Informed Consent to Participate in Telehealth Consultations 

Effective: October 10, 2021

 

Last Updated: October 10, 2021

 

Aila Health Inc. (referred to in this document as “Aila Health”) is a technology company that offers a platform for you to receive personalized, supportive care for autoimmune and other chronic conditions. Aila Medical P.C. and its related practices including Aila Health, P.C. (collectively referred to in this document as “Aila Medical”) is a professional organization that hires healthcare providers and makes all medical decisions regarding your care. 

 

Aila Medical, Affiliates, and/or Associates is a separate entity that is independent from Aila Health, Inc. and its Affiliates; Aila Health, Inc. is not licensed to practice medicine, and has been contracted by Aila Medical, Affiliates, and/or Associates to furnish administrative services for Aila Medical, Affiliates, and/or Associates, and to assist with the provision of technologies and administrative services used to support telemedicine encounters.

 

This “Telehealth Informed Consent” informs the patient (“patient,” “you,” or “your”) concerning the treatment methods, risks, alternatives, and limitations of using a telehealth platform.


 

Services

Aila Medical provides clinical services via telehealth through a team-based care approach. All care teams consist of multiple licensed medical practitioners (“Medical Practitioners”), and while you will have a designated clinician, in any given encounter, you may interact with multiple healthcare practitioners. Our medical team is made up of physicians, nurse practitioners, physician assistants, nutritionists and licensed mental health professionals. 

 

Telehealth allows you to receive health care service in the convenience of your home. However, Telehealth involves the use of electronic communications technologies to enable the transfer of medical/health and other information between a health care provider and patient who are in different locations. Telehealth technologies may include interactive two-way audio and video, interactive audio, remote monitoring, patient medical records, medical images, e-mail, output data from medical devices, and sound and video files to enable medical practitioners at different locations to share individual patient medical information. Information conveyed using telehealth may be used for the purpose of providing patient care (e.g. diagnosis, treatment, follow-up and/or education of patients). Telehealth services offered by Aila Medical may also include chart review, remote prescribing, remote monitoring, appointment scheduling, health information sharing, and non-clinical services, such as patient education.  The information you provide may be used for diagnosis, therapy, medical triage, external referrals, follow-up and/or patient education, and may include any combination of the following: (1) health records and test results; (2) interactive, asynchronous or synchronous chat, audio, and/or video communications; (3) live two-way audio and video; or (4) output data from medical devices and sound and video files.  Aila Health is not intended for the provision of clinical diagnosis requiring an in-person evaluation.

 

Aila Medical and Aila Health provides telehealth and is not a pharmacy. If you request that your medicines be delivered to you in the mail, we'll arrange for an independent third party US pharmacy to dispense and mail your medicines. Aila Medical does not prescribe any controlled substances.


 

AILA MEDICAL PROVIDERS DO NOT ADDRESS MEDICAL EMERGENCIES. IF YOU BELIEVE YOU ARE EXPERIENCING A MEDICAL EMERGENCY, YOU SHOULD DIAL 9-1-1 AND/ OR GO TO THE NEAREST EMERGENCY ROOM. PLEASE DO NOT ATTEMPT TO CONTACT AILA HEALTH INC, AILA MEDICAL, OR YOUR PROVIDER. AFTER RECEIVING EMERGENCY HEALTHCARE TREATMENT, YOU SHOULD VISIT YOUR LOCAL PRIMARY CARE PROVIDER. 

 

Do not disregard, avoid, or delay in obtaining in-person care from your doctor or other qualified professional because of information or advice you received through this platform.


 

Health Coaching

For purposes of health coaching services, it is important to understand that the services do not include the provision of medical care. Aila Health health coaches are not acting in a health care professional capacity. Aila Health coaches do not provide any medical or clinical services, and do not diagnose, treat, or manage any illness, disease, or condition or hold themselves out as being able to do so. 

 

Aila Health and its health coaches do not have expertise in diagnosing, examining, or treating medical or psychological conditions of any kind, or in determining the effect of any specific exercise on a medical condition. You should not change your treatment or care plan, medication or therapy based on information you received through the services or from one of our health coaches. Consultation with our health coaches is supplemental to any treatment or care provided by the Medical Practitioner and should not replace regular medical visits with the Medical Practitioner. Always seek the advice of the Medical Practitioner regarding your medical condition or the use (or frequency) of any medication or medical device. Information provided by our health coaches is offered for informational purposes only and is not a recommendation or endorsement of any drug, device or treatment or representation that a particular drug, device or treatment is safe, appropriate, or effective for you. Questions regarding any drug, device or treatment always should be directed to your licensed Medical Practitioner. Never disregard professional medical advice or delay in seeking it because of something you have read in connection with our services. Always consult with your healthcare professional if you have any questions or concerns about your health or condition or experience any changes in your condition or health status. Aila Health health coaches do not provide emergency services, time sensitive or urgent, remote or critical care services. 


 

Mental Health

Aila Medical contracts with medical practitioners specially trained in mental healthcare services who are trained to evaluate a person’s mental health and use psychotherapeutic techniques to improve mental health. The psychotherapeutic process involves a relationship between you and a trained clinician who has the desire and willingness to help you accomplish your individual goals. The benefits of therapy can include: a higher level of functional coping, solutions to specific problems, new insights into self, more effective means of communicating in relationships, symptomatic relief, and improved self-esteem. While psychotherapeutic techniques can be of benefit to most people, the therapeutic process is not always helpful. The therapeutic process involves sharing sensitive, personal, and private information that may at times be distressing. The therapeutic process can evoke strong feelings and sometimes produce unanticipated changes in one’s behavior. It is important that you discuss with a clinician any questions or discomfort you have regarding the therapeutic process or any behavioral changes you may be experiencing. 

 

If we become aware of or contemplate an emergency, we may secure from any hospital, physician, and/or medical personnel (“Emergency Responders”) any emergency treatment that we deem necessary for your immediate care in our sole discretion. You understand and agree that, if we take any action to secure Emergency Responders on your behalf, you, and not we, will be solely responsible for payment of all medical services rendered in connection with that treatment. 

If you are thinking about suicide or if you are considering harming yourself or others or if you feel that any other person may be in any danger or if you have any medical emergency, you must immediately call the emergency service number (911 in the U.S.) and notify the relevant authorities. Seek immediate in-person assistance. 

 

Expected Benefits

  • Improved access to care by enabling you to remain in your home while the Medical Practitioner obtains a medical history and orders labs, imaging, external referrals, or other medical workup at distant/other sites.

  • More efficient care evaluation and management.

  • Obtaining expertise of a specialist as appropriate.

 

Possible Risks

  • Delays in evaluation and treatment could occur due to deficiencies or failures of the equipment and technologies.

