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.
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.
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.
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.
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.
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.
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.
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: firstname.lastname@example.org . 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.
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.
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 email@example.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.
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 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 firstname.lastname@example.org 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.
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.