Telehealth Consent Form
1. I authorize Meili Medicine to allow me/the patient to participate in a Telehealth (videoconferencing) service with Meili Medicine
2. The type of service to be provided by Meili Medicine via Telehealth is, but is not limited to, video consultation, nutritional counseling, prescription of Chinese herbal formulas & individual herbs, nutraceutical prescriptions, and suggestions for lifestyle modifications.
3. I understand that this service is not the same as a direct patient/healthcare provider visit, because I/the patient will not be in the same room as the healthcare provider performing the service. I understand that parts of my/the patient’s care and treatment that require physical tests or examinations may be conducted by providers and their staff at my/the patient’s location under the direction of the Telehealth healthcare provider.
4. I/the patient agree to the nature and purpose of the videoconferencing technology and expected risks, benefits, and complications (from known and unknown causes), attendant discomforts and risks that may arise during the Telehealth session, as well as possible alternatives to the proposed sessions, including visits with a physician in-person. I am aware of the attendant risks of not using Telehealth sessions. I have been given an opportunity to ask questions, and all of my questions have been answered fully and satisfactorily.
5. I understand that there are potential risks to the use of this technology, including but not limited to interruptions, unauthorized access by third parties, and technical difficulties. I am aware that either my/the patient’s healthcare provider or I can discontinue the Telehealth service if we believe that the videoconferencing connections are not adequate for the situation.
6. I understand that the Telehealth session may be audio or video recorded at any time.
7. I agree to permit my/the patient’s healthcare information to be shared with other individuals for the purpose of scheduling and billing. I agree to permit individuals other than my/the patient’s healthcare provider and the remote healthcare provider to be present during my/the patient’s Telehealth service to operate the video equipment, if necessary. I further understand that I will be informed of their presence during the Telehealth services. I acknowledge that if safety concerns mandate additional persons to be present, then my or guardian's permission may not be needed.
8. I acknowledge that I have the right to request the following: a. Omission of specific details of my/the patient’s medical history/physical examination that is personally sensitive, or b. Asking non-medical personnel to leave the Telehealth room if not mandated for safety concerns or c. Termination of the service at any time.
9. IF I AM EXPERIENCING A MEDICAL EMERGENCY, I SHOULD DIAL “911” IMMEDIATELY.
10. It is the responsibility of the Telehealth provider to conclude the service upon the termination of the videoconference connection.
11. I/the patient understand(s) that my/the patient’s insurance will not be billed and is not accepted through this service at this time. I/the patient understand(s) that Meili Medicine does not offer billing codes for the service at this time.
12. My/the patient’s consent to participate in this Telehealth service shall remain in effect for the duration of the specific service identified above, or until I revoke my consent in writing.
13. I/the patient agree that there have been no guarantees or assurances made about the results of this service.
14. I/the patient acknowledge the Telehealth program’s no-show policy which states that I/the patient will be discharged from the Telehealth program if I/the patient no-show for 2, consecutive Telehealth appointments, without prior contact with the scheduling staff/platform at Meili Medicine. I/the patient acknowledges that I will be charged for the session if I am 10 minutes late to a stable connection on the video platform without further services.
15. I/the patient acknowledge that I AM REQUIRED TO CONNECT TO THE SITE 10 MINUTES PRIOR TO MY APPOINTMENT WHERE WILL REMAIN IN AN ONLINE WAITING ROOM UNTIL MY APPOINTMENT BEGINS. IT IS MY RESPONSIBILITY TO ENSURE PROPER EQUIPMENT, DOWNLOADS, SOFTWARE, AND INTERNET CONNECTION PRIOR TO MY APPOINTMENT.
I confirm that I have read and fully understand both the above and the Telehealth: What to Expect Form provided.
16. Electronic Communications
When I/the patient use any Meili Medicine, or send e-mails, text messages, and other communications from my desktop or mobile device to us, I am communicating with us electronically. I consent to receive communications from us electronically. I agree that (a) all agreements and consents can be signed electronically and (b) all notices, disclosures, and other communications that we provide to you electronically satisfy any legal requirement that such notices and other communications be in writing.
17. Site Access, Security and Restrictions; Passwords
If I/the patient creates a subscriber account for Meili Medicine, I agree to complete the registration process by providing current, complete, and accurate information as required by Meili Medicine. I am responsible for all activities that occur under my account. If access to the Site or a portion, thereof is limited requiring a user ID and password (“Protected Areas”), I agree to access Protected Areas using only my user ID and password as provided to me by the site. I agree to protect the confidentiality of my user ID and password, and not to share or disclose my user ID or password to any third party. I agree that I am fully responsible for all activity occurring under my user ID. My access to the Site may be revoked by Meili at any time with or without cause.