  • Because your doctor cannot physically examine you in-person, there is a chance that certain diagnoses or issues could be missed and risk causing you significant bodily harm, or death. 

  • The Medical Practitioner may determine that the transmitted information is of inadequate quality, thus necessitating a rescheduled telehealth consult or a meeting with a local in-person doctor.

  • A lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other errors.

  • Disruption of transmission by technology failures.

  • Security protocols could fail, causing a breach of privacy or personal medical information including but not limited to your contact information, protected health information, or mental health information.

 

Security

Electronic systems incorporate network and software security protocols to protect your confidentiality and the confidentiality of your data. Our system also includes measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.  All the services delivered to the patient through telehealth will be delivered over a secure connection that complies with the requirements of the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”).

I AGREE TO HOLD HARMLESS AILA MEDICAL, AILA HEALTH AND ITS EMPLOYEES, CONTRACTORS, AGENTS, DIRECTORS, MEMBERS, MANAGERS, SHAREHOLDERS, OFFICERS, REPRESENTATIVES, ASSIGNS, PARENTS, PREDECESSORS, AND SUCCESSORS FOR DELAYS IN EVALUATION OR FOR INFORMATION LOST DUE TO SUCH TECHNICAL FAILURES.

 

Medical Information and Records

All laws applicable to medical records privacy and access apply to telemedicine. Dissemination of any patient identifiable images or information from your telemedicine visit require your consent.  Our Notice of Privacy Practices describes how the Aila Medical protects, uses, and discloses medical information about you and how you can get access to this information.

 

 

Confidentiality

All existing confidentiality protections under federal and state law apply to information used or disclosed during your telemedicine visit. Dissemination of any personally identifiable images or information from the telehealth visit to researchers or other educational entities will not occur without my affirmative consent.

 

 

Duties and Obligations

Aila Medical’s practitioners and Aila Health health coaches have certain duties and obligations that may require the disclosure of your confidential information under certain situations, including, but not limited to: 

a. A duty to warn about serious harm to myself. 

b. A duty to warn about serious harm to others. 

c. An obligation to report to the appropriate state agency current child abuse or neglect, elderly abuse, or otherwise disabled individual abuse. 

d. An obligation to respond to a valid subpoena or court order seeking the disclosure of my records. 

When our duty of care begins

I understand that the doctor will take responsibility for my care only after I have created an account, answered all the required health questions and provided a photo and/or have had a video visit and made payment, and the doctor has subsequently reviewed my request for treatment and the health questions that I have completed and any photos and/or information received from a video visit, reviewed all my information, and then subsequently determined that I am a good candidate for the telehealth services.

 

I understand that the duty of care does not begin at the point of me answering questions or making payment or starting a video visit but at the point at which the doctor accepts the duty of care.

 

I understand that the doctor has the right to refuse to take responsibility for my care if the doctor makes a professional judgment that I am not a good candidate for this service. I understand that making a request for treatment (by completing a visit on the Website and making payment or by starting a video visit) or sending a message through the app does not in and of itself create a duty of care or create a doctor-patient relationship.



 

BY CLICKING ACCEPT, I ACKNOWLEDGE THAT I UNDERSTAND AND AGREE WITH THE FOLLOWING:

I certify that I am over the age of eighteen (18) and have the legal ability to consent to this agreement.

I voluntarily give my informed consent to receive medical services including telemedicine from Aila Health Medical Group, Aila Health PC, Affiliates, and/or Associates, and its physicians (including primary care practitioners and specialists) for myself or for the patient for whom I am the parent or legal guardian. This medical care may include services related to my health (or the identified person) and may include (but not limited to) preventative care, medical examinations, diagnostic testing (including testing for sexually transmitted infections and/or HIV, if separate consent is not required by law), therapeutic treatments, rehabilitative care, health maintenance, palliative care, counseling, assessment or review of physical or mental status/function of the body. This consent includes contact and discussion with other health care professionals for care and treatment. My consent shall also cover the carrying out of the orders of my treating provider by other Aila Health staff.

 

I hereby consent to receiving Aila Medical’s services via telehealth technologies.  I understand that Aila Medical and its providers offer telehealth-based medical services, but that these services do not replace the relationship between me and my in-person doctor, including my primary care doctor, in-person specialist, in-person mental health provider, or in-person dietician.   

I understand that by using the Aila Health platform and working with Aila Medical practitioners, I'm giving my explicit consent for the doctor to access medication history, where it's available, from records provided by pharmacy databases via the services of Surescripts. I understand that, if appropriate, the doctor may take this information into account when making a treatment and prescribing decision but this doesn't change how important it is that I provide full, true and complete information during the Aila Health visit.

If I request or initiate a telehealth visit (a "virtual visit"), I hereby consent to participate in such telehealth visit and its recording and I understand I may terminate such visit at any time.

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, without affecting my right to future care or treatment. I understand that I may suspend or terminate use of the telehealth services at any time for any reason or for no reason without affecting my right to future care or treatment or risking the loss or withdrawal of any program benefits to which I would otherwise be entitled.

I understand that if I am concerned that I may be experiencing a medical emergency or that I may require urgent care, I should call 911 immediately and that Aila Health Inc, Aila Medical, and the Medical Practitioners are not an appropriate place to receive care nor are they able to connect me directly to any local emergency services.

I understand that I may expect the anticipated benefits from the use of telehealth in my care, but that no results can be guaranteed or assured.

There is no guarantee that I will be treated by an Aila Medical provider. My Provider reserves the right to deny care for potential misuse of the services or for any other reason if, in the professional judgment of my Provider, the provision of the Services is not medically or ethically appropriate.It is up to the Aila Medical, Affiliates, and/or Associates physicians to determine whether or not my needs are appropriate for a telemedicine encounter.

I have been given an opportunity to review the credentials of Aila Medical, its Affiliates’, and/or Associates’ physicians and to select a physician from Aila Medical, its Affiliates, and/or Associates prior to any initial consultation.

In choosing to participate in a telehealth visit, I understand that some parts of the services involving tests (e.g., labs or bloodwork) may be conducted at another location such as a testing facility, at the direction of my Provider.

I have the right to request a copy of my medical records. I can request to obtain or send a copy of my medical records to my primary care or other designated health care provider contracting group: team@ailahealth.com . A copy will be provided to me at a reasonable cost of preparation, shipping, and delivery.

I understand the telehealth services provided by Aila Medical is not health insurance and does not meet any individual health insurance mandate that may be required by federal law.

It is my duty to inform my Aila Medical, Affiliates, and/or Associates physician of interactions regarding my care that I may have with other healthcare providers to ensure my Aila Medical, Affiliates, and/or Associates provider has a full clinical picture when making treatment decisions.I understand that by using Aila Health I accept the responsibility to provide full and truthful answers to all questions and, when requested, to provide unaltered photos of me that are taken at the time of using our service.

