IF YOU BELIEVE YOU ARE EXPERIENCING A MEDICAL EMERGENCY, DIAL 9-1-1 AND/OR GO TO THE NEAREST EMERGENCY ROOM.
IF YOU ARE CONTEMPLATING SUICIDE, DIAL 9-1-1 OR CONTACT THE NATIONAL SUICIDE PREVENTION LINE AT 9-8-8.
We are pleased you have chosen Caire Health, which operates under the brand name Upliv for your telehealth needs. This Telehealth Consent is intended to inform you of what you can expect from your telehealth provider in terms of his or her credentials and in connection with your treatment via telehealth. After you have carefully read this consent form and had an opportunity to have your questions answered, certain state laws require that you must sign and date it before beginning services.
Important Information about Caire Health
Caire Women’s Health, Inc. does business as Caire Health and operates websites and other related telehealth technologies to facilitate telehealth services (the “Platform”). Caire Women’s Health, Inc. also operates as the management support organization to several affiliated professional entities, including, Caire Medical (CA) PC, Caire Medical (CT) PLLC, Caire Medical (NJ) LLC, and Medical Services of New Hyde Park P.C. (hereinafter collectively referred to as the “Caire Health Practices”). The Caire Health Practices contract with providers to deliver telehealth, telebehavioral health, and wellness-focused services to patients (each a “Provider”). Caire Women’s Health, Inc. and the Caire Health Practices are collectively referred to herein as “Caire Health.” This Telehealth Consent is entered into between the applicable Caire Health Practice and the patient.
Important Information about your Provider’s Credentials and Our Services
Depending on the telehealth services you receive, your Provider may be a licensed physician, nurse practitioner, physician assistant, psychologist, professional counselor, licensed clinical social workers, marriage and family therapists, or equivalent license professional, or a health coach.
Your Provider’s credentials will be made available to you before scheduling a telehealth appointment. If you have any questions about these credentials, please direct them to your Provider.
If we operate in a state that requires additional disclosures applicable to your Provider, you can find those disclosures under the State-Specific Disclosures section toward the end of this Telehealth Consent.
At times, your Provider may seek supervision or consultation with other Caire Health providers regarding your treatment to enhance the services being provided to you. All team members are ethically and legally bound to maintain the privacy and confidentiality of your health information. Exceptions to confidentiality exist in certain situations, including: threat of serious harm to self or others; reasonable suspicion of abuse or neglect of a child, or abuse, neglect, or exploitation of an incapacitated or dependent adult; court order and/or subpoena; with your permission (i.e. voluntary release signed by you); during supervisory consultations; for purposes of treatment, payment, or healthcare operations as permitted by law, including to any person or entity liable for payment of telehealth services on your behalf in order to verify coverage or payment questions, or for any other purpose related to benefit payment; and as otherwise required by law.
A record of this Telehealth Consent is maintained in the files and records of the applicable Caire Health Practice delivering your services, and your on-going participation in services provided by Caire Health using telehealth technologies serves as an on-going acknowledgement of your acceptance of this Telehealth Consent.
What is Telehealth?
Telehealth involves the delivery of health and wellness services using electronic communications, information technology, or other means between a licensed, certified, or registered health care professional at one location and a patient in another location. Telehealth may be used for diagnosis, treatment, follow-up, and/or patient education. Telehealth services may involve various modalities, including asynchronous interactions, real-time video and audio encounters, and interactive audio with store and forward. This “Telehealth Consent” informs the patient (“patient,” “you,” or “your”) concerning the treatment methods, risks, and limitations of utilizing telehealth to meet your health and wellness needs.
What are the Possible Benefits of Telehealth?
Generally speaking, telehealth can make it easier and more efficient for you to access health and wellness services at convenient times without the necessity of an in-office appointment. Telehealth can also make it easier for you to access the expertise of specialists you might not otherwise be able to access.
What are the Possible Risks of Telehealth?
Information transmitted to your Provider may not be sufficient to allow for appropriate health or wellness services to meet your particular need. Some clinical needs may not be appropriate for a telehealth visit and your Provider will make that determination. Limitations inherent in the use of the Platform may affect your Provider’s ability to provide health care services to you, and in some cases, an in-person physical examination, test, or other procedure not available on the Platform might provide information important or relevant with respect to your health care services. In some cases, the quality of the information you submit to your Provider (including any photograph(s) and other data you upload) may affect the quality of the health care services that your Provider is able to deliver through the Platform.
The technology necessary to interact with your Provider may fail and delay your services. If a technological failure prevents you from communicating with your Provider, you can reach Caire Health at [+1 (516)-882-7132, Monday-Friday, 9:00 a.m. to 5:00 p.m. ET].
Although the electronic communication systems that we use will incorporate security protocols designed to protect your privacy and ensure the integrity of your personal health or medical information against intentional or unintentional corruption, security protocols could fail, causing a breach of privacy of your personal health or medical information.
In rare events, a lack of access to complete medical records and/or the quality of transmitted data could result in adverse drug interactions, allergic reactions, and/or other clinical judgment errors. You may stop or decline any ongoing health care services provided by a Provider using the Platform at any time; however, you acknowledge that Caire Health has no obligation for your ongoing care or selection of separate health care services in such circumstances.
By accepting this Telehealth Consent, I acknowledge, understand and agree to the following:
I have reviewed this Telehealth Consent carefully, and understand there are risks, limitations, and benefits of utilizing telehealth.
I understand and acknowledge that I must be located in a state in which my Provider is licensed and qualified to provide the telehealth services. I have read and understand the disclosures in the State-Specific Disclosures section of this Telehealth Consent (if any) next to the state in which I am located at the time of the telehealth encounter.