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I am prohibited from violating or attempting to violate the security of the Site, including, without limitation, (a) accessing data not intended for such user or logging onto a server or an account which the user is not authorized to access; or (b) attempting to probe, scan or test the vulnerability of a system or network or to breach security or authentication measures without proper authorization; or (c) accessing or using the Site or any portion thereof without authorization, in violation of these Terms of Use or in violation of applicable law. If I am under 18, you may use the Meili Services only with the involvement of a parent or guardian.
I may not use any scraper, crawler, spider, robot, or other automated means of any kind to access or copy data on the Site, deep-link to any feature or content on the Site, bypass our robot exclusion headers, or other measures we may use to prevent or restrict access to the Site.
Violations of system or network security may result in civil or criminal liability. Meili will investigate occurrences that may involve such violations and may involve, and cooperate with, law enforcement authorities in prosecuting users who are involved in such violations. I agree not to use any device, software, or routine to interfere or attempt to interfere with the proper working of this Site or any activity being conducted on this Site.
18. User Information
If I/the patient submits, uploads, posts or transmits any health information, medical history, conditions, problems, symptoms, personal information, consent forms, agreements, requests, comments, ideas, suggestions, information, files, videos, images or other materials to us or our Site (“User Information”), I agree not to provide any User Information that (1) is false, inaccurate, defamatory, abusive, libelous, unlawful, obscene, threatening, harassing, fraudulent, pornographic, or harmful, or that could encourage criminal or unethical behavior, (2) violates or infringes the privacy, copyright, trademark, trade dress, trade secrets or intellectual property rights of any person or entity, or (3) contains or transmits a virus or any other harmful component. I agree not to contact other site users through unsolicited e-mail, telephone calls, mailings, or any other method of communication. I represent and warrant to Meili Medicine and its Providers that I have the legal right and authorization to provide all User Information to Meili Medicine and its Providers for use as set forth herein and required by Meili Medicine and the Provider.
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19. Cancellation Policy
I am aware that it is recommended that I arrive in the virtual waiting room10 minutes prior to my appointment to ensure your login and internet connection is stable. I am aware if I am more than 5 minutes late, my appointment is canceled & non-refundable and I will be asked to reschedule. I am aware that all appointments canceled with less than 24-hour notice will incur a $65 fee.
20. I hereby request and consent to the performance of Chinese Medicine treatments and other complementary medicine procedures including various methodologies on me/the patient (or on the patient named below, for whom I am legally responsible) via Telehealth.
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21. Chinese Medicine attempts to normalize physiological functions, modify the perception of pain, and treat certain diseases or dysfunctions of the body. I/the patient has been informed that Chinese Medicine is a safe method of treatment, but occasionally there may be some reactions to herbs that include but are not limited to lightheadedness, nausea, or other GI-related reactions. There have been extremely rare instances reported of spontaneous miscarriage. The herbs and nutritional supplements (which are from plant, animal, and mineral sources) that have been recommended are traditionally considered safe in the practice of Chinese Medicine. I understand that some herbs may be inappropriate during pregnancy. If I experience any gastrointestinal upset or allergic reactions to the herbs, I will inform the acupuncturist.
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22. I/the patient do not expect the acupuncturist to be able to anticipate and explain all risks and complications. I wish to rely on the acupuncturist to exercise judgment during the course of the procedure, which the acupuncturist feels at the time, based upon the facts then known, is in my best interests.
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23. I/the patient understand that the clinical and administrative staff may review my medical records and lab reports, but all my records will be kept confidential and will not be released without my consent. I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions about its content.
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24. I understand my patient records and patient information will be kept confidential and shared only when necessary to provide care and services, by my authorization, or when required or permitted by law.
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By signing below, I agree to all of the above. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment.
Patient/Relative/Guardian Signature* Print Name: Relationship to Patient (if required) Date Witness Date Interpreter (if required) Date * The signature of the patient must be obtained unless the patient is a minor unable to give consent or otherwise lacks capacity. I hereby certify that I have explained the nature, purpose, benefits, risks of, and alternatives to (including no treatment) the proposed procedure, has offered to answer any questions, and have fully answered all such questions. I believe that the patient/relative/guardian fully understands what I have explained and answered.