 

I understand that the doctor is unable independently to verify the information and photos I provide and that the doctor will make a professional judgment based on the information and photos I provide.

Video images and audio recordings of me may be captured and stored electronically. I understand that these recordings may be later viewed and used for purposes of evaluation and training, which may include Aila Medical, Affiliates, and/or Associates or Aila Health’s non-physician personnel. I understand and consent to the use of these images and audio recordings for the telemedicine consultation and, potentially, evaluation, education and training.

 

I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. Persons may be present during the consultation other than the Aila Medical, Affiliates, and/or Associates physician in order to operate the telemedicine technologies. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history/examination that are personally sensitive to me; (2) ask non-medical personnel to leave the telemedicine examination; and/or (3) terminate the consultation at any time.

TECHNOLOGY 

There is a risk of technical failures during the telemedicine encounter beyond the control of Aila Medical, Affiliates, and/or Associates and Aila Health, Inc. I agree to hold harmless Aila Medical, Affiliates, and/or Associates and Aila Health, Inc. for delays in evaluation or for information lost due to such technical failures.

In the event of any problem with the website or related services, I agree that my sole remedy is to cease using the website or terminate access to the service. Under no circumstances will Aila Medical, its Affiliates, and/or Associates and Aila Health any subsidiary or affiliate be liable in any way for the use of the telemedicine services, including but not limited to, any errors or omissions in content or infringement by any content on the website of any intellectual property rights or other rights of third parties, or for any losses or damages of any kind arising directly or indirectly out of the use of, inability to use, or the results of use of the website, and any website linked to the website, or the materials or information contained on any or all such websites. I agree that I will not hold Aila Health, Inc. or Aila Medical, its subsidiaries or affiliates liable for any punitive, exemplary, consequential, incidental, indirect or special damages (including, without limitation, any personal injury, lost profits, business interruption, loss of programs or other data on my computer or otherwise) arising from or in connection with your use of the website whether under a theory of breach of contract, negligence, strict liability, malpractice or otherwise, even if we or they have been advised of the possibility of such damages.

ACCEPTING OUR TREATMENT PLAN

 

A variety of alternative methods of medical care may be available to me, and that I may choose one or more of these at any time. My physician has explained the alternatives to my satisfaction.

 

I will not be prescribed any controlled substance, as determined by any applicable federal or state agency, and there is no guarantee that I will receive a prescription for any medication.

 

I understand that all the medicines that the doctor may prescribe or recommend, including over-the-counter medicines, can cause serious side effects and adverse events that include severe allergic reaction, permanent disability, and death.

 

I understand that it is my responsibility to make an informed decision whether to accept a treatment plan that the doctor proposes after weighing the risks and benefits of the medicine being prescribed, alternative treatment options and the risks and benefits of such alternatives, and the option of not seeking any treatment.

 

I understand the importance of reading the information the doctor provides about adverse events, including the signs and symptoms of serious side effects and common side effects from taking a medicine, as this will ensure that I seek appropriate medical attention in a timely manner.

 

I understand that adverse events can be caused by a number of things, including an allergic reaction, side effects, or interactions between a medicine that the doctor prescribes and any medical conditions I may have, other prescription medicines or other things (e.g., supplements, herbs, over-the-counter medicines, or recreational drugs) I'm taking, and lifestyle choices such as smoking tobacco products or drinking alcohol.

ELECTRONIC COMMUNICATIONS

Telemedicine may involve electronic communication of my personal medical information to Aila Medical physicians or other healthcare providers who may be located in other areas, including in other states.

I understand and agree that my provider may contact me using automated calls, emails and/or text messaging sent to my landline and/or mobile device. These communications may notify me of preventative care, test results, treatment recommendations, outstanding balances, or any other communications from my provider. I understand that I may opt-out of receiving all such communications from my provider by notifying my provider’s staff, by unsubscribing from the email list, or by emailing the Privacy Officer at privacy@ailahealth.com.

I understand that by using the service I won't necessarily speak or message with a doctor or nurse in real time and there may be delays in correspondence between myself and my clinician. The only exception to this is patients who will have a video visit with a doctor.

I understand that I must check the App or Website for messages because this is the way that the doctor will communicate important information to me. I understand that if I don't check the App or Website regularly, then my care may be delayed.

I understand that Aila Medical and Aila Health checks telephone messages and Secure Messages during business hours and responds to them on a regular basis throughout the week. I understand that if I have any questions relating to my care that aren't urgent, I can message the care team through the App or Website. I understand that the doctor may not review and respond to my messages immediately. I acknowledge and agree that I will not use Secure Messages to deal with emergencies or other time-sensitive issues. 

I understand and agree that email communications (outside of the secure Patient Portal or app) may not be secure and the confidentiality of emails cannot be assured or guaranteed. I therefore take the risk that all email communications may not be confidential. 

I understand that Aila Health may keep copies of email and Portal communications, and that such messages may be included in my health record.

I understand that there may be a delay of up to 48 hours before a doctor or care team member reviews my request for treatment and any messages I send.

 

WEBSITES, SOCIAL MEDIA

 

I understand that the only content in the App or Website that constitutes professional medical advice is the personalized messages the doctor sends me (once I have completed the health questions and made payment, and the doctor has subsequently taken responsibility for my care) and any content that the doctor links to in such messages and advice that a doctor provides in a video visit. I understand that all other content in the App or Website does not constitute professional medical advice and is instead for information purposes only. Never disregard professional medical advice or delay in seeking it because of something you have read on our App or Website.

 

Aila Medical makes no representation that materials on this website are appropriate or available for use in any other location. I understand that if I access these services from a location outside of the United States, that I do so at my own risk and initiative and that I am ultimately responsible for compliance with any laws or regulations associated with my use.

 

I understand that the Aila Health website or app may contain links to other sites that are owned or operated by third-parties. Aila Health and Aila Medical are not responsible for the content, privacy or security practices of any third-parties. To protect your Personal Information, we encourage you to learn about the privacy policies of those third-parties.

 

I understand that Aila Health has accounts on social media platforms through which Aila Health may post information or conduct promotional activities. If you use social media to follow Aila Health or interact with the company, Aila Health may collect Personal Information you choose to share.. Please understand that your use of the social media services may result in the collection or sharing of Personal Information about you by those social media services. Aila Health and Aila Medical has no control over, and decline all responsibility for, the use of my personal data by these third-parties. My use of social media, including my interactions with Aila Health or Aila Medical on social media, are at my own discretion. I have reviewed the privacy policies and settings on the social media services with which I interact and understand how your information may be collected, used, and shared by those social media services.

