Terms and Conditions
1. Website Content
Other than the personalized content we send you in a message within or through the Site or the personalized advice we give you during a video visit, you should not consider content on Site to be medical advice.
2. User Accounts
When you register on the Site, you need to create an account ("Account") by entering your name, email address, password, telephone number, physical address and certain other information we need to know in order to provide the Service. You may not transfer or share your Account password with anyone, or create more than one Account. If you create more than one Account this substantially limits our ability to provide appropriate care because we have no way of linking your various accounts and no way of knowing that previous accounts you set up relate to you. If you create more than one Account this increases the chances that you will experience serious adverse events from any medicines we prescribe. You are responsible for maintaining the confidentiality of your Account password and for all activities that occur under your Account. You are responsible for changing your password promptly if you think it has been compromised. To change your password go into ‘Account’ within the Site. We reserve the right to take any and all action, as it deems necessary or reasonable, regarding the security of your Account. You may not use anyone else’s account at any time.
3. Right to Modify
4. Ownership of Site
Certain names, logos, and other materials displayed on the Site may constitute trademarks, trade names, service marks or logos ("Marks") of Medzino or other entities. You are not authorized to use any such Marks without the express written permission of Medzino. Ownership of all such Marks and the goodwill associated therewith remains with us.
6. Services Provided - Medical Care/Advice from Medzino
We offer an online telehealth communication platform for Providers and their patients to connect via the Site through the use of synchronous and asynchronous telecommunications technologies. The Site facilitates communication between patients and our Providers regarding consultations and treatment options for men’s health, women’s health, sexual health, skin conditions; chronic health conditions; and healthy wellbeing (i.e. smoking cessation, acid reflux, cold sores, and migraine relief).
Medzino doctors provide medical advice and/or care through diagnoses and prescription services. Medzino employs its own United States based Providers who provide clinical telehealth services. These Providers deliver clinical services via the Medzino platform to their patients. Providers are not contracted or employed by third parties.
Medzino and the Providers are responsible for the quality and appropriateness of the care they render to you. The Providers are employed by Medzino and are using the Site as a way to communicate with you only. Your interactions with the Providers via the Site are not intended to take the place of your relationship with your regular health care practitioners or primary care physician. Medzino does not recommend or endorse any specific Providers, tests, physicians, medications, products, or procedures. You acknowledge that your reliance on any Providers or information delivered by the Providers via the Site or Service is solely at your own risk and you assume full responsibility for all risks associated herewith.
You should always seek the advice of qualified health care professionals with any questions or concerns you may have regarding your individual needs and any medical conditions.
**IF YOU ARE EXPERIENCING A HEALTH RELATED EMERGENCY, CONTACT 911 OR GO TO THE NEAREST EMERGENCY ROOM IMMEDIATELY.**
7. Risks of Telehealth Services
By using the Services, you acknowledge the potential risks associated with telehealth services. These include but are not limited to the following: information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical or health care decision making by the Provider; delays in evaluation or treatment could occur due to failures of electronic equipment; a lack of access to your medical records may result in adverse drug interactions or allergic reactions or other judgment errors; although the electronic systems we use incorporate network and software security protocols to protect the privacy and security of health information, those protocols could fail causing a breach of privacy of your health information. You are asked to review the Telehealth Consent Form included with these Terms as Exhibit A.
8. Prescription Services
Neither Medizno nor its doctors endorse any specific medication, pharmacy, or pharmacologic product. If a Provider prescribes a medication, he/she will limit supply based upon state regulations and will only prescribe a medication as determined in his/her own discretion and professional judgment. There is no guarantee a prescription will be written.
Providers do not prescribe DEA controlled substances or scheduled medications, or certain other drugs which may be harmful because of their potential for abuse. Providers reserve the right to deny care for actual or potential misuse of the Services. You agree that any prescriptions that you acquire from a Provider will be solely for your personal use.
