[Ampersex.VA PC, Marsha Medical Group, AS Medical of NY, P.C] Telehealth Terms of Use and Informed Patient Consent

Last updated: July 31, 2023

Telehealth involves the use of live audio-video or other forms of synchronous and asynchronous electronic communications to deliver health care services to patients while the health care provider (the “Provider”) is located at a physical location different from the patient receiving the health care services (the “Telehealth Services”).

By agreeing to receive Telehealth Services from [Ampersex.VA PC, Marsha Medical Group, AS Medical of NY, P.C] (the “Practice”) via the athenaTelehealth tool, I acknowledge that

  • The Provider will be at a different physical location than me.
  • It is my responsibility to provide accurate, complete, and current information about me and my health condition(s) to the Provider while receiving Telehealth Services.
  • I can withhold or withdraw consent to receive Telehealth Services at any time without affecting my right to future care or treatment, and I may terminate Telehealth Services at any time.
  • Unless otherwise prohibited by applicable law, to the extent any part of Telehealth Services are recorded, including my voice, image, or any information about me or the health care services I received through Telehealth Services, I acknowledge and consent to such audio and video recording. Any such recordings will be used and maintained in accordance with the Practice’s Notice of Privacy Practices and all applicable privacy laws.  
  • The Practice has made reasonable and appropriate efforts to eliminate any confidentiality risks associated with Telehealth Services. I am also responsible for mitigating any risks to my privacy or confidentiality stemming from the location or circumstances of my participation in Telehealth Services (e.g., joining the telehealth encounter from a quiet space, ensuring others do not overhear my conversation or see my computer or mobile device screen). All existing confidentiality protections under federal and state law apply to my information disclosed during Telehealth Services.
  • The Practice and the Provider may use, share, or disclose my health information for reimbursement purposes, with other healthcare providers for treatment purposes, or for any other purposes in accordance with the Practice’s Notices of Privacy Practices and as permitted by applicable law.  
  • All existing laws regarding access to my medical information apply to Telehealth Services. All of my medical information transmitted during Telehealth Services may be incorporated into my medical record and may be provided to other healthcare providers and entities for continuity of care purposes or as otherwise permitted under applicable law.
  • There are potential risks to using electronic communications for the purpose of a health care visit, including, but not limited to, interruptions, unauthorized access, technical difficulties, and call termination. I acknowledge and accept those risks, understanding there are alternatives to receiving Telehealth Services. Either me or the Provider can discontinue Telehealth Services if either of us determines that Telehealth Services are not right for my health care.
  • I understand and acknowledge that Telehealth Services are not intended to be, and do not act as, emergency services. If I am experiencing an emergency, I should not rely on Telehealth Services and instead should call 911.
  • If I have questions or concerns about Telehealth Services, it is my responsibility to contact the Practice. By participating in Telehealth Services, I acknowledge and agree that I have had sufficient opportunity to speak with the Provider and have no questions or concerns that would preclude me from participating.
  • I understand what it means to receive Telehealth Services and am legally authorized to acknowledge, agree, and consent to these Terms of Use and Informed Patient Consent (a) on behalf of myself for use of Telehealth Services in my medical care, and/or (b) on behalf of any other individual(s) that will be receiving Telehealth Services for their medical care during the course of my treatment.
  • I am responsible for all charges (a) that I may incur from my mobile or internet service provider, as applicable, when receiving Telehealth Services; and (b) that are not covered by my insurer or third-party payor, including any applicable deductibles or co-payments that apply to Telehealth Services. It is my responsibility to determine whether my insurance covers Telehealth Services.

By joining the telehealth encounter and receiving Telehealth Services from the Practice through the athenaTelehealth tool, I represent that I have read, understand, and agree to these Terms of Use and Informed Patient Consent; I have been advised of the potential risks, benefits, and alternatives of Telehealth Services; I have been given the opportunity to ask questions and have no remaining questions at this time; and I hereby give my informed consent for the use of Telehealth Services in my medical care and/or the medical care of the individual(s) that will be using Telehealth Services, as applicable.