 

RELEASE OF MEDICAL INFORMATION 

If you need copies of your health information for your own personal use or to forward to a health care provider or organization, Aila Medical’s team is here to help you. By agreeing to this form, you consent to allow Aila Medical to release your medical records to another party on your behalf.

With the Service, Members may direct Aila Health and Aila Medical to retrieve their own Patient Information maintained by third-party providers with which they have patient relationships and/or on third-party sites. Members may link directly to on-line accounts with third-party providers or fill out and sign Health Insurance Portability and Accountability Act release authorization forms (“HIPAA Forms”) and direct Aila Health and Aila Medical to send such forms to third-party providers with a record request cover sheet so that Aila Health and Aila Medical may receive such Patient Information in paper or electronic form and upload such Patient Information to your account.

Aila Health and Aila Medical may review the Patient Information received from third-party providers to normalize and label data for display, but Aila Health and Aila Medical is not responsible for any errors in the Patient Information resulting from such review process. Aila Health and Aila Medical makes no effort to review the Patient Information for any other purpose, including but not limited to accuracy, legality or non-infringement. Aila Health and Aila Medical is not responsible for any Patient Information provided by third-party providers or their patient portal sites.

By becoming a Member and linking to third-party provider accounts online or executing a HIPAA Form, you acknowledge that you are requesting Aila Health and Aila Medical to obtain your Patient Information for your account and to communicate with third-party providers concerning your Patient Information.

You acknowledge that there may be delays in record request processing from third-party providers. Aila Health and Aila Medical may be unable to obtain some or all of your Patient Information and cannot guarantee or assume responsibility for the completeness, timeliness, accuracy, relevance, deletion or non-delivery of any Patient Information. Aila Health and Aila Medical is not responsible for the way in which data is displayed on the Site or through the Service.

ASSIGNMENT OF BENEFITS

I authorize payment for the healthcare provider’s services to be made directly to Aila Medical instead of to me, unless Aila Medical specifically directs otherwise or the applicable plan requires otherwise.

PRIVACY POLICY

 

I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine, and that no information obtained in the use of telemedicine which identifies me will be disclosed to researchers or other entities without my consent.

I understand that my provider’s Privacy Policy and HIPAA Notice are available on the Aila Health website.

I hereby acknowledge that I have received my provider’s Financial Policy as well as my provider’s Notice of Privacy Practices. I agree to the terms of my provider’s Financial Policy, the sharing of my information via HIE,* and consent to my treatment by my provider. This form and my assignment of benefits applies and extends to subsequent visits and appointments with all Aila Health affiliated providers.

*Note: If you do not want to participate in Health Information Exchange (HIE), it is your responsibility to follow the instructions outlined on the my provider HIE Opt-Out Request Form and/or contact the HIE directly.

Please contact privacy@ailahealth.com to complete the HIE Opt-Out Form.

 

PROMO CODE PROGRAMS

 

I understand that if I receive a promo code for Aila Medical's services from a third party such as my employer, health insurer, or other organization ('Promo-Code-Provider'), I assume all risks associated with my use of the promo code. I understand and agree to fully release, waive, and forever discharge the Promo-Code-Provider from any and all losses, rights, liabilities, claims, demands, legal actions or right of action that I may have now or in the future, known or unknown, for any damages or personal injury that may occur during my use of a promo code for Aila Health. I understand that by consenting to these terms and using the Aila Health service, I forfeit any and all right to bring a suit against the Promo-Code-Provider arising from my use of the coupon. This release applies even if the injury or damage is caused in whole or in part by the negligence or fault of the Promo-Code-Provider, however, I understand that the forgoing release does not apply to gross negligence or willful misconduct by the Promo-Code-Provider. I understand that in the event that Aila Medical, or any of its affiliates (including business associates and vendors) unintentionally discloses or disseminates my personal health information, my only recourse is against Aila Medical, Aila Health and its affiliates, and not against Promo-Code-Provider.

SURESCRIPTS

I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form:

 

In accordance with your State Law and the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I understand that:

1. Aila Health Inc. uses SureScripts, Inc., a prescription system that allows prescriptions and related information to be exchanged between my providers and the pharmacy. The information sent between these systems may include details of any and all prescription drugs I am currently taking and/or have taken in the past. 

2.This authorization may include disclosure of prescription information related to alcohol and drug abuse, mental health treatment, and/or confidential HIV related information by SureScripts, Inc. to Aila Health Inc.

3. I have the right to revoke this authorization at any time by writing to Aila Health Inc. I understand that I may revoke this authorization except to the extent that action has already been taken based on this authorization.

4. Signing this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditioned upon my authorization of this disclosure.

5. Information disclosed under this authorization might be re-disclosed by the recipient, and this re-disclosure may no longer be protected by state or federal law.

6. This authorization expires one year from the date of my signature below.

7. THIS AUTHORIZATION DOES NOT AUTHORIZE AILA HEALTH TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CARE WITH ANYONE OTHER THAN THOSE PERMITTED UNDER APPLICABLE LAW.

 

Only use our service if you've read this information and subsequently made an informed decision that our service is right for you. If you have any questions, please send us a message through the App or Website or call us at 415-480-1640


 

I have been offered a copy of this consent form.

Additional State-Specific Consents:

The following consents apply to patients accessing the Aila Medical or Aila Health  website for the purposes of participating in a telehealth consultation as required by the states listed below:

FOR ALABAMA RESIDENTS

This Agreement does not constitute health insurance of the laws of this state. An uninsured patient that enters into this Agreement may still be subject to tax penalties under the Patient Protection and Affordable Care Act, Public Law 111-148, for failing to obtain insurance. Patients insured by health insurance plans that are compliant with the Patient Protection and Affordable Care Act already have coverage for certain preventive care benefits at no cost to the patient. Payments made by a patient for services rendered under this Agreement may not count toward the patient's health insurance deductibles and maximum out-of-pocket expenses. A patient is encouraged to consult with the patient's health insurance plan before entering into this Agreement and receiving care.

 

FOR ARIZONA RESIDENTS

I understand I am entitled to all existing confidentiality protections pursuant to A.R.S. § 12-2292. I also understand all medical reports resulting from the telemedicine consultation are part of my medical record as defined in A.R.S. § 12-2291. I also understand dissemination of any images or information identifiable to me for research or educational purposes shall not occur without my consent, unless authorized by state or federal law. (A.R.S. § 36-3602). Aila Medical is not an insurance company, and Aila Medical guidelines and this Agreement are not an insurance policy. Participation in this Agreement or a subscription to any of its documents should not be considered to be a health insurance policy. Regardless of whether you receive treatment for health care issues through this Agreement, you are always personally responsible for paying any additional health care expenses you may incur. If you have health insurance, it may include, at no additional charge, some of the preventive services that are also available under this Agreement. Aila Medical will not bill your health insurance carrier for primary care services provided under this Agreement.

