Consent to Treatment for Telehealth and Remote Patient Monitoring-Based Services

BY CLICKING “NEXT,” CHECKING A RELATED BOX TO SIGNIFY YOUR ACCEPTANCE, USING ANY OTHER ACCEPTANCE PROTOCOL PRESENTED THROUGH THE SERVICE OR OTHERWISE AFFIRMATIVELY ACCEPTING THIS CONSENT, YOU ACKNOWLEDGE THAT YOU HAVE READ, ACCEPTED, AND AGREED TO BE BOUND BY THIS CONSENT. IF YOU DO NOT AGREE TO THIS CONSENT, DO NOT CREATE AN ACCOUNT OR USE THE SERVICE. YOU HEREBY GRANT AGENCY AUTHORITY TO ANY PARTY WHO CLICKS ON THE “NEXT” BUTTON OR OTHERWISE INDICATES ACCEPTANCE OF THIS CONSENT ON YOUR BEHALF.

IF YOU ARE EXPERIENCING A LIFE-THREATENING SITUATION SUCH AS CONTEMPLATING SUICIDE, CALL 911.

I. Introduction

Telehealth (or Telemedicine, often these terms are used interchangeably) involves the real-time evaluation, diagnosis, consultation, and treatment of a health condition using advanced telecommunication technology, which often includes the use of interactive audio, video, or other electronic media. The use of telehealth technology allows the Bariendo provider to see and communicate with you, the patient, in real-time from a remote or distant location. Remote patient monitoring is a form of asynchronous telehealth where technology is used to collect health data about you remotely and that health data is transmitted to your healthcare provider for evaluation. Both telehealth and remote patient monitoring shall be referred to generally as telehealth herein.

II. Consent for Telehealth-Based Treatment

I voluntarily request and consent to Bariendo physician(s) and/or non-physician practitioners (“Bariendo Providers”), and any associates, technical assistants, and/or other professionals as such Bariendo Providers may deem necessary (“Bariendo Telehealth Providers”), participating in my medical care by utilizing telehealth services.

I understand that Bariendo Telehealth Providers: (a) may conduct their practice in a different location than the one where I may be physically present for such medical care; (b) may not have the opportunity to perform an in-person physical examination of me at the time my telehealth services are provided; and (c) may rely on information provided by me through remote patient monitoring or before, during, and during or after our telehealth services encounter.

I understand that the Bariendo Telehealth Providers’ advice, recommendations, and/or decisions may be based on factors not within their control, such as incomplete or inaccurate data provided by me, remote patient monitoring technologies, or distortions of diagnostic images or specimens that may result from electronic transmission issues. I understand that I must provide information about my medical history, condition(s), and current or previous medical care that is complete and accurate to the best of my knowledge and ability. I also understand that, in the event the telehealth services are interrupted due to a technology problem or an equipment failure, alternative means of communication may be implemented and/or an in-person medical evaluation with my health care provider may be necessary.

I understand that the level of care provided by Bariendo Telehealth Providers is to be the same level of care that is available to me through an in-person medical visit; provided, however, if Bariendo Telehealth Providers determine that the provision of telehealth services will not adequately address my medical needs, the treating Bariendo Telehealth Provider(s) may require me to schedule and attend an in-person medical examination with my health care provider.

I understand that if, after a telehealth services session, I experience any urgent medical symptoms or conditions, I will alert my treating physician or, in the case of an emergency, I will dial 911 or go directly to the nearest emergency room.

In the event of an adverse reaction to treatment or in the event of an inability to communicate as a result of a technological or equipment failure, contact us at [email protected] or (888) 211-8385.

I understand that after any real-time telehealth services session, the Bariendo Telehealth Provider(s) must give me guidance regarding any appropriate follow-up care and, if required by law, must share information regarding my telehealth services session with my primary care physician. I hereby authorize Bariendo and my Bariendo Telehealth Provider(s) to share such information, which may include but is not limited to copies of my medical records, a report containing an explanation of the telehealth services provided to me, and/or any evaluation, analysis, or diagnosis of my medical condition made by the Bariendo Telehealth Provider(s).

III. Consent for Group Telehealth-Based Treatment

I understand that Bariendo may make available real-time group telehealth sessions in preparation for my procedure. If I prefer not to participate in a group telehealth session, I may notify Bariendo and request a private telehealth session. If I participate in a group telehealth session, I agree:

1. Bariendo cannot guarantee my privacy when in a group telehealth session, including the privacy of any information I choose to share during the group telehealth session;

2. During the group telehealth session, I may be asked questions about my own personal health that is related to preparation for the procedure, which may include questions about medication and blood work;

3. If I prefer not to answer these questions in a group setting, I can provide this information separately or request a private telehealth session;

4. To be in a private area with no others in the room with me and to minimize disruptions as much as possible. If this is not possible, I will consider wearing headphones;

5. To not disclose any information about group members outside of the session. This includes not revealing the names of other members of the group or what is said and done in the group; and

6. To not make any recordings (video, audio or pictures) of the group meeting.

IV. Remote Patient Monitoring

I understand Bariendo may use remote patient monitoring (“RPM”) as part of my care, which is the use of technology to collect health data about me that is transmitted to my healthcare provider for evaluation. For example, Bariendo may provide me with a smart scale that collects my weight data and transmits it to my healthcare provider. I understand that I am the only person that should be using the RPM device(s) provided to me, and I will use the RPM device(s) solely for the purposes of transmitting information to my Bariendo provider. I understand that RPM data will be reviewed by Bariendo periodically and is not monitored 24/7, and I will call 911 for any medical emergencies. Use of the RPM device(s) is not a substitute for keeping my healthcare provider fully informed of my medical condition and any new healthcare developments.

V. Privacy Policy

I acknowledge that I have been given a copy of Bariendo’s privacy policy. I understand that I am encouraged to review this policy prior to any consultation, evaluation, and/or treatment by Bariendo Telehealth Provider(s).

VI. State Boards

I acknowledge that I may file a complaint with the Massachusetts Medical Board or any other state Medical Board relating to the provision of any telehealth services. You can file a complaint against a Massachusetts physician by submitting a complaint electronically via the online complaint website at mass.gov/massmedboard/complaints. A paper complaint can be submitted as well. The form can be downloaded from the board’s website: www.mass.gov/massmedboard. You may also call the board’s consumer protection unit at (781) 876-8200 and request that a complaint form be mailed to you.

I have been given an opportunity to ask questions about the telehealth services to be provided to me, including any relevant risks and hazards involved with the provision of such services.

Based on the above, I believe that I have sufficient information to give this informed consent for the provision of telehealth services by Bariendo Telehealth Providers.

Your Acknowledgments

By clicking “Next”, checking a related box to signify your acceptance, using any other acceptance protocol presented through the Service, or otherwise explicitly accepting this consent, you hereby agree to and provide your consent for the following terms:

1. I hereby authorize Bariendo to use the telehealth practice platform for telecommunication for evaluating, testing, and diagnosing my medical condition.

2. I acknowledge the possibility of encountering technical difficulties either before or during telehealth sessions, which may result in the inability to commence or conclude my appointment as planned.

3. I accept that the providers can conduct interactive sessions with video calls; however, I am informed that the sessions can be conducted via regular voice communication if the technical requirements such as internet speed cannot be met.

4. I understand that I will be responsible for any fee associated with the telehealth appointment.

5. I agree that my medical records on telehealth can be kept for further evaluation, analysis, and documentation, and in all of these, my information will be kept private.