This consent form (“Consent”) describes how you (referred to as “you” or “your”), as a user of Color’s Services, will review the specific risks, benefits, and limitations of the testing, prescribing, recommendation and/or administration of treatments, counseling, medical consultation in person or via telephone or video telehealth services, and other services (collectively “Healthcare Service(s)”) to which access is provided by Color Health, Inc., our affiliates, and partners (“Color”, “we”, “us” or “our”), and how you consent to selected Healthcare Service(s).
Color may connect you with clinicians at Color Medical, and/or unaffiliated clinicians, laboratories, pharmacies, and other professionals, all of whom may have their own applicable terms of service and other policies. We do not control or interfere with the practice of medicine by clinicians, who are solely responsible for the medical care and treatment they provide to you.
Your use of Color’s Healthcare Services is entirely voluntary. It is your choice whether to utilize our Healthcare Services or not based on your review of risks, benefits, and limitations of individual tests, treatments or other services, and your consultation with a healthcare provider.
Procedure for Color Healthcare Services
You may have the opportunity to select specific tests, treatments or other services, including, but not limited to, testing for or treatment of infectious diseases, genetic and other testing, and/or consultation with a healthcare provider regarding abnormal laboratory results.
You will have the opportunity to review a summary of the risks, benefits, and limitations of each Healthcare Service. You are encouraged to discuss any questions or concerns with a healthcare provider of your choosing.
By selecting a Healthcare Service, you are representing that you have had an adequate opportunity to review the risks, benefits, and limitations of the Healthcare Service, and had the opportunity to discuss those with your healthcare provider, if desired, and you are providing your consent to Color to provide access to the selected Healthcare Service. In some cases, you may be asked to provide additional documentation of consent (e.g., by written or electronic means) for certain Healthcare Services.
Use of Telehealth Services
Color may provide access to telehealth services and connect users to third party healthcare providers to enable those providers to evaluate the individual’s medical information remotely for the purpose of providing care. “Telehealth services” may include remote diagnosing and prescribing, appointment scheduling, health information sharing, and non-clinical services, such as patient education. The information you provide may be used for diagnosis, treatment, follow-up and/or patient education. Health information may be shared by you and the telehealth provider via any combination of the following: health records and test results; images and asynchronous communications; live two-way audio and video; interactive audio with store and forward; and output data from medical devices and sound and video files.
The laws that protect the privacy and confidentiality of healthcare information also apply to telehealth. Color uses and discloses Protected Health Information in a number of ways connected to your treatment, payment for your care, and our healthcare operations as more fully described in Color’s HIPAA Notice of Privacy Practices.
There are benefits and risks to the use of telehealth. Potential benefits may include making it easier, more convenient, and more efficient to receive medical care and treatment. Telehealth services also allow you to seek care at times that are more convenient for you. Potential risks may include, without limitation:
- The information available to the telehealth provider may not be sufficient to allow the provider to make an appropriate medical decision, including diagnosis or treatment.
- The inability for the telehealth provider to conduct an in-person examination may in some cases prevent the provider from providing a diagnosis or treatment or from identifying the need for emergency medical care or treatment.
- Technology issues, such as disruptions of signals or problems with the Internet’s infrastructure, may cause broadcast and reception problems (e.g., poor picture or sound quality, dropped connections, audio interference) that prevent effective interaction between you and the treating healthcare provider, and may lead to loss of information.
As with any Internet-based communication, there is a risk of security breach. Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient data and will include measures to safeguard the data and to ensure its integrity.
Individuals other than the telehealth provider may also be present or have access to my information for the telehealth session to assist with operation, delivery or repair of the telehealth service and technologies. These persons will adhere to applicable privacy and security policies.
I attest to the following:
- I have the legal authority to give consent for Healthcare Services.
- I understand and agree that the Healthcare Services to which Color provides access may not be appropriate for certain populations of people with certain conditions or symptoms. Prior to receiving Healthcare Services, I have had the opportunity to consult with my healthcare provider.
- I understand and agree that I will be given and will review information about selected Healthcare Services, including the benefits, risks, possible problems or complications, and alternate choices for my medical care.
- I understand that I have the right to consult my own healthcare provider before deciding whether to receive a Healthcare Service or to refuse any Healthcare Service if I determine that I do not accept the potential risks or that it is otherwise not appropriate for me.
- I understand and agree that a healthcare provider I access through Color will not have access to my full medical records and that the health information I provide at the time of my Healthcare Service or telehealth visit may be the only source of health information used by the healthcare provider during the course of my evaluation and treatment.
- I understand, agree, and expressly consent to Color obtaining, using, storing, and disseminating to necessary third parties, information about me, including my image, as necessary to provide the telehealth services. I consent to release of my medical records to my primary care provider or other healthcare provider identified by me. I further understand that I will have access to all medical information resulting from the Healthcare Service or telehealth consultation as provided by applicable law for patient access.
- I understand and agree that the identity and credentials of my healthcare provider will be provided in advance of or at the time of my Healthcare Service or telehealth visit. In the event of technology failure, my clinician will provide next steps or follow-up information.
- I understand and agree that, by signing up for a Healthcare Service, I consent to performance and delivery of that Healthcare Service by Color.
- I understand that I have the right to decline or withdraw consent to any Healthcare Service and to Color’s use of telehealth at any time. I understand that if I withdraw my consent for a Healthcare Service or to the use of telehealth, it will not affect any future services or care benefits to which I am entitled, but withdrawal of consent will affect the ability to continue to receive a specific Healthcare Service until new consent for that Healthcare Service is given.
- I understand and agree that Color’s Healthcare Services and telehealth services are not intended for emergency care or emergency health situations. In the event of a medical emergency or an adverse reaction to treatment, I understand that I should call 911.
- I understand the risks, benefits, and limitations to telehealth services described above.
- I understand that my electronic signature has the same effect as my handwritten signature.
State-Specific Consents for Telehealth Services:
The following information applies to patients accessing telehealth services from the states listed below.
- New York: I understand that I can ask my telehealth provider how to verify his/her professional license.
- NOTICE CONCERNING COMPLAINTS – 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.
- AVISO SOBRE LAS QUEJAS – Las quejas sobre médicos, así como sobre otros profesionales acreditados e inscritos del Consejo Médico de Tejas, incluyendo asistentes de médicos, practicantes de acupuntura y asistentes de cirugía, se pueden presentar en la siguiente dirección para ser investigadas: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018. Si necesita ayuda para presentar una queja, llame al: 1-800-201-9353, Para obtener más información, visite nuestro sitio web en www.tmb.state.tx.us.
- Utah: For additional information on telehealth website owner-operator, location, and contact information, contact firstname.lastname@example.org.
- To submit a complaint about a nurse, pharmacist, or pharmacy please visit this webpage: File a complaint with the Bureau of Health Professions Licensure
- To submit a complaint about a doctor, you can either:
- File a complaint electronically on the Board of Registration in Medicine Online Complaint System.
- Download the Board of Registration in Medicine Complaint Form and mail it to: Consumer Protection Coordinator, Board of Registration in Medicine, 178 Albion Street, Suite 330, Wakefield, MA 01880.
- Download the Board of Registration in Medicine Complaint Form and fax it to (781) 876-8381.
You (a) certify that you are the patient, or that you are authorized to provide consent on behalf of the patient as the patient’s representative or legal guardian, (b) acknowledge and accept the risks identified above and the terms associated with the receipt of Healthcare Services, including via telehealth services, and (c) give your informed consent to receive Healthcare Services under the terms described herein.