Telemedicine Consent

TELEMEDICINE CONSENT

Last updated: April 14, 2023

This Telemedicine Consent is made available to you by your healthcare provider, which currently is either Delaware Telehealth Medical Group, P.A., Kansas Telehealth Medical Group, P.A., Florida Telehealth Medical Group, P.A., New Jersey Telehealth Medical Group, P.A., or California Telehealth Medical Group, P.C. (each a “Provider”).

For more information about the BlueChew platform, please see our Privacy Policy, Terms and Conditions, or email us at support@bluechew.com.

Telemedicine involves using technology to enable healthcare providers to evaluate and treat patients from different locations. Telemedicine communications may include transmission of your medical records, photos and other personal health information, and may include interactions via dynamic intake forms, live 2-way video and audio, and other methods. Your Provider leverages one or more technology platforms network and software security protocols to help protect the privacy and security of your health information, including the BlueChew platform.

POSSIBLE BENEFITS OF TELEMEDICINE

Easier access to medical care and treatment, at times and from locations that are convenient to you.
You do not need to be physically present for an in-office appointment.
Reduced healthcare costs, including lowered costs for online visits and prescriptions.

POSSIBLE RISKS OF TELEMEDICINE

Telemedicine is not intended to replace a relationship with your local and in-person physician relationship.
Because your Provider does not have access to your complete medical records, if you do not disclose a full list of your medical history, including diagnoses, treatments, and medications/supplements, your Provider may not receive enough information to enable diagnosis or prescription treatments and some negative outcomes may occur.
Your Provider will not be able to conduct certain tests, blood work or assess vital signs in-person, which could prevent your Provider from identifying a need for emergency medical care or treatment, or underlying causes of any condition for which you are seeking treatment.
Your Provider may advise you to seek alternative care or meet with your local physician, and may not provide you with a prescription or other treatment.
Delays in evaluation, consultation, diagnosis, or treatment may occur due to technical or Internet deficiencies or failures, which may include poor video and audio quality or other service interruption issues. If the telemedicine services provided to you are interrupted due to a technical or Internet deficiency or failure or another service issue, please contact your Provider.
Telemedicine is not the appropriate course of action in certain medical scenarios. This includes, but is not limited to immediate medical situations or allergic or adverse reactions. In these scenarios, please contact your primary care provider or go to your local hospital. If the situation is a medical emergency, dial 911 immediately.
Security protocols or safeguards could fail causing a breach of privacy and unintentional disclosure of your health information.
State laws may prohibit telemedicine or treatment options, including that you may not be able to receive prescription medications via telemedicine if you reside in certain states.

YOUR CONSENT TO TELEMEDICINE SERVICES

By Clicking “I Agree”, you confirm that you have read the prior section, and you understand the risks and benefits of telemedicine, and you acknowledge and agree:

To receive telemedicine services from one or more Providers with whom you are connected via the BlueChew platform and with which BlueChew has relationships, although they are separate from BlueChew.
That your Provider retains sole discretion in determining whether your condition is suitable for treatment via the telemedicine services.
That a variety of alternative methods for health care services may be available to you and that you may choose one or more of those at any time.
That your information, including identifiable health information, will be collected, used, disclosed, and safeguarded in accordance with the BlueChew Privacy Policy and the Notice of Privacy Practices provided by your Provider and/or their affiliated practice.
The identity and credentials of your Provider is provided through email correspondence when a written request is submitted via the BlueChew platform.
That you authorize BlueChew, and your Provider with whom you are connected via the BlueChew platform, to share information regarding telemedicine services for treatment, payment and health care operations purposes, including consent to share medical records with your primary care or other physicians.
That if you receive a prescription from a Provider, you authorize BlueChew to send your healthcare and personal information to your dispensing physician or a compounding pharmacy so that you may receive your prescription and other pharmacy services.
That although telemedicine may provide benefits for you, no benefits or specific results can be guaranteed, and that your condition may not improve, and in some cases, may get worse.
That the telemedicine services are not intended to replace your relationship with your primary care physician or any other existing provider.
That failure to provide accurate health and medical information to your Provider may impact the benefits you receive from the telemedicine services.
That emergency medical services are not provided through the telemedicine services, and you should call 911 or seek immediate medical attention in your area if you believe you are experiencing a medical emergency.
You have access to all of your health and wellness information relating to telemedicine services in accordance with applicable laws and regulations.
Telemedicine is constantly evolving, and may include different technology in the future that is not specifically described in this consent.
You will hold BlueChew, your Provider, and any applicable practice harmless for loss of your personal information resulting from a technical or Internet failure.
You are located in the city and state you provided above, and you will be present in that city and state during all telemedicine services provided hereunder.
You can withhold or withdraw this consent at any time by emailing us at medical@bluechew.com.
Unless you revoke your consent, this informed consent will be renewed upon each telemedicine encounter, and your Provider may continue to provide services to you via telemedicine without the need for you to complete another consent.

MEDICAL COMPLAINT INFORMATION

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 on-line complaint form is found at here.

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 in 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.

VERMONT
The Vermont Board of Medical Practice investigates complaints of unprofessional conduct. If you have a concern about a medical professional, you may contact the Board as indicated below. For more information see the Board's website here.
VERMONT DEPARTMENT OF HEALTH
BOARD OF MEDICAL PRACTICE
108 Cherry Street, PO Box 70
Burlington, VT 05402-0070
802-657-4220