Telehealth involves the use of secure electronic communications, information technology, or other means to enable a healthcare provider and a patient at different locations to communicate and share individual patient health information for the purpose of rendering clinical care. This “Telehealth Informed Consent” informs the patient (“patient,” “you,” or “your”) concerning the treatment methods, risks, and limitations of using a telehealth platform.
Telehealth services offered by Optigy Group, LLC (“Group”), which is contracted with BSC Medco, Inc. (“Kiaora”) and the Group’s engaged providers (our “Providers” or your “Provider”) may include a patient consultation, diagnosis, treatment recommendation, prescription, and/or a referral to in-person care, as determined clinically appropriate (the “Services”).
Kiaora does not provide the Services; instead it performs administrative, payment, and other supportive activities for Group and our Providers.
The types of electronic transmissions that may occur using the Kiaora telehealth platform include, but are not limited to:
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. 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 further acknowledge and understand the following:
Additional State-Specific Consents: The following consents apply to patients accessing Group’s website for the purposes of participating in a telehealth consultation as required by the states listed below:
Alaska: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here.
California: I have been informed of the following notice:
The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. It can be found at https://openpaymentsdata.cms.gov.
Iowa: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here.
Indiana: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here.
Kentucky: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here (or, alternatively, by accessing this URL in my browser: kbml.ky.gov/grievances/Pages/default.aspx).
Maine: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here; Or, the Maine Board of Osteopathic Licensure’s website, here.
Oregon: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here.
Rhode Island: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here.
Texas: I have been informed of the following notice:
NOTICE CONCERNING COMPLAINTS
Complaints about physicians, as well as other licensees and registrants of the Texas Medical Board, including physician assistants, acupuncturists, surgical assistants, medical radiologic technologists, non-certified radiologic technicians, respiratory care practitioners, medical physicists, and perfusionists may be reported for investigation at the following address:
AVISO SOBRE LAS QUEJAS
Quejas sobre médicos, así como sobre otros profesionales médicos de la Junta Médica de Texas, incluyendo asistentes medicos profesionales, acupunturistas, asistentes quirúrgicos, tecnólogos médicos en radiología, técnicos radiólogos no certificados, profesionales de cuidados respiratorios, físicos médicos, y perfusionistas se pueden presentar en la siguiente dirección para ser investigadas:
Vermont: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here; Or, the Vermont Board of Osteopathic Examiners’ website, here.
By checking the box presented to me during my intake process hosted on the Kiaora web platform, I (or in the case of my guardian acting on my behalf) acknowledge that I have carefully read, understand, and agree to the terms of this “TELEHEALTH INFORMED CONSENT” and consent to receive the Services. I (or in the case of my guardian acting on my behalf) further understand and agree that this Telehealth Informed Consent will be electronically linked to my individual account, associated with my name created on the Kiaora web platform and made part of my medical record with the Group.