FOR ARKANSAS RESIDENTS

This Agreement is not health insurance and does not meet any individual insurance mandate that may be required by federal law. This Agreement may be terminated by either party as specifically provided within this Agreement. The fees shall be paid by you or a third party. Notice: A direct primary care agreement is not an insurance policy, and the select medical services as specified under a direct primary care agreement may not constitute the minimum essential health benefits under federal healthcare laws established by the Patient Protection and Affordable Care Act (Pub. L. No. 111-148) as amended by The Health Care and Education Reconciliation Act of 2010 (Pub. L. No. 111-152), and any amendments to, or regulations or guidance issued under, those statutes existing on January 1, 2017. Medical services provided under a direct primary care agreement may not be covered by or coordinated with your health insurance and you may be responsible for any payment for medical services not covered by health insurance under your insurer's statement of benefits policy.

FOR CALIFORNIA RESIDENTS

You or your legal representative retains the option to withhold or withdraw consent to receive health care services via the Service at any time without affecting your right to future care or treatment nor risking the loss or withdrawal of any benefits to which you or your legal representative would otherwise be entitled. All existing confidentiality protections apply. All existing laws regarding patient access to medical information and copies of medical records apply. Dissemination of any of any of your identifiable images or information from the telemedicine interaction to researchers or other entities shall not occur without your consent. All provisions herein, including your informed consent to receive services via the Service are for the benefit of the treating provider as well as for your benefit. Medical doctors are licensed and regulated by the Medical Board of California, (800) 632-2322, www.mbc.ca.gov

 

FOR CALIFORNIA AND NEW YORK RESIDENTS

This Agreement is not a health benefit plan as otherwise described by law as it only pertains to a limited set of services provided through Aila Medical. This Agreement does not satisfy minimum essential coverage standards for health insurance under state or under the federal Patient Protection and Affordable Care Act, as currently enacted or hereafter amended, 26 U.S.C. 5000a, and there may be tax consequences for those who do not have not qualified comprehensive health coverage in addition to this Agreement. If this Agreement terminates for any reason, and you have not already purchased health care insurance coverage that will satisfy state and federal minimum coverage standards, you will not be able to purchase new individual health insurance until the next health insurance open enrollment period has begun. Aila Medical and its providers are not affiliated with any health insurance plan, and none of the medical services provided hereunder will be covered by your health insurance. Aila Medical only covers those services specifically identified in this Agreement when delivered or arranged by Aila Medical providers according to the terms of this Agreement. Aila Medical providers may refer a patient to a non-Aila Medical provider for medical services, prescription drugs or supplies, but in that circumstance, you will need to contact your health insurance provider and follow the health plan’s managed care procedures in order to obtain coverage for the referred services, prescription drugs or supplies under the health plan’s benefits. Certain services identified in this Agreement may already be covered under your health plan at no additional cost when provided by non-Aila Medical providers. You will need to contact your health plan to understand the benefits and limitations of your health insurance plan and any overlap between the services offered under this Agreement and the coverage under your health insurance plan.

 

FOR COLORADO RESIDENTS

The patient may refuse telemedicine services at any time, without loss or withdrawal of treatment. All applicable confidentiality protections shall apply to the services. The patient shall have access to all medical information from the services, under state law. (CO 25.5-5-320.) This Agreement is not health insurance. This Agreement does not meet any individual health benefit plan mandate that may be required by federal law. And, you are not entitled to health insurance protections for consumers under Title 10. Every patient record in the custody of a psychologist, except psychotherapy notes, must be available to you or your personal representative upon submission of a valid authorization for inspection of records, dated and signed by you, at reasonable times and upon reasonable notice. A summary of records pertaining to your mental health records may, upon written request accompanied by a signed and dated authorization, be made available to you or your personal representative following termination of the treatment program with the psychologist.

 

FOR DISTRICT OF COLUMBIA RESIDENTS

A mental health professional, mental health facility or data collector shall permit you or your representative, upon written request, to inspect and duplicate your record of mental health information maintained by the mental health professional, mental health facility or data collector within 30 days from the date of receipt of the request. A mental health professional, responsible for the diagnosis or treatment shall have the opportunity to discuss the mental health information with you or your representative at the time of such inspection.

 

FOR FLORIDA RESIDENTS

This Agreement is not health insurance and Aila Medical, Affiliates, and/or Associates will not file any claims against your health insurance policy or plan for reimbursement of any health care services covered by this Agreement. This Agreement does not qualify as minimum essential coverage to satisfy the individual shared responsibility provision of the federal Patient Protection and Affordable Care Act, as currently enacted or hereafter amended, 26 U.S.C. 5000a. This Agreement is not workers’ compensation insurance and does not replace an employer’s obligation under Chapter 440.Each provider is a physician licensed by the Florida Board of Medicine or the Florida Board of Osteopathic Medicine. Each provider’s hours are variable. To access a provider’s in-office schedule, go to that provider’s login page where the provider’s in-office hours are posted.

 

FOR GEORGIA RESIDENTS

This Agreement is not health insurance. The patient has the right to file a grievance with the Georgia Composite Medical Board concerning the physician, staff, office, and treatment received. The patient should either call the Board with such a complaint or send a written complaint to the Board. The Georgia Composite Medical Board current phone number is (404) 656-3913 and the address is 2 Peachtree Street NW, 6th Floor, Atlanta, GA 30303-3465. 

 

FOR HAWAII RESIDENTS

All medical reports resulting from telehealth services are part of your health record and shall be made available to you. Patient medical records shall be maintained in compliance with all applicable state and federal requirements including privacy requirements. If you request copies of your medical records, the copies shall be made available to you unless, in the opinion of the health care provider, it would be detrimental to your health to obtain the records. If the health care provider is of the opinion that release of the records to you would be detrimental to your health, the health care provider shall advise you that copies of the records will be made available to your attorney upon presentation of a proper authorization signed by you.

 

FOR IDAHO RESIDENTS

This Agreement does not provide health insurance coverage, including the minimal essential coverage required by applicable federal law. It provides only the services described herein. It is recommended that health care insurance be obtained to cover medical services not provided for under this Agreement. This Agreement may not be sold or transferred by Aila Medical, Affiliates, and/or Associates without your written consent and may be transferred only to another primary care provider. This Agreement may not be sold to a group, employer or group of subscribers because it is an individual agreement between Aila Medical, Affiliates, and/or Associates and you. I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here.

FOR INDIANA RESIDENTS

This Agreement is not health insurance. Either party may terminate this Agreement upon written notice to the other party as specifically provided within this Agreement. I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here.

