Effective Date: July 27, 2020
Before you give your consent to request telehealth services, please be aware of how receiving healthcare services from licensed health care professionals remotely through the Jetdoc telehealth platform and mobile application (the “Platform”) differs from in-person care. The terms “Jetdoc”, “we”, “us”, or “our” refer to Jetdoc, Inc. and the terms “you” and “yours” refer to the patient using the Platform to request telehealth services (the “Services”) from licensed health care providers contracting with Jetdoc (“Providers”) for use of the Platform. Please read each item carefully.
You understand that you should never use the Platform in a medical emergency. You understand that in a medical emergency you should dial 911 or visit an emergency room.
In using the Services on the Platform, you understand that you will be provided with the name, credentials, licensure/certification, and qualifications of the Provider who will be providing your care.
You understand that by using the Platform for Services, you will not have an in-person physical exam that might identify a potentially serious medical condition. You also understand and agree that the health information you provide through the Platform may be the only source of health information used by Providers during the course of your evaluation and treatment through the Platform, and that such Providers may not have access to any other health information held by your previous medical providers (e.g., allergies, drug reactions, etc.). You understand that you are not guaranteed treatment through the Platform and that a Provider will determine whether or not it is appropriate to treat you through the Platform.
You certify that all of the information you provide to the Platform for the Services is true, accurate, and complete. You understand that if you knowingly provide false, misleading, or incomplete information to a Provider, it may have a negative effect on your treatment and your health. We also reserve the right to terminate your access to the Platform if you knowingly provide incorrect information. You understand that you should ask questions about anything you do not understand. You understand that a Provider is available to answer any questions you may have when receiving Services through the Platform.
You understand that you will need to pay for Services received through the Platform yourself and that Jetdoc will not bill any insurance. You understand that by using this Platform, you are freely electing to pay out of pocket for all Services provided through the Platform and that you may be foregoing discounts or insurance coverage that would otherwise be available to you if you sought alternative care options. You understand that it is your responsibility to arrange and pay for any follow-up care that the Provider recommends you receive. You understand that you will be told how to get care in the case of an emergency.
In addition to the information you share with us through the Platform, the Platform will also collect your location information. You understand, agree, and expressly consent to Jetdoc obtaining, using, storing, and disseminating to necessary third parties, information about you and your image, as necessary to provide Services through the Platform. You further understand that records of Services provided to you through the Platform may be lost through technical failures and result in a breach of our confidentiality to you. You understand that if you are experiencing technical difficulties through the Platform, you may email firstname.lastname@example.org
. You understand that technical issues in the Platform may result in a delay in receiving Services. In the event of an issue with connecting with the Platform, please try to reconnect to the Platform to continue the Services. You hereby release and hold harmless Jetdoc from any loss of data or information due to technical failures associated with the Platform.
You agree that it is your choice whether or not to use the Services on the Platform. You understand that at any time, you can change your mind about receiving Services and may terminate your account with Jetdoc. If you would like to have the records relating to the Service received through the Platform sent to your primary care provider, you understand that you will need to request such transfer of records. You may obtain copies of your medical records for Services by emailing us at email@example.com
. Jetdoc will respond to messages as they are received but does not guarantee an immediate response.
You understand that under applicable state laws, Providers may be required to report suspicions of child abuse, neglect, statutory rape, domestic violence, and sexual assault. Jetdoc does not become involved in those decisions. You hereby release and hold harmless Jetdoc and Providers for Provider’s good faith compliance with state mandatory reporting laws.
Jetdoc makes every effort to comply with applicable state laws and regulations with respect to its telehealth platform. You may be entitled to certain additional protections. State specific informed consent laws applicable to telehealth may be reviewed in the section below, Additional State-Specific Consent for Telehealth Services.
You understand that this Informed Consent is intended to incorporate these additional state protections. Should you have any questions about your rights under state law, please contact firstname.lastname@example.org
You hereby consent to the use of telehealth to examine, consult, diagnose, or treat you and you understand that you may seek in-person care or follow up care through a health center should you so choose.