You agree to fully and carefully read all provided product information and labels and to contact a physician or pharmacist if you have any questions regarding the prescription. Medzino and our partner pharmacy fully honor patient freedom of choice and, if you receive a prescription for a medication, you always have the option to instruct your Provider to transmit that prescription to the pharmacy of your choice.
9. Not Insurance
Medzino is not an insurer. The Services are not insurance products, and the amounts you pay to Medzino are not insurance premiums. If you desire any type of health or other insurance, you will need to purchase such insurance separately.
10. Availability of Services
Medzino operates subject to state and federal regulations, and the Services may not be available in your state. You represent that you are not a person barred from enrolling for and/or receiving the Services under the laws of the United States or other applicable jurisdictions in which you may be located. Access to and use of the Site and/or the Services is limited exclusively to users located in States within the United States where the Services are available. Services are not available to users located outside the United States. Accessing the Site or Services from jurisdictions where content is illegal, or where we do not offer Services, is prohibited.
11. Purchase Orders and Fulfillment
Your placement of an order does not necessarily ensure that we will accept your order. We may require additional information regarding your order if you have not provided all the information required by us to completed. Once a properly completed order and authorization of your form of payment is received, we will process your order and Product for shipment. If, for some reason, we determined that we cannot ship your Product(s) within thirty (30) days following our receipt of a properly completed order, we will cancel your order and advise you of such action. We do not accept orders from dealers, wholesalers or other customers who intend to resell items offered on our Site.
12. Errors, Incorrect Pricing, and Risk of Loss
In the event a Product or Service is listed at an incorrect price due to typographical error, or error in pricing information received from a third party, we shall have the right to refuse or cancel any orders placed for the Product(s) and/or Service(s) listed at the incorrect price. We shall have the right to refuse or cancel any such orders whether or not the order has been confirmed and your credit or debit card charged. If you credit or debit card has already been charged for the purchase and your order is canceled, we will promptly issue a credit to your credit or debit card account in the amount of the charge.
All Products purchased from our Site are delivered to shipment carriers. The risk of loss and title for such Products pass to you when they are delivered to the carrier.
13. Website Images
All product images on the website are for illustration purposes only, the actual product you receive may vary, we are unable to accept any cancellations or refund requests based on the final packaging being different as long as the contents of the package are correct
14. Electronic Communications
When you use the Site or Services, or send e-mails, messages, and other communications from your desktop or mobile device to us, you are communicating with us electronically. You consent to receive communications from us electronically. You agree that (a) all agreements and consents can be signed electronically and (b) all notices, disclosures, and other communications that we provide to you electronically satisfy any legal requirement that such notices and other communications be in writing. Medzino may contact you by telephone, mail, or email to verify your account information. Medzino may request further information from you and you agree to provide such further information to ensure that you have not fraudulently created your Account. If you do not provide this information in the manner requested within 14 days of the request, we reserve the right to suspend, discontinue, or deny your access to and use of the Site and the Services until you provide the information to us as requested.
15. No Users Under 18
The Site and Services are only for users of the age of 18. If you are under the age of 18, please do not attempt to register with us at this Site or provide any personal information about yourself to us. If we learn that we have collected personal information from someone under the age of 18, we will promptly delete that information. If you believe we have collected personal information from someone under the age of 18, please contact us immediately.
16. Links to External Sites
Medzino makes no representations whatsoever about any other website that you may access through this Site. When you access a non-Medzino site, you must acknowledge that it is independent from Medzino, and that Medzino has no control over the content on that website. In addition, a link to a non-Medzino website does not mean that Medzino endorses or accepts any responsibility for the content, or the use, of the linked site. It is up to you to take precautions to ensure that whatever you select for your use or download is free of such items as viruses, worms, Trojan horses, and other items of a destructive nature. If you decide to access any of the third party sites linked to this Site, you do this entirely at your own risk.
