use of telehealthin my care, but that no results can be guaranteed or assured.
• I understand that my healthcare information may be shared with other individualsfor scheduling and billing purposes or for the provision, coordination ormanagement of your healthcare, subject to the terms of the GenieMD PrivacyPolicy and GenieMD Medical Group Notice of Privacy Practices as applicable.Persons may be present during the consultation other than the GenieMDprovider in order to operate the telehealth technologies. I further understand thatI will be informed of their presence in the consultation and thus will have the rightto request the following: (1) omit specific details of my medicalhistory/examination that are personally sensitive to me; (2) ask non-medicalpersonnel to leave the telehealth examination; and/or (3) terminate theconsultation at any time.
• I understand that I will not be prescribed any narcotics for pain, nor is there anyguarantee that I will be given a prescription at all.
• I understand that if I participate in a consultation, that I have the right to request acopy of my medical records which will be provided to me at reasonable cost ofpreparation, shipping and delivery.

Additional State-Specific Consents: The following consents apply to users accessingthe GenieMD website for the purposes of participating in a telehealth consultation asrequired by the states listed below:

Alaska: I understand my primary care provider may obtain a copy of my records of mytelehealth encounter. (AK Stat. 08.64.364).

Arizona: I understand I am entitled to all existing confidentiality protections pursuant toA.R.S. Åò 12- 2292. I also understand all medical reports resulting from the telemedicineconsultation are part of my medical record as defined in A.R.S. Åò 12-2291. I alsounderstand dissemination of any images or information identifiable to me for research oreducational purposes shall not occur without my consent, unless authorized by state orfederal law. (A.R.S. Åò 36-3602).

Connecticut: I understand that my primary care provider may obtain a copy of myrecords of my telehealth encounter. (C.G.S.A. Åò 19a-906).

D.C.: I have been informed of alternate forms of communication between me and aphysician for urgent matters. (17 DCMR Åò 4618.10).

Kentucky: If I am a Medicaid recipient, I recognize I have the option to refuse thetelehealth consultation at any time without affecting the right to future care or treatmentand without risking the loss or withdrawal of a Medicaid benefit to which I am entitled. Iunderstand that I have the right to be informed of any party who will be present at thesite during the telehealth consult and I have the right to exclude anyone from beingpresent. I also understand that I have the right to object to the videotaping of thetelehealth consultation. (KY Admin. Regs. Tit. 907, 3:170).

Louisiana: I understand the role of other health care providers that may be presentduring the consultation other than the GenieMD provider. (46 La. Admin. Code Pt XLV,Åò 7511).

Maryland: Regarding audiologists, speech language pathologists, and hearing aiddispensers, I recognize the inability to have direct, physical contact with the patient is aprimary difference between telehealth and direct in-person service delivery. Theknowledge, experiences, and qualifications of the consultant providing data andinformation to the provider of the telehealth services need not be completely known toand understood by the provider. The quality of transmitted data may affect the quality ofservices provided by the provider. Changes in the environment and test conditionscould be impossible to make during delivery of telehealth services. Telehealth servicesmay not be provided by correspondence only. (Code of MD Reg. 10.41.06.04).

Nebraska: If I am a Medicaid recipient, I retain the option to refuse the telehealthconsultation at any time without affecting my right to future care or treatment andwithout risking the loss or withdrawal of any program benefits to which the patient wouldotherwise be entitled. All existing confidentiality protections shall apply to the telehealthconsultation. I shall have access to all medical information resulting from the telehealthconsultation as provided by law for access to my medical records. Dissemination of anypatient identifiable images or information from the telehealth consultation to researchersor other entities shall not occur without my written consent. I understand that I have theright to request an in-person consult immediately after the telehealth consult and I willbe informed if such consult is not available. (NE Revised Stat. 71-8505; NE Admin.Code Tit. 471, Ch. 1).

New Hampshire: I understand that the GenieMD provider may forward my medicalrecords to my primary care or treating provider. (N.H. Rev. Stat. Åò 329:1-d).

New Jersey: I understand I have the right to request a copy of my medical informationand I understand my medical information may be forwarded directly to my primary careprovider or health care provider of record, or upon my request, to other health careproviders. (NJ Rev. Stat. Åò 45:1-62).

Pennsylvania: I understand that I may be asked to confirm my consent to behavioralhealth or tele-psych services.

Rhode Island: If I use e-mail or text-based technology to communicate with myGenieMD provider, then I understand the types of transmissions that will be permittedand the circumstances when alternate forms of communication or office visits should beutilized. I have also discussed security measures, such as encryption of data, passwordprotected screen savers and data files, or utilization of other reliable authenticationtechniques, as well as potential risks to privacy. I acknowledge that my failure to complywith this agreement may result in the GenieMD provider terminating the e-mailrelationship. (Rhode Island Medical Board Guidelines).

South Carolina: I understand my medical records may be distributed in accordance withapplicable law and regulation to other treating health care practitioners. (S.C. Code1976 Åò 40-47-37).

Tennessee: I understand that I may request an in-person assessment before receivinga telehealth assessment if I am a Medicaid recipient.

Texas: I understand that my medical records may be sent to my primary care physician.(V.T.C.A., Occupations Code Åò 111.005).

Vermont: I understand that I have the right to receive a consult with a distant-siteprovider and will receive one upon request immediately or within a reasonable time afterthe results of the initial consult. I understand that receiving tele-dermatology or teleophthalmologyservices via GenieMD does not preclude me from receiving real-timetelemedicine or face-to-face services with the distant provider at a future date. (VT Stat.Ann. Åò 9361).

Note, these state-specific telehealth consent rules are constantly changing and beingupdated/revised. One approach is to have us update this form periodically to revise fornew state specific changes. Another approach is to eliminate this state-specific sectionand just use an informed consent which substantially complies with the spirit andpurpose of the rules, albeit might not meet each state’s specific language.

Patient Consent:

I have read this document carefully, and understand the risks and benefits of thetelehealth consultation and have had my questions regarding the procedure explainedand I hereby give my informed consent to participate in a telehealth consultation underthe terms described herein.

By checking the Box containing "INFORMED CONSENT FOR TELEHEALTHSERVICES" I hereby state that I have read, understood, and agree to the terms of thisdocument.