You further acknowledge and agree that:
- You are at least eighteen (18) years of age;
- You understand that you have read and understood the information above, including the benefits, risks and limitations of using the Platform for Services, and you may seek in-person care or follow up care with another provide of your choosing in person;
- If applicable, you attest that you have legal authority to act as guardian or personal representative of all individuals registered under your Account;
- Our Providers may determine that our clinical services are not appropriate for some or all of your treatment needs and may elect not to provide Services to you through the Platform.
- This informed consent will become a part of your medical record.
Additional State-Specific Consent for Telehealth Services
The following consents apply to users accessing the Jetdoc Servicse, and only to the extent that the Jetdoc Services are available to users in such states (the state-specific language below does not imply the Jetdoc Services are available in such state), for the purposes of participating in a telehealth consultation as required by the states listed below:
I understand my primary care provider may obtain a copy of my records of my telehealth encounter. (Alaska Stat. § 08.64.364).
I understand I am entitled to all existing confidentiality protections pursuant to A.R.S. § 12-2292. I also understand all medical reports resulting from the telemedicine consultation are part of my medical record as defined in A.R.S. § 12-2291. I also understand dissemination of any images or information identifiable to me for research or educational purposes shall not occur without my consent, unless authorized by state or federal law. (Ariz. Rev. Stat. Ann. § 36-3602).
The patient may refuse telemedicine services at any time, without loss or withdrawal of treatment. All applicable confidentiality protections shall apply to the services. The patient shall have access to all medical information from the services, under state law. (CO 25.5-5-320).
I understand that my primary care provider may obtain a copy of my records of my telehealth encounter. (Conn. Gen. Stat. Ann. § 19a-906).
I have been informed of alternate forms of communication between me and a physician for urgent matters. (D.C. Mun. Regs. tit. 17, § 4618.10).
I have been given clear, appropriate, accurate instructions on follow-up in the event of needed emergent care related to the treatment. (Ga. Comp. R. & Regs. 360-3-.07(7)).
An appropriate consent is required, which must disclose the delivery models, provider qualifications, treatment methods, or limitations and telehealth technologies.
Medicaid Telehealth Policy. Rev. 7/1/2018, p. 4 & Idaho Medicaid Provider Handbook. General Provider and Participant Information. Jan 17, 2019, p. 53. (Accessed Sept. 2019).
I understand that if I have a primary care provider or other treating physician, the person providing telemedicine services must send within three business days a report to such primary care or other treating physician of the treatment and services rendered to me during the telemedicine encounter. (Kan. Stat. Ann. § 40-2,212(2)(d)(1)(A)).
If I am a Medicaid recipient, I recognize I have the option to refuse the telehealth consultation at any time without affecting the right to future care or treatment and without risking the loss or withdrawal of a Medicaid benefit to which I am entitled. I understand that I have the right to be informed of any party who will be present at the site during the telehealth consult and I have the right to exclude anyone from being present. I also understand that I have the right to object to the videotaping of the telehealth consultation. (907 Ky. Admin. Regs. 3:170).
I understand the role of other health care providers that may be present during the consultation other than the Jetdoc provider. (46 La. Admin. Code Pt XLV, § 7511)
Regarding audiologists, speech language pathologists, and hearing aid dispensers, I recognize the inability to have direct, physical contact with the patient is a primary difference between telehealth and direct in-person service delivery. The knowledge, experiences, and qualifications of the consultant providing data and information to the provider of the telehealth services need not be completely known to and understood by the provider. The quality of transmitted data may affect the quality of services provided by the provider. Changes in the environment and test conditions could be impossible to make during delivery of telehealth services. Telehealth services may not be provided by correspondence only. (Md. Code Regs. 10.41.06.04).
