DudeMeds LLC

PATIENT TELEHEALTH CONSENT FORM

Effective Date: January 1, 2024

THIS NOTICE DESCRIBES YOUR CONSENT FOR TELEHEALTH. PLEASE REVIEW IT CAREFULLY.

Thank you for the opportunity to serve you! We look forward to becoming your partner in your health care and understanding your health care needs better. Please review the follow consents PRIOR to your visit with us. We will ask you for your consent via electronic measures if you had the opportunity to review the consents and allow you the opportunity to ask any questions.

General Consent for Care and Treatment. I have the right, as a patient, to be informed about my condition and the recommended surgical, medical or diagnostic procedure to be used so that I may make the decision whether or not to undergo any suggested treatment or procedure after knowing the risks and hazards involved. At this point in my care, no specific treatment plan has been recommended. This consent form is simply an effort to obtain your permission to perform the evaluation necessary to identify the appropriate treatment and/or procedure for any identified condition(s). This consent provides us with your permission to perform reasonable and necessary medical examinations, testing and treatment. By my electronic consent, I am indicating that (1) I intend that this consent is continuing in nature even after a specific diagnosis has been made and treatment recommended; and (2) I consent to treatment at this office or any other satellite office under common ownership. The consent will remain fully effective until it is revoked. I have the right at any time to discontinue services. I have the right to discuss the treatment plan with my physician about the purpose, potential risks and benefits of any test ordered for me. If I have any concerns regarding any test or treatment recommend by my health care provider, I am encouraged to ask questions. I voluntarily request a physician, and/or mid-level provider (nurse practitioner, physician assistant, or clinical nurse specialist), and other health care providers or the designees as deemed necessary, to perform reasonable and necessary medical examination, testing and treatment for the condition which has brought me to seek care at this practice. I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents.

Consent to Treatment Using Telemedicine. I consent to treatment involving the use of electronic communications to enable health care providers at different locations to share my individual patient medical information for diagnosis, therapy, follow-up, and/or education purposes. I consent to forwarding my information to a third party as needed to receive telemedicine services, and I understand that existing confidentiality protections apply. I acknowledge that while telemedicine can be used to provide improved access to medical care, as with any medical procedure, there are potential risks and no results can be guaranteed or assured. These risks include, but are not limited to: technical problems with the information transmission; equipment failures that could result in lost information or delays in treatment. I understand that I have a right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future treatment and without risking the loss or withdrawal of any program benefits to which I would otherwise be entitled.

Patient Consent and Acknowledgement form for Privacy Notice of Privacy Practice/clinics.

I acknowledge that I have received the Notice of Privacy Practice, which describes the ways in which the practice/clinic may use and disclose my healthcare information for its treatment, payment, healthcare operations and other described and permitted uses and disclosures, I understand that I may contact the Privacy Officer designated on the notice if I have a question or complaint. I understand that this information may be disclosed electronically by the Provider and/or the Provider’s business associates. To the extent permitted by law, I consent to the use and disclosure of my information for the purposes described in the Notice of Privacy Practice. Disclosures to Friends and/or Family Members. I may give permission for my Protected Health Information to be disclosed for purposes of communicating results, findings and care decisions to the family members and others. I will communicate the Name, Relationship, and contact information to the clinical team to ensure it is documented. Communications about My Healthcare. I agree the Provider or an agent of the Provider or an independent physician’s office may contact me for the purposes of scheduling necessary follow-up visits recommended by the treating physician. Note: This location uses an Electronic Health Record that will update all your demographics and consents to the information that you just provided. Please note this information will also be updated for your convenience to all our affiliated locations that share an electronic health record in which you have a relationship. Consent for Photographing or Other Recording for Security and/or Health Care Operations. I consent to photographs, digital or audio recordings, and/or images of me being recorded for patient care, security purposes and/or the practice’s/clinic’s health care operations purposes (e.g., quality improvement activities). I understand that the practice/clinic retains the ownership rights to the images and/or recordings. I will be allowed to request access to or copies of the images and/or recordings when technologically feasible unless otherwise prohibited by law. I understand that these images and/or recordings will be securely stored and protected. Images and/or recordings in which I am identified will not be released and/or used outside the facility without a specific written authorization from me or my legal representative unless otherwise permitted or required by law. Consent to Email, Cellular Telephone, or Text Usage for Appointment Reminders and Other Healthcare Communications. If at any time I provide an email address or cellphone number at which I may be contacted, I consent to receiving un secure instructions and other healthcare communications at the email or text address I have provided or you have obtained, at any text number forwarded, or transferred from that number. These instructions may include, but not be limited to: post-procedure instructions, follow-up instructions, educational information, and prescription information. Other healthcare communications may include, but are not limited to, communications to family or designated representatives regarding my treatment or condition, or reminder messages to me regarding appointments for medical care. Note: You may opt out of these communications at any time. The practice/clinic does not charge for this service, but standard text messaging rates or cellular telephone minutes may apply as provided in your wireless plan (contact your carrier for pricing plans and details). Release of Information. I hereby permit practice/clinic and the physicians or other health professionals involved in the inpatient or outpatient care to release healthcare information for purposes of treatment, payment, or healthcare operations. Healthcare information regarding a prior service(s) at other DudeMeds LLC affiliated providers may be made available to subsequent DudeMeds LLC affiliated providers to coordinate care.