17. User Information
If you submit, upload, post or transmit any health information, medical history, conditions, problems, symptoms, personal information, consent forms, agreements, requests, comments, ideas, suggestions, information, files, videos, images or other materials to us or our Site (“User Information”), you agree not to provide any User Information that (1) is false, inaccurate, defamatory, abusive, libelous, unlawful, obscene, threatening, harassing, fraudulent, pornographic, or harmful, or that could encourage criminal or unethical behavior, (2) violates or infringes the privacy, copyright, trademark, trade dress, trade secrets or intellectual property rights of any person or entity, or (3) contains or transmits a virus or any other harmful component. You agree not to contact other site users through unsolicited e-mail, telephone calls, mailings or any other method of communication. You represent and warrant to Medzino that you have the legal right and authorization to provide all User Information to Medzino for use as set forth herein and required by Medzino.
You agree not to (i) access the Site or use the Services in any unlawful way or for any unlawful purpose; (ii) post or transmit (a) a message under a false name, or (b) any data, materials, content, or information (including, without limitation, advice, and recommendations) (collectively “Information”) which is (1) libelous, defamatory, obscene, fraudulent, false, or contrary to the ownership or intellectual property rights of any other person, or (2) contains or promotes any virus, worm, Trojan horse, time bomb, malware, or other computer programing or code that is designed or intended to damage, destroy, intercept, download, interfere, manipulate, or otherwise interrupt or expropriate the Site or the Services, personal information, software, equipment, servers, or Information or facilitate or promote hacking or similar conduct; (iii) impersonate or misrepresent your identity or falsely state or misrepresent your affiliation with a person or entity; (iv) tamper, hack, spoof, copy, modify, or otherwise corrupt the administration, security, or proper function of the Site or the Services; (v) use robots or scripts with the Site; (vi) attempt to reverse engine, reverse assemble, reverse compile, decompile, disassemble, translate, or otherwise alter, defraud, or create false results from any executable code, information on, or received by this Site; (vii) to have any antivirus or antispyware software running that is set to override the internet browser’s cookies setting; (viii) incorrectly identify the sender of any message transmitted to Medzino. You may not alter the attribution or origin of electronic mail, messages, or posting; (ix) harvest or collect PHI about any other individual who uses the Site or the Services; (x) infringe or facilitate infringement on any copyright, patent, trademark, trade secret, or other proprietary, publicity, or privacy rights of any party, including such rights of third parties.
18. Disclaimer of Warranties
YOU EXPRESSLY AGREE THAT USE OF THE SITE IS AT YOUR SOLE RISK. WE PROVIDE THE SITE ON AN “AS IS” AND “AS AVAILABLE” BASIS. MEDZINO EXPRESSLY DISCLAIMS ALL WARRANTIES OF ANY KIND, WHETHER EXPRESS OR IMPLIED, INCLUDING, BUT NOT LIMITED TO ANY WARRANTIES OF MERCHANTABILITY, FITNESS FOR A PARTICULAR USE OR PURPOSE, NON-INFRINGEMENT, TITLE, OPERABILITY, CONDITION, QUIET ENJOYMENT, VALUE, ACCURACY OF DATA, AND SYSTEM INTEGRATION.
19. Limited Liability
YOU UNDERSTAND THAT TO THE EXTENT PERMITTED UNDER APPLICABLE LAW, IN NO EVENT WILL MEDZINO OR ITS OFFICERS, EMPLOYEES, DIRECTORS, PARENTS, SUBSIDIARIES, AFFILIATES, AGENTS OR LICENSORS BE LIABLE FOR ANY INDIRECT, INCIDENTAL, SPECIAL, CONSEQUENTIAL OR EXEMPLARY DAMAGES, INCLUDING BUT NOT LIMITED TO, DAMAGES FOR LOSS OF REVENUES, PROFITS, GOODWILL, USE, DATA OR OTHER INTANGIBLE LOSSES ARISING OUT OF OR RELATED TO YOUR USE OF THE SITE, REGARDLESS OF WHETHER SUCH DAMAGES ARE BASED ON CONTRACT, TORT (INCLUDING NEGLIGENCE AND STRICT LIABILITY), WARRANTY, STATUTE OR OTHERWISE. To the extent that we may not, as a matter of applicable law, disclaim any implied warranty or limit its liabilities, the scope and duration of such warranty and the extent of our liability will be the minimum permitted under such applicable law.
