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TELEMEDICINE CONSENT

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. BLUECHEW’s technology platform incorporates network and software security protocols to protect the privacy and security of your health information.

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.
  • Your health care provider may not receive enough information to enable diagnosis or prescription treatments.
  • Your health care 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 diagnosis or treatment could occur due to technical failures.
  • 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.
  • The transmission of your medical information could be disrupted or distorted by technical failures.
  • 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 Consent” or by using the Websites or the Services, 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 healthcare providers with whom you are connected via the BLUECHEW platform and with which we have relationships, although they are separate from BLUECHEW.
  • The identity and credentials of your healthcare provider is provided through email correspondence when a written request is submitted via the BLUECHEW platform.
  • That you authorize BLUECHEW, and your health care providers 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 healthcare 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.
  • You may need to seek in-person medical care and treatment from another healthcare provider.
  • To seek emergency help when needed, and continue to consult with your local physician.
  • That the confidentiality and privacy protections that apply to in-person health care services also apply to telemedicine services.
  • 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.
  • This serves as a request for consent for the physicians on the BlueChew portal to send a copy of all medical records to your primary care provider. To grant this consent, please email us with your formal request to medical@bluechew.com
  • 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 healthcare provider may continue to provide services to you via telemedicine without the need for you to complete another consent.

I understand that telemedicine is the use of electronic information and communication technologies by a health care provider to deliver services to an individual when he/she is located at a different site than the provider; and hereby consent to those physicians on the BlueChew portal to provide health care services to me via telemedicine.

I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine.

MEDICAL COMPLIANT INFORMATION

CALIFORNIA
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 Consumer Complaint Form should be submitted to:
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 by calling 916-263-2382.

INDIANA
To file a consumer compliant 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 https://indianaattorneygeneral.secure.force.com/ConsumerComplaintForm.

RHODE ISLAND
Department of Health
Complaint Unit
401-222-5200

TAXAS
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: http://www.healthvermont.gov/health-professionals-systems/board-medical-practice/file-complaint. VERMONT DEPARTMENT OF HEALTH
BOARD OF MEDICAL PRACTICE
108 Cherry Street, PO Box 70
Burlington, VT 05402-0070
802-657-4220