I understand that the electronic nature of the telehealth services means that there is a greater risk to the privacy of my health information.
I understand that depending on the services I receive, my Provider may be a nurse practitioner or physician assistant, psychologist, counselor, therapist, or equivalent professional, as applicable, and not a physician.
I understand that persons other than my Provider may be present during the telehealth visit in order to operate the Platform and/or for language translation assistance, if requested. If another person is present during the telehealth visit, I will be informed of the individual’s presence and his/her role and will have the right to (a) omit specific details of your medical history/examination that are personally sensitive to you; (b) ask non-medical personnel to leave the telehealth consultation; and/or (c) terminate the consultation at any time.
I understand that information I provide as part of any telehealth offering is viewed by my Provider as accurate, true, and complete. I understand that I can log into my patient account on the Platform by logging into the Platform at any time to (i) access or amend any information I may provide, or (ii) review my health information.
I understand that there is no guarantee that I will be given a prescription and that the decision of whether a prescription is appropriate will be made in the professional judgment of my Provider. I understand that while the use of telehealth may provide benefits to me, no such benefits or specific results can be guaranteed and my condition may not improve.
I understand that there is a risk of technical failures during the telehealth encounter beyond the control of my Caire Health Practice and Provider(s). I AGREE TO HOLD HARMLESS CAIRE WOMEN’S HEALTH, INC., THE CAIRE HEALTH PRACTICES, AND ITS AND THEIR EMPLOYEES, CONTRACTORS, AGENTS, DIRECTORS, MEMBERS, MANAGERS, SHAREHOLDERS, OFFICERS, REPRESENTATIVES, ASSIGNS, PARENTS, PREDECESSORS, AND SUCCESSORS FOR DELAYS IN EVALUATION OR FOR INFORMATION LOST DUE TO SUCH TECHNICAL FAILURES.
I understand that the Platform makes available a specific set of services and I may need to seek other resources for my other health needs. I understand that alternatives to telehealth consultation are available to me, such as in-person services. I understand that the telehealth-based medical services I receive from my Caire Health Practice and Provider(s) do not replace the relationship between me and my primary care doctor. I understand that there is no guarantee that I will be treated by a Provider and my Provider may deny or stop providing care at any time if, in the professional judgment of my Provider, the provision of the services, including when provided via telehealth, is not medically or ethically appropriate. I understand that the Providers, and not Caire Women’s Health, Inc., are responsible for the quality and appropriateness of the care they render to me and make all decisions regarding clinical care in their independent discretion without the influence of Caire Women’s Health, Inc.
I understand that by using the Platform, I am not always speaking or messaging with my Provider in real-time, and there may be a delay before my messages or information is reviewed. I understand that I must check the Platform for messages because this is the way that my Provider will communicate important information to me. I understand that if I do not check the Platform regularly, then my services may be delayed.
I have been given an opportunity to select a provider from my Caire Health Practice prior to my consult, including a review of the provider’s credentials. I understand that I have the opportunity to discuss the use of telehealth, including the health care services, with my Provider(s), including the benefits and risks of such use and the alternatives to the use of telehealth. I have the right to withdraw my consent to the use of telehealth in the course of my care, without prejudice to any future care or treatment and without risking the loss or withdrawal of any health benefits to which I am entitled, but I understand that the Providers who provide health care services via the Platform do not offer in-person treatment. I understand that if I am experiencing a medical emergency, that I will be directed to dial 9-1-1 immediately and that my Caire Health Practice and Provider(s) are not able to connect me directly to any local emergency services.
I understand that federal and state law requires health care providers to protect the privacy and the security of health information. I understand that Caire Health will take steps to make sure that my health information is not seen by anyone who should not see it. I understand that I will have access to my medical record pertaining to the health care services of Providers utilizing the Platform in accordance with applicable laws and regulations. and that my primary care provider, or other treating provider, may obtain copies of my health and wellness information.
I understand that while the Platform may make available access to pharmacy or diagnostic lab services that are coordinated with the health care services, I am able to request any pharmacy or lab of my preference.
I give consent to Caire Health to use, disclose, and/or release my medical information, including my “sensitive health information”, for purposes of treatment, payment, or health care operations, such as with my primary care provider or other health care providers, including out of state health care providers, in connection with my treatment, with contractors and/or affiliates of Caire Health for scheduling and billing purposes, with any person or entity liable for payment on my behalf in order to verify coverage or payment questions, or for any other purpose related to benefit, or with my employer’s designee if the services delivered are related to a claim under worker’s compensation. “Sensitive health information” includes information about: (a) maternity records (including medical records of new mothers and newborns) or infertility or fertility assistance, IVF, or artificial insemination; (b) psychiatric treatment, mental health or illness, or developmental or intellectual disability; (c) HIV/AIDS testing or treatment or status, or other communicable, sexually transmitted, or blood borne diseases; (d) substance use disorder treatment; (e) genetic information or test results; (f) substance use disorder treatment; (g) child or domestic abuse and neglect or abuse of an adult with a disability; (h) sexual assault; and (i) any other type of information that is given special privacy protection under state or federal laws.
I give consent to my Provider to record a telehealth session. I will not record the session without my Provider’s consent.
I give consent to receiving telehealth services from my Caire Health Practice and Provider via telehealth technologies.
We do not currently operate in a state that requires additional disclosures. We will add any required disclosures as we expand our operations. Such additional disclosures will apply to patients accessing the Platform to receive telehealth services as required by state law.