FOR IOWA RESIDENTS

This Agreement may be terminated as specifically provided within this Agreement. NOTICE: This Agreement is not health insurance and is not a plan that provides health coverage for purposes of any federal mandates. This Agreement only covers the primary care health services described in this Agreement. It is recommended that you obtain health insurance to cover health care services not covered under this Agreement. You are personally responsible for the payment of any additional health care expenses you may incur. You will receive at least sixty (60) days advance written notice from Aila Medical, Affiliates, and/or Associates for the following changes to this Agreement: Any change in the scope of the primary care health services covered under this Agreement. Any change in Aila Medical’s locations where you may access primary care health services. Any change in the out-of-office services that are covered under this Agreement. Any change in the direct service charge. Any change in the additional costs for primary care health services not covered by the direct service charge. Any change in the renewal terms. Any change in the terms to terminate this Agreement. This Agreement shall not be sold or transferred by Aila Medical, Affiliates, and/or Associates without your prior written consent or the prior written consent of your legal representative, whoever is a party to this Agreement. You are prohibited from selling or transferring this Agreement. I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here.

 

FOR KANSAS RESIDENTS

Required Signage for K.A.R. 100-22-6 Prepared by the State Board of Healing Arts April 5, 2007. It is unlawful for any person who is not licensed under the Kansas Healing Arts Act to open or maintain an office for the practice of the healing arts in Kansas. Services are provided by a person who is licensed to practice the healing arts in Kansas. Questions and concerns regarding this professional practice may be directed to: KANSAS STATE BOARD OF HEALING ARTS 235 S. Topeka Boulevard Topeka, Kansas 66603--PHONE: (785) 296-7413 TOLL FREE: 1(888) 886-7205 FAX: (785) 296-0852 WEBSITE: www.ksbha.org

Either party may terminate this Agreement as specifically provided within this Agreement. Aila Medical, Affiliates, and/or Associates shall not bill an insurer or other third party payer for the services provided under this Agreement. You must pay Aila Medical, Affiliates, and/or Associates for all services not specified in this Agreement and not otherwise covered by insurance.

 

NOTICE. THIS MEDICAL AGREEMENT DOES NOT CONSTITUTE INSURANCE, IS NOT A MEDICAL PLAN THAT PROVIDES HEALTH INSURANCE COVERAGE FOR PURPOSES OF THE FEDERAL PATIENT PROTECTION AND AFFORDABLE CARE ACT, AND COVERS ONLY LIMITED, ROUTINE HEALTH CARE SERVICES AS DESIGNATED IN THIS AGREEMENT.

FOR KENTUCKY RESIDENTS

This Agreement does not constitute a health benefit plan and does not meet any individual health benefit plan mandate that may be required by federal law. Aila Medical, Affiliates, and/or Associates shall not bill a health benefit plan or the Medicaid program on a fee-for-service basis for the services provided under this Agreement. You are not required to pay more than twelve (12) months of the agreed-upon fee in advance. The agreed-upon fee and any additional fees may be paid by a third party. Either party may terminate this Agreement as specifically provided within the Agreement. I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here.

FOR LOUISIANA RESIDENTS

This Agreement shall be terminated as specifically provided within this Agreement. Aila Medical, Affiliates, and/or Associates shall provide a history of payments and services received upon your request. If you pay more than one periodic fee in advance, the funds shall be held in a trust account and paid to Aila Medical, Affiliates, and/or Associates as earned at the beginning of each period Any unearned direct fees held in trust following receipt of termination of this Agreement shall be promptly refunded to you. Aila Medical, Affiliates, and/or Associates shall provide notice of any change in fees not less than sixty (60) days from the date of the change. This Agreement does not provide comprehensive health insurance coverage. It provides only the health care services specifically described. You should obtain and maintain insurance for services not provided by this Agreement, and Aila Medical, Affiliates, and/or Associates will not bill a health insurance issuer for services covered under this Agreement. You can contact the Louisiana State Board of Medical Examiners at (504) 568-6820 or 630 Camp Street, New Orleans, LA 70130.

FOR MAINE RESIDENTS

The services provided pursuant to this Agreement are not considered health insurance and do not meet requirements of any federal law mandating individuals to purchase health insurance. Any fees charged by Aila Medical, Affiliates, and/or Associates pursuant to this Agreement may not be reimbursed or apply towards a deductible under a health insurance policy with an insurer. I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here.

FOR MARYLAND RESIDENTS

Our procedure to verify the identification of the individual transmitting the communication: We verify your identification through the assignment and use of a unique username and password combination. When you sign into the Service, your username and password identify you. Access to data via the Service is restricted through the use of unique usernames and passwords. The username and password assigned to you are personal to you and you must not share them with any other individual. When you choose a provider, you will set up an appointment time. Provider is hereby providing you with access to Provider’s notice of privacy practices. During the appointment, the provider will communicate with you and respond to your questions in real time. A primary difference between telehealth and direct in-person service delivery is the inability to have direct physical contact with you. On occasion Aila Health, Affiliates, and/or Associates may seek the advice of a consultant on your behalf. In these cases, the knowledge, experience, and qualifications of the consultant providing data and information to Aila Medical, Affiliates, and/or Associates need not be completely known to and understood by Aila Medical, Affiliates, and/or Associates. The quality of transmitted data may affect the quality of Services provided by Aila Medical, Affiliates, and/or Associates. Changes in the environment and test conditions could be impossible to make during delivery of Services. Services may not be provided by correspondence only. Telehealth services must be delivered by either audio or audio-visual devices.

FOR MICHIGAN RESIDENTS

This Agreement is not health insurance. Aila Medical, Affiliates, and/or Associates shall not bill an insurer or other third-party payer for the services provided under this Agreement. You must pay Aila Medical, Affiliates, and/or Associates for all services not specified in this Agreement and not otherwise covered by insurance.

 

FOR MINNESOTA RESIDENTS

Disclosures of your health records without your written consent shall be made in accordance with state and federal law regarding privacy and confidentiality. Examples of such disclosures include, but are not limited to, for specific public health activities, for health oversight activities, for judicial and administrative proceedings, for specific law enforcement purposes. You have the right to access and obtain copies of your health records and other information about you that is maintained by Aila Medical, Affiliates, and/or Associates For more specific information regarding your rights to access to health records, please refer to the Minnesota Department of Health Notices Related to Health Records at health.state.mn.us/facilities/notices/index.html 

 

Upon written request of your spouse, parent, child or sibling, if you are evaluated for or diagnosed with mental illness, a provider must ask you whether you wish to authorize a specific individual to receive information regarding your current and proposed course of treatment. If authorized, the provider shall communicate to the designated individual about your current and proposed course of treatment with such individual. In addition, a provider providing mental health treatment may disclose limited information to a family member/other person if: the request is in writing; the person lives with, provides care for, or is directly involved in your treatment and that involvement is verified by and documented in the medical record; before disclosure, you are informed in writing of the request, the person making the request, and the reason for the request; your agreement, objection or inability to consent or object is documented in the patient’s record; and disclosure is necessary for the patient’s treatment.

