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Telehealth Consent
Last Updated: May 5, 2020

Informed Consent for Telehealth Services

Telehealth involves the use of electronic communications to enable healthcare providers at different locations to share individual patient medical information for the purpose of improving patient care. Telehealth services offered by Prairie Health may also include, without limitation, chart review, remote prescribing, medication management, laboratory services, appointment scheduling, health information sharing (including care coordination with your other treating providers), and non-clinical services, such as patient education. The information you provide may be used for diagnosis, therapy, medication management, follow-up care and/or patient education, and may include any combination of the following: (1) health records and test results; (2) images and asynchronous communications; (3) live two-way audio and video; (4) interactive audio with store and forward; and (5) output data from medical devices and sound and video files.

The electronic communication systems we use will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

Psychiatrists, nurse practitioners, therapists, social workers, and care managers affiliated with Prairie Health (our “providers”) are an addition to, and not a replacement for, your primary care physician. Responsibility for your overall medical care should remain with your local primary care doctor, if you have one, and we strongly encourage you to locate one if you do not.

Expected Benefits:
- Improved access to care by enabling you to remain in your home while the Prairie Health provider consults and obtains test results 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.
- In rare events, our provider may determine that the transmitted information is of inadequate quality, thus necessitating a rescheduled telehealth consult or a meeting with your local primary care doctor.
- In very rare events, security protocols could fail, causing a breach of privacy of personal medical information.
- In rare events, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors.
- If you need to receive follow-up care, assistance in the event of an adverse reaction to the treatment, or in the event of an inability to communicate as a result of a technological or equipment failure, please contact Prairie Health through the patient portal or via email at inquiry@prairiehealth.co.

By signing up to Prairie Health, you acknowledge that you understand and agree with the following:
1. I hereby consent to receiving Prairie Health’s services via telehealth technologies. I understand that Prairie Health and its providers offer telehealth-based medical services, but that these services do not replace the relationship between me and my primary care doctor. I also understand it is up to the Prairie Health provider to determine whether or not my specific clinical needs are appropriate for a telehealth encounter. If in the professional judgment of my prescriber I am not appropriate for telehealth-based care, I understand that I will be notified and provided with some assistance to find an in-person service which may be more appropriate.

2. I understand I will be initially assigned a provider, but that I may submit a request to change providers by sending an email to inquiry@prairiehealth.co. I acknowledge that all reasonable effort will be made to honor my request. If my request cannot be honored I understand I have the right to seek services from a provider other than Prairie Health.

3. I understand that Prairie Health will rely on all information I provide to Prairie Health as accurate and complete. I understand that Prairie Health will use such information in its delivery of services to me. I further understand that the inaccuracy of any such information I provide to Prairie Health may impact the efficacy of such services.

4. I understand Prairie Health will provide me with information related to my diagnosis, treatment and ongoing care and that the success of my treatment and care is dependent upon my review of this information. Therefore, I agree to review all such information Prairie Health provides to me.

5. I understand that federal and state law requires health care providers to protect the privacy and the security of health information. I understand that Prairie Health will take steps to make sure that my health information is not seen by anyone who should not see it. I understand that telehealth may involve electronic communication of my personal medical information to other health practitioners who may be located in other areas, including out of state.

6. I understand there is a risk of technical failures during the telehealth encounter beyond the control of Prairie Health. I agree to hold harmless Prairie Health for delays in evaluation or for information lost due to such technical failures.

7. 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.

8. I understand that alternatives to telehealth consultation, such as in-person services are available to me, and in choosing to participate in a telehealth consultation, I understand that some parts of the services involving tests may be conducted by individuals at my location, or at a testing facility, at the direction of the Prairie Health provider (e.g., labs or bloodwork). 9. 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.

10. 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 Prairie Health provider in order to operate the telehealth 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 telehealth examination; and/or (3) terminate the consultation at any time.

11. I understand that I will not be prescribed any narcotics for pain, nor is there any guarantee that I will be given a prescription at all.

12. I understand there may be side effects from certain medications prescribed, and that my provider will specifically address these risks when prescribing such medication to me.

13. I understand that if I participate in a consultation, that I have the right to request a copy of my medical records which will be provided to me at reasonable cost of preparation, shipping, and delivery.

14. I understand Prairie Health is a telehealth-based service that is not equipped to handle psychiatric or medical emergencies. If I have an emergency that needs immediate response, I will call 911 or go to my nearest emergency room, and I understand that the Prairie Health providers are not able to connect me directly to any local emergency services.

Patient Consent
I have read this document carefully, and understand the risks and benefits of the telehealth consultation, and I have had my questions regarding the procedure explained. I hereby give my informed consent to participate in a telehealth consultation under the terms described herein.

741-741

If you’re in emotional distress, text HOME to connect with a counselor immediately.

911

If you’re having a medical or mental health emergency, call 911 or go to your local ER.