20. Allegations of Copyright Infringement
The Digital Millennium Copyright Act of 1998 (the "DMCA") provides recourse for copyright owners who believe that material appearing on the Internet infringes their rights under U.S. copyright law. If you believe in good faith that materials appearing on the App or Website infringe your copyright, you (or your agent) may send us a notice requesting that the material be removed, or access to it blocked. In addition, if you believe in good faith that a notice of copyright infringement has been wrongly filed against you, the DMCA permits you to send us a counter-notice. Notices and counter-notices must meet statutory requirements imposed by the DMCA.
Review the U.S. Copyright Office Web site, http://www.loc.gov/copyright. Any written Notification of Claimed infringement should comply with Title 17, United States Code, Section 512(c)(3)(A) and should be provided in writing to Medzino.
21. Intellectual Property
With the exception of your electronic medical record, Medzino retains all right, title, and interest in and to the Site, the Services and any information, products, documentation, software, or other materials on the Site, and any patent, copyright, trade secret, trademark, service mark, or other intellectual property, or proprietary right in any of the foregoing, except for information on the Site licensed by Medzino (in that case, the license provider retains all right, title, and interest therein). The information available through the Site and the Services is the property of Medzino, as applicable. You agree not to store, copy, modify, reproduce, retransmit, distribute, disseminate, rent, lease, loan, sell, publish, broadcast, display, or circulate such information to anyone. Use, reproduction, copying, or redistribution of Medzino trademarks, service marks, and logos are strictly prohibited without the prior written permission of Medzino, as applicable. The immediately foregoing sentence also applies to any third party trademarks, service marks, and logos posted on the Site. Nothing contained on the Site should be construed as granting, by implication, estoppel, waiver or otherwise, any license or right to use any trademarks, service marks or logos displayed on the Site without the written grant thereof by Medzino or the third party owner of such trademarks, service marks, and/or logos. The Site may contain other proprietary notices and copyright information, the terms of which you agree to follow.
23. Dispute Resolution; Arbitration
We endeavor to work in good faith to resolve any issue you have with the Site, including Products and Services ordered or purchased through the Site, if you bring that issue to the attention of our customer service department. However, we realize that there may be rare cases where we may not be able to resolve an issue to a customer's satisfaction.
YOU AND THE COMPANY AGREE THAT EACH MAY BRING CLAIMS AGAINST THE OTHER ONLY IN YOUR OR ITS INDIVIDUAL CAPACITY, AND NOT AS A PLAINTIFF OR CLASS MEMBER IN ANY PURPORTED CLASS OR REPRESENTATIVE PROCEEDING. Further, unless both you and Medzino agree otherwise, the arbitrator may not consolidate more than one person's claims with your claims, and may not otherwise preside over any form of a representative or class proceeding. The arbitrator may award declaratory or injunctive relief only in favor of the individual party seeking relief and only to the extent necessary to provide relief warranted by that party's individual claim.
24. Governing Law; Venue
The laws of the State of Delaware shall govern these Terms. The exclusive jurisdiction and venue for any claims will be in state or federal courts located in and for Sussex County, Delaware.
