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Telehealth Services
Last updated: September 3, 2024

Informed Consent Regarding Telehealth Services and Patient Financial Responsibility Consent

This Informed Consent Regarding Telehealth Services and Patient Financial Responsibility does not supersede or modify any Terms of Service, Notice of Privacy Practices, or Privacy Policy of 9amHealth Inc, the Providers, or the Medical Groups.

9amHealth Inc.’s clinical care is provided by 9amHealth Medical Group of California, PC, a professional corporation, and its affiliates (“9amHealth Medical Group”) (9amHealth Medical Group collectively referred to as “Medical Groups”, “We”, “Our”, or “Us”). 9amHealth Inc. connects you to one of a Our doctors or other appropriate health care provider to determine a diagnosis and develop a personalized treatment plan during your consultation(s). 9amHealth Inc. does not provide any medical services, does not practice medicine, and does not influence the practice of medicine or the services provided by any licensed professional provided by Our providers, each of whom are responsible for his or her services as well as compliance with the requirements applicable to his or her profession and licensure obligations.

The purpose of this consent is to inform the patient (“patient,” “you,” or “your”) about telehealth and to obtain your informed consent to the use of telehealth in the delivery of healthcare provided by Our providers and Medical Groups using the digital platforms owned and operated by 9amHealth Inc. and its subsidiaries.

By agreeing to receive telehealth services from Our providers and Medical Groups, I acknowledge the following:

Telehealth involves the use of electronic communication technologies to enable the transfer of medical/health and other information between a healthcare provider and members who are not in the same location. Telehealth technologies may involve asynchronous communications (such as questionnaires and messaging) as well as synchronous communications (such as real-time audio or live video interactions). Telehealth technologies may also involve the electronic transmission of medical records, images, personal health information, medical device data, videos, audio or other data between you and a healthcare provider. Electronic transmissions may also include appointment scheduling, prescription refill reminders, communications with medical professionals including treatment recommendations and exchange or clinical information, delivery of a consultation that includes a diagnosis, treatment and prescriptions.

Our telehealth services also include remote monitoring when prescribed or referred by your medical provider. These services include the remote monitoring of your weight, blood pressure or blood sugars to promote increased engagement with our medical providers. These services are billed to your insurance if and when applicable.

Benefits of telehealth include but are not limited to improved access to care and follow-up care. Evaluations, diagnosis and treatment can be completed from the comfort of your location. Weight loss and cardiometabolic care has substantial health benefits including improvement in blood markers such as blood sugar, cholesterol and blood pressure.

The location and time flexibilities of telehealth may make it easier for you to access medical care. If you need follow up care, you can contact a Provider through the Platform, or by calling, (202) 932-9958. OUR PROVIDERS DO NOT ADDRESS MEDICAL EMERGENCIES. IF YOU BELIEVE YOU ARE EXPERIENCING A MEDICAL EMERGENCY, YOU SHOULD DIAL 9-1-1 AND/OR GO TO THE NEAREST EMERGENCY ROOM.  PLEASE DO NOT ATTEMPT TO CONTACT 9amHealth, Inc, Medical GROUP, OR YOUR PROVIDER.  AFTER RECEIVING EMERGENCY HEALTHCARE TREATMENT, YOU SHOULD VISIT YOUR LOCAL PRIMARY CARE PROVIDER.

While the benefits of telehealth allow for ease and convenience, there could be risks to the use of telehealth. I understand that I won’t be in the same room as my provider so it may feel different than an office visit. I understand that my provider may make a mistake because they cannot examine you as closely as at an office visit. I understand that my provider may decide I still need an office visit and seek in person care. I understand that I may encounter technical problems, which interrupt or stop your visit before it is completed. I understand that other potential risks associated with the use of telehealth include, but may not be limited to, the following:

  • In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision making by the provider.
  • Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment.
  • In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information.
  • In rare instances, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors.

There may be other risks that are currently not known.

By clicking “I agree”, I am providing my informed consent to receive medical services, including telehealth from Our physicians and other applicable health care providers for myself. This medical care may include services related to my health (or the identified person) and may include, but not be limited to, preventative care, diagnostic testing,therapeutic treatments, rehabilitative care, health maintenance, counseling, assessment, or review of physical or mental status/function of the body.

9amHealth Inc. is a separate entity that is independent from 9amHealth Medical Group. 9amHealth Inc. does not provide medical care and has contracted with Our providers to provide medical care.

By accepting this Informed Consent for Telehealth, you acknowledge you understand and consent to the following:

