I authorize the medical staff, other personnel, and such associates, assistants, and other health care providers of Careway Health Medical PA, its affiliates, associated professional medical corporations (including Careway Health West Medical PC), and their respective contracted health care providers ("Careway Health") to provide care, including telehealth or other services, as Careway Health Medical PA's staff finds necessary or advisable in my care. If I am making this authorization on behalf of another person, I acknowledge that I am consenting on behalf of the patient and I am legally authorized to do so.
I authorize the medical staff, other personnel, and such associates, assistants, and other health care providers of Careway Health to request, receive, and use my medical records as Careway Health's staff finds necessary or advisable in my care. If I am making this authorization on behalf of another person, I acknowledge that I am consenting on behalf of the patient and I am authorized to do so.
I understand that telehealth/telemedicine requires the transmission of personal health information via internet and/or other electronic communication methods, for use in diagnosis, therapy, follow-up, and/or education. The personal health information transmitted may include but not be limited to:
I understand that healthcare providers involved in telehealth/telemedicine may include primary care practitioners, specialists and/or subspecialists, nurse practitioners, registered nurses, medical assistants, and other healthcare providers who are a part of my clinical care team. In addition, my family members, caregivers, or other legal representatives or guardians may participate in the telehealth/telemedicine service, and I agree to share my personal health information with them as needed.
I understand that individuals other than my clinical care team or consulting providers may also be present and have access to my information while in the process of operating, maintaining, or repairing the computer, video, or audio equipment used. These persons will adhere to applicable privacy and security policies.
I understand that the laws that protect privacy and the confidentiality of personal health information also apply to telehealth/telemedicine, and that no information obtained in the use of telehealth/telemedicine that identifies me will be disclosed to anyone without my consent except for the purposes of treatment, education, billing, and/or healthcare operations, unless an exception to confidentiality applies (i.e., mandatory reporting of child, elder, or vulnerable adult abuse, posing a danger to self or others, or my raising mental/emotional health as an issue in a legal proceeding).
I understand that, as with any internet-based communication, telehealth/telemedicine involves a risk of security breach. Electronic systems used 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.
I understand that Careway Health Medical PA and its affiliates may send appointment reminders, care-coordination messages, and other health-related information to me by ordinary (unencrypted) SMS text. I acknowledge that such messages could be read by anyone with access to my mobile device or phone account. I consent to receive these SMS messages and understand that I may withdraw this consent at any time.
I understand that telehealth/telemedicine sessions may not always be possible. Disruptions of signals or problems with the internet's infrastructure may cause broadcast and reception problems (e.g., poor picture or sound quality, dropped connections, and/or audio interference) that prevent effective interaction between consulting clinician(s), participant, patient, or care team.
I hereby release and hold harmless Careway Health Medical PA, its affiliates, and all members of my care team from any loss of data or information that may be due to technical failures associated with the telehealth/telemedicine service.
I understand that the health information that I provide at the time of my telehealth/telemedicine service may be the only source of health information used by the medical professionals during the course of my evaluation and treatment at the time of my telehealth/telemedicine visit, and that such professionals may not have access to my full medical record or information held by Careway Health Medical PA and its affiliates.
I understand that I will be given information about test(s), treatments(s) and procedures(s), as applicable, including the benefits, risks, possible problems or complications, and alternate choices for my medical care through the telehealth/telemedicine visit.
I understand that a variety of alternative methods of health care may be available to me, and that I may choose one or more of these at any time. My provider has explained the alternatives to my satisfaction.
I understand that I have the right to withhold or withdraw consent to the use of telehealth/telemedicine services at any time and revert back to traditional in-person clinical services including finding an alternate provider if needed. I understand that if I withdraw my consent for telehealth/telemedicine, it will not affect any future services or care benefits to which I am entitled.
I understand that if I am having suicidal or homicidal thoughts, actively experiencing psychotic symptoms, or experiencing a mental health crisis that cannot be resolved remotely, it may be determined that telehealth/telemedicine services are not appropriate and that a higher level of care is required.
I understand that I have the right to inspect all information obtained and recorded in the course of a telehealth/telemedicine interaction, and that I may receive copies of this information for a reasonable fee.
I understand that I may anticipate benefits from the use of telehealth/telemedicine in my care, but that no results can be guaranteed or assured.
I hereby consent to the use of telehealth/telemedicine in the provision of care, under the terms and conditions set forth above. I certify that I am the patient and am 18 years of age or older, or that I am the legal representative of the patient, or that I am otherwise legally authorized to provide consent. I have carefully read and understand the above statements. I have had all of my questions answered. I understand that this informed consent will become a part of my medical record.
Careway Health Medical PA and its affiliates are committed to providing a safe, respectful, and supportive environment for all patients, staff, and community partners. To ensure we can effectively navigate your care, you agree to adhere to the following behavioral expectations:
Respectful Communication: I understand that Careway Health Medical PA and its affiliates enforce a strict zero-tolerance policy for verbal abuse, harassment, hate speech, discriminatory remarks, or severe profanity directed at staff, community partners, or other patients.
Safety and Non-Violence: I understand that any expressed or implied threats of physical harm, violence, or retaliation against staff, partners, or property are strictly prohibited.
Honesty and Integrity: I agree to provide accurate information regarding my identity, needs, and resources. I understand that deceptive practices, falsifying identity, or fraud will not be tolerated.
Telehealth Boundaries: I agree to maintain appropriate professional boundaries during all telehealth sessions. This includes dressing appropriately, avoiding inappropriate exposure, and strictly refraining from recording any audio or video of telehealth sessions without the explicit, documented consent of my care team at Careway Health Medical PA and its affiliates.
Consequences of Violation: I understand that failing to adhere to this Code of Conduct constitutes a breakdown of the provider-patient relationship. I acknowledge that a violation of these terms may result in the immediate termination of my services with Careway Health Medical PA and its affiliates without prior notice, and the immediate deactivation of my access to the secure portal.
Emergency Escalation: I understand that Careway Health Medical PA and its affiliates reserve the right to contact local emergency dispatch or Adult/Child Protective Services if my behavior poses an active safety threat to myself, the staff, or the public.
By checking the box associated with "Consent Agreement", you acknowledge that you understand and agree with the following:
Careway Health’s services may include longitudinal care coordination, behavioral health support, condition-specific navigation, and related non-procedural clinical services designed to support patients between visits and alongside their existing medical providers. Careway Health collaborates with, rather than replaces, my existing doctors.
I acknowledge that:
You understand that you have the right to withhold or withdraw your consent to the use of telehealth in the course of your care at any time, without affecting your right to future care or treatment, or, affecting your ability to access covered services from Medi-Cal in the future. You understand that you have the right to access Medi-Cal covered services through an in-person, face-to-face visit or through telehealth. You understand that Medi-Cal provides coverage for transportation services to in-person services when other resources have been reasonably exhausted. Cal. Welf. & Inst. Code Ann. § 14132.725(d)).
You understand that the provider may forward your medical records to your primary care or treating provider. Ohio Admin. Code 4731-37-01(C)(4).You have been advised of our fees. This information is required by the counselor, social worker, and marriage and family therapist board, which regulates the practices of professional counseling, social work, and marriage and family therapy in this state. Ohio Rev. Code § 4757.13.
I agree a digital copy of this agreement shall be valid as the original.