 

FOR MISSOURI RESIDENTS

This Agreement is not health insurance.

 

FOR MISSISSIPPI RESIDENTS

This Agreement may terminate as specifically provided within this Agreement. Upon termination of this Agreement, you shall not be liable for the remainder of any unearned payments associated with the Agreement. However, you shall be responsible for the true cost of the services rendered regardless of when this Agreement is terminated. This Agreement is not health insurance. This Agreement standing alone does not satisfy the health benefit requirements as established in the federal Affordable Care Act. And, without adequate insurance coverage in addition to this Agreement, you may be subject to fines and penalties associated with the federal Affordable Care Act.

FOR MONTANA RESIDENTS

Aila Medical, Affiliates, and/or Associates does not bill any third parties on a fee-for-service basis or otherwise for the services covered by this Agreement. Any visit fee charged by Aila Medical, Affiliates, and/or Associates is less than the monthly equivalent of the periodic fee. This Agreement is not insurance and is not meant to replace health insurance coverage.

FOR NEBRASKA RESIDENTS

This Agreement may be terminated as specifically provided within this Agreement. You are required to pay Aila Medical, Affiliates, and/or Associates for any service not specified in this Agreement and not otherwise covered by insurance. Aila Medical, Affiliates, and/or Associates shall provide at least sixty (60) days advance notice of any changes to the direct service charges applicable to the patient. NOTICE: This Agreement does not constitute insurance and is not a medical plan that provides health insurance coverage for purposes of any federal mandates. This Agreement only provides for the primary care services described in the Agreement. It is recommended that insurance be obtained to cover medical services not provided for under this Agreement. You are always personally responsible for the payment of any additional medical expenses you may incur. This Agreement shall not be sold or transferred by either party without the written consent of the other party to this Agreement.

 

FOR NEW HAMPSHIRE RESIDENTS

This Agreement is not health insurance and Aila Medical, Affiliates, and/or Associates will not file any claims against your health insurance policy or plan for reimbursement of any primary care services covered by this Agreement. This Agreement is not workers' compensation insurance and does not replace an employer's obligations under RSA 281-A.

 

FOR OKLAHOMA RESIDENTS

Either party may terminate this Agreement as specifically provided within this Agreement. I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here; Or, the Oklahoma Board of Osteopathic Examiners’ website, here.

 

FOR OREGON RESIDENTS

You have choices with respect to receiving care and treatment from Aila Medical, Affiliates, and/or Associates. In this regard, you have a choice when you are referred to a facility or other health care provider by Aila Medical, Affiliates, and/or Associates for a diagnostic test or health care treatment, and may elect to receive the diagnostic test or other health care treatment from a facility or health care provider other than the one recommended by Aila Medical, Affiliates, and/or Associates. If you choose to have the diagnostic test, health care treatment or service at a facility different from the one recommended by Aila Medical, Affiliates, and/or Associates, you are responsible for determining the extent or limitation of coverage for the diagnostic test, health care treatment or service at your chosen facility.

 

This Agreement is not considered a contract of insurance. Aila Medical, Affiliates, and/or Associates provides only the limited scope of primary care services specified in this Agreement. You must pay for all services not specified in this Agreement. The Department of Consumer and Business Services issued a certification to this practice. You can contact consumer advocates at the Department of Consumer and Business Services at (888) 977-4894, dcbs.insmail@state.or.us, or www.insurance.oregon.gov.

 

FOR SOUTH DAKOTA RESIDENTS

All fees and charges shall be disclosed by Aila Health, Affiliates, and/or Associates upon your request. A licensee of the healing arts shall provide copies of all medical records, reports and X-rays pertinent to your health, if available, to you or your designee upon receipt by the licensee of a written request or a legible copy of a written request signed by you.

 

FOR TENNESSEE RESIDENTS

Fees are not earned by Aila Medical, Affiliates, and/or Associates until the month paid by the periodic fee has been completed. In addition, (1) this Agreement does not constitute health insurance under the laws of the State of Tennessee; (2) an uninsured patient that enters into a direct primary care agreement may still be subject to tax penalties under the federal Patient Protection and Affordable Care Act, as currently enacted or hereafter amended, 26 U.S.C. 5000a, for failing to obtain insurance; (3) patients insured by health insurance plans that are compliant with the Patient Protection and Affordable Care Act already have coverage for certain preventative care benefits at no cost to the patient; (4) payments made by you for services rendered under this Agreement may not count towards the your health insurance deductibles and maximum out-of-pocket expenses; (5) you are encouraged to consult with your health insurance plan, before entering into this Agreement and receiving care; and (6) a Aila Medical, Affiliates, and/or Associates physician who breaches this Agreement may be liable for damages and may be subject to discipline by the appropriate licensing board.

 

FOR TEXAS RESIDENTS

This Agreement is not insurance. I understand that my medical records may be sent to my primary care physician with my consent. (V.T.C.A., Occupations Code § 111.005). 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.

 

FOR UTAH RESIDENTS

This Agreement is not health insurance. Either party may terminate this Agreement as specifically provided within this Agreement. Aila Medical, Affiliates, and/or Associates shall not bill an insurer or other third-party payer for the services provided under this Agreement.

 

FOR WASHINGTON RESIDENTS

This Agreement does not provide comprehensive health insurance coverage. It provides only the health care services specifically described. You are encouraged to obtain and maintain insurance for services not provided by Aila Medical, Affiliates, and/or Associates, and Aila Medical, Affiliates, and/or Associates will not bill a carrier for services covered under this Agreement. You are billed at the beginning of each billing cycle. Direct fees for services provided by Aila Medical, Affiliates, and/or Associates shall not vary from patient to patient based on health status or sex. Contact information for the Office of the Insurance Commissioner is as follows: https://www.insurance.wa.gov/contact-us and the consumer hotline is 1-800-562-6900.

 

FOR WISCONSIN RESIDENTS

You have the right to request and receive information within a reasonable period of time after you request the fees charged for a health care service, diagnostic test, or procedure provided by Aila Health, Affiliates, and/or Associates

 

FOR WYOMING RESIDENTS

This Agreement may be terminated as specifically provided within this Agreement. The periodic fees and any additional fees charged to you may be paid by a third party. Aila Medical, Affiliates, and/or Associates shall not charge or receive additional compensation for the health care services included in the periodic fee. This Agreement is not health insurance and does not meet any individual health insurance mandate that may be required by federal law.