If I am a Medicaid recipient, I retain the option to refuse the telehealth consultation at any time without affecting my right to future care or treatment and without risking the loss or withdrawal of any program benefits to which the patient would otherwise be entitled. All existing confidentiality protections shall apply to the telehealth consultation. I shall have access to all medical information resulting from the telehealth consultation as provided by law for access to my medical records. Dissemination of any patient identifiable images or information from the telehealth consultation to researchers or other entities shall not occur without my written consent. I understand that I have the right to request an in-person consult immediately after the telehealth consult and I will be informed if such consult is not available. (Neb. Rev. Stat. Ann. § 71-8505; 471 Neb. Admin. Code § 1-006.05).
I understand that the Jetdoc provider may forward my medical records to my primary care or treating provider. (N.H. Rev. Stat. § 329:1-d).
I understand I have the right to request a copy of my medical information and I understand my medical information may be forwarded directly to my primary care provider or health care provider of record, or upon my request, to other health care providers. (N.J. Rev. Stat. Ann. § 45:1-62).
I understand that I may be asked to confirm my consent to behavioral health or tele-psych services.
If I use e-mail or text-based technology to communicate with my Jetdoc provider, then I understand the types of transmissions that will be permitted and the circumstances when alternate forms of communication or office visits should be utilized. I have also discussed security measures, such as encryption of data, password protected screen savers and data files, or utilization of other reliable authentication techniques, as well as potential risks to privacy. I acknowledge that my failure to comply with this agreement may result in the Jetdoc provider terminating the e-mail relationship. (Rhode Island Medical Board Guidelines).
I understand my medical records may be distributed in accordance with applicable law and regulation to other treating health care practitioners. (S.C. Code Ann. § 40-47-37).
I have received disclosures regarding the delivery models and treatment methods or limitations. I have discussed with the Jetdoc provider the diagnosis and its evidentiary basis, and the risks and benefits of various treatment options. (S.D. SB136 (not yet codified)).
I understand that I may request an in-person assessment before receiving a telehealth assessment if I am a Medicaid recipient.
I understand that my medical records may be sent to my primary care physician. (Tex. Occ. Code Ann. § 111.005).
I understand (i) any additional fees charged for telehealth services, if any, and how payment is to be made for those additional fees, if the fees are charged separately from any fees for face-to-face services provided in combination with the telehealth services; (ii) to whom my health information may be disclosed and for what purpose, and have received information on any consent governing release of my patient-identifiable information to a third-party; (iii) my rights with respect to patient health information; (iv) appropriate uses and limitations of the site, including emergency health situations. I understand that the telehealth services Jetdoc provides meets industry security and privacy standards, and comply with all laws referenced in Subsection 26-60-102(8)(b)(ii). I was warned of: potential risks to privacy notwithstanding the security measures and that information may be lost due to technical failures, and agree to hold the provider harmless for such loss. I have been provided with the location of Jetdoc’s website and contact information. I was able to select my provider of choice, to the extent possible. I was able to select my pharmacy of choice. I am able to a (i) access, supplement, and amend my patient-provided personal health information; (ii) contact my provider for subsequent care; (iii) obtain upon request an electronic or hard copy of my medical record documenting the telemedicine services, including the informed consent provided; and (iv) request a transfer to another provider of my medical record documenting the telemedicine services. (Utah Admin. Code r. 156-1-602).
I acknowledge that I have received details on security measures taken with the use of telemedicine services, such as encrypting date of service, password protected screen savers, encrypting data files, or utilizing other reliable authentication techniques, as well as potential risks to privacy notwithstanding such measures; I agree to hold harmless Jetdoc for information lost due to technical failures; and I provide my express consent to forward patient-identifiable information to a third party. (Virginia Board of Medicine Guidance Document 85-12).
I understand that I have the right to receive a consult with a distant-site provider and will receive one upon request immediately or within a reasonable time after the results of the initial consult. I understand that receiving tele-dermatology or tele-ophthalmology services via Jetdoc does not preclude me from receiving real-time telemedicine or face-to-face services with the distant provider at a future date. (Vt. Stat. Ann. § 9361).