Hinge Health Informed Consent Agreement
Telehealth involves the use of electronic communications to enable health care providers (“treating providers”) and patients to exchange health and medical information from one site to another for the purpose of treatment or patient care. Telehealth does not include the provision of health care services only through an audio only telephone, email messages, text messages, facsimile transmission, U.S. Mail or other parcel service, or any combination thereof. Treating providers may include physical therapists, primary care practitioners, specialists, and/or subspecialists. The information may be used for diagnosis, therapy, follow-up and/or education, and may include any of the following:
- Patient medical records;
- Medical images;
- Live two-way audio and video; and/or
- Output data from medical devices and sound and video files.
The Telehealth services you receive from treating providers are not intended to replace a primary care physician relationship or be your permanent medical home. You may form an ongoing treatment relationship with some treating providers. You should seek emergency help or follow-up care when recommended by the treating provider or when otherwise needed, and continue to consult with your primary care physician and other healthcare professionals as recommended.
The practice of healthcare by Telehealth does not alter any obligation of the treating providers regarding patient confidentiality or recordkeeping. Electronic systems used 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.
- Reduce the need for travel to a distant consultation site;
- Reduce cost and improve access to limited services and care management; and/or
- Obtain expertise of a distant health care provider or specialist.
Possible Risks: As with any medical procedure, there are potential risks associated with the use of Telehealth. These risks include, but may not be limited to:
- In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision making by the health care provider(s);
- Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment including disconnection of the technology during a Telehealth consult. If this happens you may be contacted by phone or other means of communication.
- In rare instances, security protocols could fail, causing a breach of privacy of personal medical information.
- In rare cases, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors.
By signing this form, I understand the following:
- I understand that the laws that protect privacy and the confidentiality of medical information also apply to Telehealth, and that no information obtained in the use of Telehealth which identifies me will be disclosed to researchers or other entities without my consent. More information is provided in the Notice of Privacy Practices available at https://www.hingehealth.com/hipaa/ and https://www.hingehealth.com/mso-notice-of-privacy-practices/.
- 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 by emailing email@example.com, without affecting my right to future care or treatment.
- I understand that I have the right to inspect all information obtained and recorded in the course of a Telehealth interaction, and I may receive copies of this information for a reasonable fee.
- I understand that my primary care provider may obtain a copy of my telehealth encounter.
- I understand that 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 treating provider has explained the alternatives to my satisfaction.
- I understand that my treating provider may determine that the Telehealth services are not appropriate for some or all of my treatment needs, and accordingly may not elect to provide Telemedicine services.
- If someone other than my healthcare provider is present during the consultation in order to operate the video equipment or take notes, that individual will be properly trained and required to keep the information confidential. I further understand that I will be informed of their presence in the consultation and have the right to request the following: (1) omit specific details about my personal medical history or physical examination that is personally sensitive to me; (2) ask non-medical personnel to leave the Telehealth examination room and/or (3) terminate the consultation at any time.
- I understand that Telehealth may involve electronic communication of my personal medical information to other healthcare or medical practitioners who may be located in other areas, including out of state.
- I understand that my treating provider may perform a physical examination through these technologies.
- I understand that providers may record video conference consultations and Hinge Health MSO may record telephone calls for quality purposes. I understand that Hinge Health MSO itself does not provide any medical or provider services.
- I understand that it is my duty to inform my treating provider of electronic interactions regarding my care that I may have with other healthcare providers.
- 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.
- I understand that receiving Telehealth services does not prohibit my ability to also consult with another physician who I have an ongoing relationship with, and who has agreed to supervise my treatment, including the use of any prescribed medications.
- I acknowledge that I may be receiving the physical therapy services without having obtained a referral for those physical therapy services from a physician, dentist, podiatrist, or nurse practitioner. I understand that a physical therapy diagnosis is not a medical diagnosis by a physician or based on radiological imaging. If I am obtaining physical therapy services without a referral, my healthcare plan/insurer may not cover the cost of those physical therapy services. I may, therefore, be personally responsible for the total cost of the physical therapy services I receive. My healthcare plan/insurer may cover the costs of those same physical therapy services if I received a referral from a physician, dentist, podiatrist, or nurse practitioner prior to obtaining those same services. Full information on the scope and limitations of the practice of physical therapy can be reviewed here.
Patient Consent To The Use of Telemedicine
I have read and understand the information provided above regarding Telehealth, have discussed it with my healthcare provider or such assistants as may be designated, and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of Telehealth for my healthcare.
I hereby authorize Hinge Health to use Telehealth in the course of my diagnosis and treatment.