 

FOR VERMONT RESIDENTS

I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here; Or, the Vermont Board of Osteopathic Examiners’ website, here.

 

FOR VIRGINIA RESIDENTS

Aila Health, Affiliates, and/or Associates will maintain your records while you are an active patient or will transfer your records to another practitioner or health care provider should you wish to seek care elsewhere. Aila Health, Affiliates, and/or Associates shall maintain your records for a minimum of six (6) years following your last encounter with a Provider with the following exceptions:

 

Records of a minor child, including immunizations, must be maintained until the child reaches the age of 18 or becomes emancipated, with a minimum time for record retention of six years from the last patient encounter regardless of the age of the child; Records that have previously been transferred to another practitioner or health care provider or provided to the patient or his personal representative; or Records that are required by contractual obligation or federal law to be maintained for a longer period of time. Patient records will only be destroyed in a manner that protects patient confidentiality, such as by incineration or shredding. Your Aila Health, Affiliates, and/or Associates physician will introduce themselves and discuss their credentials at the time of your first consultation. Information about each Aila Health, Affiliates, and/or Associates physician can also be found on the website (ailahealth.com). Aila Health, Affiliates, and/or Associates offers a variety of types of activities using telemedicine services. These include but are not limited to: diagnosis and management of both acute and chronic medical conditions, prescriptions, ordering of laboratory testing, radiographic studies, and other diagnostic testing, patient education, and appointment scheduling. The patient agrees that it is the role of the physician to determine whether or not the condition being diagnosed and/or treated is appropriate for a telemedicine encounter. Aila Health, Affiliates, and/or Associates uses the latest security measures with the use of telemedicine services to ensure patient’s protected health information is secure. Aila Health, Affiliates, and/or Associates utilizes a secure server for storage of information. All computers are password protected and the Aila Health, Affiliates, and/or Associates EMR is password protected. Notwithstanding such measures there is still potential risk to privacy. Patients will hold Aila Health, Affiliates, and/or Associates harmless for information lost due to technical failure. Aila Health, Affiliates, and/or Associates will obtain expressed patient consent to forward patient-identifiable information to a third party.

 

This Agreement does not provide comprehensive health insurance coverage and is not considered insurance. This Agreement does not satisfy the health benefit requirements as established in the federal Patient Protection and Affordable Care Act, as currently enacted or hereafter amended, 26 U.S.C. 5000a. You are hereby informed of your financial rights and responsibilities to Aila Medical, Affiliates, and/or Associates pursuant to this Agreement. You are encouraged to obtain and maintain insurance for services not provided by Aila Medical, Affiliates, and/or Associates, and Aila Medical, Affiliates, and/or Associates will not bill a health carrier for services covered under this Agreement.

 

FOR WEST VIRGINIA RESIDENTS

Either party may terminate this Agreement as specifically provided within this Agreement. Any per-visit charges under this Agreement will be less than the monthly equivalent of the periodic fee. You are not required to pay more than twelve (12) months of the fee in advance. Funds are not earned by the practice until the month of ongoing care is completed. Upon discontinuing this Agreement, all unearned funds will be returned to you. This Agreement is not health insurance.

FOR ALASKA, CONNECTICUT, DELAWARE, DISTRICT OF COLUMBIA, HAWAII, ILLINOIS, MARYLAND, MASSACHUSETTS, MINNESOTA, NEW JERSEY, NEW MEXICO, NEVADA, NORTH CAROLINA, NORTH DAKOTA, OHIO, PENNSYLVANIA, RHODE ISLAND, SOUTH CAROLINA, SOUTH DAKOTA, VERMONT, AND WISCONSIN RESIDENTS

 

Monthly membership payments will be paid at the beginning of each billing cycle and are designed to provide access to the Services provided by Aila Medical, Affiliates, and/or Associates. You will be charged after you have access to those Services provided pursuant to this Agreement. This Agreement is not a health insurance plan. This Agreement is not a health benefit plan nor a discount medical plan as otherwise described by law as it only pertains to a limited set of services provided through Aila Medical, Affiliates, and/or Associates. This Agreement does not satisfy minimum essential coverage standards for health insurance under state or under the federal Patient Protection and Affordable Care Act, as currently enacted or hereafter amended, 26 U.S.C. 5000a, and there may be tax consequences for those who do not have not qualified comprehensive health coverage in addition to this Agreement. If this Agreement terminates for any reason, and you have not already purchased health care insurance coverage that will satisfy state and federal minimum coverage standards, you will not be able to purchase new individual health insurance until the next health insurance open enrollment period has begun. Aila Medical, Affiliates, and/or Associates are not affiliated with any health insurance plan, and none of the medical services provided hereunder will be covered by your health insurance. Aila Medical only covers those services specifically identified in this Agreement when delivered or arranged by Aila Medical providers according to the terms of this Agreement. Aila Medical providers may refer a patient to a non-Aila Medical provider for medical services, prescription drugs or supplies, but in that circumstance, you will need to contact your health insurance provider and follow the health plan’s managed care procedures in order to obtain coverage for the referred services, prescription drugs or supplies under the health plan’s benefits. Certain services identified in this Agreement may already be covered under your health plan at no additional cost when provided by non-Aila Medical providers. You will need to contact your health plan to understand the benefits and limitations of your health insurance plan and any overlap between the services offered under this Agreement and the coverage under your health insurance plan.

 

 

FOR RESIDENTS OUTSIDE OF THE US

Patients outside the United States are allowed to ask our doctors under the following criteria: Aila Medical, Affiliates, and/or Associates makes no representation that all products, services and/or material described on the Site, or the Services available through the Site, are appropriate or available for use in locations outside the United States or all territories within the United States. This Secure Portals allows you to access certain health and other medical consultation services (“Informational Services”). Informational Services are available to you whether or not you meet the Residency Requirements. Informational Services are for general educational purposes only and are not Healthcare Services. The information provided during informational services will not include diagnosis or treatment. Aila Medical, Affiliates, and/or Associates is not a party to your relationship with an Authorized Physician or an Authorized Non-Physician Provider providing Informational Services. Informational Services do not replace consultations with qualified medical or other relevant healthcare professionals. You agree that you bear all risk associated with the use of or reliance on Informational Services, and release and hold Aila Medical, Affiliates, and/or Associates, Authorized Physicians, and Authorized Non-Physician Providers providing Informational Services harmless from and against any claim, demand, action, cause of action, damage, loss, cost, liability or expense, including reasonable legal fees, which may be made or brought against or incurred or suffered by Aila Medical, Affiliates, and/or Associates or an Authorized Physician, or an Authorized Non-Physician Provider directly or indirectly as a result of, in respect of, or arising out of your reliance on Informational Services.