  1. I agree to 9amHealth Medical Groups to bill my insurance for applicable services rendered while actively receiving care and for any care provided to be while enrolled in services.
  2. I acknowledge that it is up to Our providers to determine whether or not my needs are appropriate or optimal for a telehealth encounter,and that may require me to seek in-person medical care from another service.
  3. I understand that I will not be prescribed any controlled substances, as determined by an applicable federal or state agency, and there is no guarantee that I will receive a prescription for any medication.
  4. I understand that a variety of alternative methods of medical care may be available to me, and that I may choose one or more of these at any time.
  5. I understand that my personal information that contains protected health information will not be shared with any third party without your consent, except as authorized by law for the purposes of medical care, payment, and administrative purposes, or as otherwise set forth in Our Notice of Privacy Practices.
  6. I agree and authorize my health care provider to share information regarding the telemedicine exam with other individuals and providers for treatment, education, payment and other healthcare operation purposes (such as scheduling and billing). These individuals and providers may be located in other areas, including in other states.
  7. It is my duty to inform my provider of interactions regarding my care that I may have with other healthcare providers to ensure my provider has a full clinical picture when making treatment decisions. I understand that some parts of the telehealth services involving physical tests that are ordered by the provider may be conducted by other providers or at a testing facility.
  8. 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 impacting my right to future care or treatment; however, I understand that it may impact my ability to continue to receive services from9amHealth Inc.
  9. I understand that if I am experiencing a medical emergency, I must dial 911 immediately and that my provider may not be able to connect me directly to any local emergency services.
  10. I understand that I have the right to inspect all information obtained and records in the course of the telehealth interaction, including my medical record.
  11. Video images and audio recordings of me may be captured and stored electronically. I understand that these recordings may be later viewed and used for purposes of evaluation and training, which may include Our providers and non-licensed personnel. I understand and consent to the use of these images and audio recordings for the telehealth consultation and,potentially, evaluation, education and training.
  12. There is a risk of technical failures during the telehealth encounter beyond the control of 9amHealth Inc. I agree to hold harmless 9amHealth Medical Group, and 9amHealth, Inc. for delays in evaluation or for information lost due to such technical failures.
  13. In the event of any problem with the technology of 9amHealth Inc.’s platform or related services, I agree that my sole remedy is to cease using the technology or terminate access to the service.
  14. I understand that the telehealth services are not accessible outside of the United States. I understand that if I access these services from a location outside of the United States, that I do so at my own risk and initiative, and that I am ultimately responsible for compliance with any foreign applicable laws or regulations associated with my use.
  15. In some cases, my Provider may be a registered dietician, pharmacist, nurse practitioner, and not a physician.
  16. I agree and authorize my provider to release information regarding the telemedicine exam to 9amHealth, Inc. and its affiliates.

I have read this Consent to Telehealth and understand the risks and benefits of the use of telehealth in my medical care. By checking the box to agree to this Informed Consent Regarding the Use of Telehealth, I am acknowledging that I have read, accepted and agreed to this consent.

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: 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.

Florida: I have received a copy of the Florida Weight Loss Consumer Bill of Rights, as set forth below:

Warning: Rapid weight loss may cause serious health problems.  Rapid weight loss is weight loss of more than 1 ½ pounds to 2 pounds per week or weight loss of more than 1 percent of body weight per week after the second week of participation in a weight-loss program. Consult your personal physician before starting any weight-loss program.Only permanent lifestyle changes, such as making healthful food choices and increasing physical activity, promote long-term weight loss. Qualifications of your weight loss provider are available upon request.

You have a right to: Ask question about the potential health risks of this program and its nutritional content, psychological support, and educational components. Receive an itemized statement of the actual or estimated price of the weight-loss program, including extra products, services, supplements, examinations, and laboratory tests. Know the actual or estimated duration of the program. Know the name, address, and qualifications of the person who has reviewed and approved the weight loss program according to section 468.505(1)(j), Florida Statutes.

I have been informed that if I want to check the licensing details for a provider I can visit the Florida Department of Health’s website, here.

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.

Idaho:  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.

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.

Oklahoma: 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 Oklahoma Board of Osteopathic Examiners’ 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, and surgical assistants may be reported for investigation at the following address: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018, Assistance in filing a complaint is available by calling the following telephone number: 1-800-201-9353, For more information, please visit our website at www.tmb.state.tx.us. 

AVISO SOBRE LAS QUEJAS- Las quejas sobre médicos, asi como sobre otros profesionales acreditados e inscritos del Consejo Médico de Tejas, incluyendo asistentes de médicos, practicantes de acupuntura y asistentes de cirugia, se pueden presentar en la siguiente dirección para ser investigadas: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018, Si necesita ayuda para presentar una queja, llame al: 1-800-201-9353, Para obtener más información, visite nuestro sitio web en www.tmb.state.tx.us   

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.

 

Patient Financial Responsibility

By checking the box associated with "TELEHEALTH AND PATIENT RESPONSIBILITY CONSENT FORM," you acknowledge that you understand and agree with the following:

As part of my current treatment plan with my 9amHealth Medical Group provider, my provider will provide diagnosis, treatment recommendations, and/or prescriptions through the use of certain electronic communications, software, and devices.

I understand, where applicable and if not enrolled in our ‘Cash-Pay’ subscription, that these telehealth services are distinct services for which 9amHealth Medical Group will bill my insurance providers, in some cases including Medicare or Medicaid.

I acknowledge that my insurance provider may not cover the entire billed amount. I understand that I am responsible for paying 9amHealth for any amounts not covered by my insurance, including non-covered charges, copayments, coinsurance, and deductibles. I understand that 9amHealth Medical Group will charge my credit card for any amounts not covered by my insurance following a visit with my 9amHealth Medical Group provider, and I may not receive a separate bill from 9amHealth. In most cases, your out of pocket expenses will be emailed to you as a statement.

By checking the box for this "TELEHEALTH AND PATIENT RESPONSIBILITY CONSENT FORM," I confirm that I have read, understood, and agree to the terms outlined in this document.