25. Force Majeure
27. Stark Law and Anti-Kickback
It is the intent of the parties that terms and conditions of this agreement comply with certain federal and state laws, rules and regulations concerning the delivery of health care services, including, without limitation, the Stark Law, the Fraud and Abuse Law, and the general proscription on false claims in Medicare and Medicaid codified at 42 U.S.C.A. SS1320a-7(a). Accordingly, the parties agree that the amount of fees set in accordance with this agreement shall not be modified except on each anniversary of the Commencement Date as provided in Paragraph 1; and shall not be premised on the volume or value of any patient.
Nothing contained herein shall be interpreted as requiring Medzino to refer or admit any patients to any hospital or medical facility owned or operated by Advisors or its affiliates, or to obtain medical goods or services from Advisors or its affiliates. In the event there is a change in the applicable federal or state statutes, rules, regulations, principles or interpretations that reasonably may render any of the material terms of this Lease unlawful or unenforceable, including any services rendered or compensation to be paid hereunder, or if the continuation of this agreement may reasonably render any other relationship(s) amongst the parties hereto illegal, either party shall have the immediate right to initiate the renegotiation of the affected Term or Terms of this agreement, upon notice to the other party, to remedy such condition.
The parties shall thereafter negotiate using their best efforts to restructure this agreement so as to make the same lawful, and to the extent possible, to maintain the economic benefits to each party as contemplated hereunder. Should the parties be unable to renegotiate the Term or Terms so affected so as to bring it/them into compliance with the statute, rule, regulation, principle or interpretation that rendered it/them unlawful or unenforceable within fifteen (15) days of the date on which notice of a desired renegotiation is given, then such disputes shall give rise to the parties' rights to arbitration.
28. HIPPA Compliance
Medzino complies with the applicable provisions of the Administrative Simplification section of the Health Insurance Portability and Accountability Act of 1996, codified at 42 U.S.C. §§ 1320d through 1320d-9 (“HIPAA”), and the requirements of any regulations promulgated thereunder, including, without limitation, federal security standards as contained in 45 C.F.R. Parts 160, 162 and 164 (collectively, the “HIPAA Regulations”). Medzino may only disclose Protected Health Information about a patient for treatment purposes to other health care providers involved in the patient's treatment or to Hospital’s workforce members involved in the patient’s care regimen. Medzino shall not request, use or further disclose any Protected Health Information other than for the Services specified in these Terms. Medzino will implement appropriate safeguards to prevent the request for, use or disclosure of Protected Health Information other than as permitted by these Terms. Medzino will make its internal practices, books, and records relating to the use and disclosure of Protected Health Information available to the Secretary of the Department of Health and Human Services to the extent required for determining federal compliance with HIPAA and associated regulations.
29. Security Breach Notification
In the event of any actual, probable, or reasonably suspected breach of security of any facilities, or any unauthorized access to or acquisition, use, loss, destruction, compromise, alteration, or disclosure of any information maintained in any Facilities (each, a “Security Breach”) that may concern patient confidential information, Medzino shall: (i) notify patient immediately of such breach, and otherwise take no less than its best efforts to notify patient within twenty four (24) hours after such Security Breach occurs; (ii) notify patient to follow all reasonable instructions provided by Medzino relating to the Confidential Information affected or potentially affected by the Security Breach; (iii) make all reasonable good faith efforts and accommodations to assist in the investigation of Security Breach; (iv) take such actions as necessary to prevent future Security Breaches; and (v) unless prohibited by an applicable statute or court order notifying patient of any third party legal process relating to any Security Breach, including, but not limited to, any legal process initiated by U.S. government authorities.
- Office Contact Information:
Medzino Health Inc.
100 Pine Street
Suite 1250 #
San Francisco, CA 94111
- Registered Agent:
16192 Coastal Highway
Lewes, DE 19958
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 Medzino may also include chart review, remote prescribing, appointment scheduling, health information sharing, and non-clinical services, such as patient education. The information you provide may be used for diagnosis, therapy, follow-up 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.
Medzino Services 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.
- Improved access to care by enabling you to remain in your home while the Medzino provider consults and obtains test results at distant / other sites.
- More efficient care evaluation and management.
- Obtaining expertise of a specialist as appropriate.
- 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 Medzino at [PHONE NUMBER].
By checking the box associated with "Informed Consent", you acknowledge that you understand and agree with the following:
- I hereby consent to receiving Medzino’s services via telehealth technologies.I understand that Medzino 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 Medzino provider to determine whether or not my specific clinical needs are appropriate for a telehealth encounter.
- I have been given an opportunity to select a provider from Medzino prior to the consult, including a review of the provider’s credentials.
- I understand that federal and state law requires health care providers to protect the privacy and the security of health information.I understand that Medzino 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.
- I understand there is a risk of technical failures during the telehealth encounter beyond the control of Medzino.I agree to hold harmless Medzino for delays in evaluation or for information lost due to such technical failures.
- 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.I understand that if I am experiencing a medical emergency, that I will be directed to dial 9 - 1 - 1 immediately and that Medzino providers are not able to connect me directly to any local emergency services.
- 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 Medzino provider(e.g.labs or bloodwork).
- 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 my healthcare information may be shared with other individuals for scheduling and billing purposes.Persons may be present during the consultation other than the Medzino 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.
- 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.
- 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.
Additional State-Specific Consents: The following consents apply to users accessing the Medzino website for the purposes of participating in a telehealth consultation as required by the states listed below:
- Alaska: I understand my primary care provider may obtain a copy of my records of my telehealth encounter. (AK Stat. 08.64.364).
- Arizona: 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. (A.R.S.§ 36 - 3602).
- Connecticut: I understand that my primary care provider may obtain a copy of my records of my telehealth encounter. (C.G.S.A.§ 19a - 906).
- D.C.: I have been informed of alternate forms of communication between me and a physician for urgent matters. (17 DCMR § 4618.10).
- Kentucky: 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. (KY Admin.Regs.Tit. 907, 3: 170).
- Louisiana: I understand the role of other health care providers that may be present during the consultation other than the Medzino provider. (46 La.Admin.Code Pt XLV, § 7511).
- Maryland: 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. (Code of MD Reg. 10.41.06.04).
- Nebraska: 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. (NE Revised Stat. 71 - 8505; NE Admin.Code Tit. 471, Ch. 1).
- New Hampshire: I understand that the [YOUR SERVICE PROVIDER] provider may forward my medical records to my primary care or treating provider. (N.H.Rev.Stat.§ 329: 1 - d).
- New Jersey: 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. (NJ Rev.Stat.§ 45: 1 - 62).
- Pennsylvania: I understand that I may be asked to confirm my consent to behavioral health or tele - psych services.
- Rhode Island: If I use e - mail or text - based technology to communicate with my Medzino 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 Medzino provider terminating the e - mail relationship. (Rhode Island Medical Board Guidelines).
- South Carolina: I understand my medical records may be distributed in accordance with applicable law and regulation to other treating health care practitioners. (S.C.Code 1976 § 40 - 47 - 37).
- Tennessee: I understand that I may request an in -person assessment before receiving a telehealth assessment if I am a Medicaid recipient.
- Texas: I understand that my medical records may be sent to my primary care physician. (V.T.C.A., Occupations Code § 111.005).
- Vermont: 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 Medzino 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).
Note, these state-specific telehealth consent rules are frequently changing and being updated/revised.
I have read this document carefully, and understand the risks and benefits of the telehealth consultation and have had my questions regarding the procedure explained and I hereby give my informed consent to participate in a telehealth consultation under the terms described herein.
By checking the Box containing "INFORMED CONSENT FOR TELEHEALTH SERVICES"I hereby state that I have read, understood, and agree to the terms of this document.
- Office Contact Information:
Medzino Health Inc.
100 Pine Street
Suite 1250 #
San Francisco, CA 94111
- Registered Agent:
16192 Coastal Highway
Lewes, DE 19958