Last updated: October 3, 2022
Consent to Telehealth
Telehealth involves the use of electronic communications to enable healthcare providers at different locations to share individual patient medical information for the purpose of improving patient care.
Telehealth services offered by Nancy P Rahnama MD, APC DBA Dr Nancy and Sustain (our “providers”) will include a patient consultation, diagnosis, and recommendation (the “Service”). The Services provided may also include appointment scheduling, chart review, remote prescribing, refill reminders, health information sharing, and non-clinical services, such as patient education. The information you provide may be used for diagnosis, therapy, follow-up and/or patient education, and may include any combination of the following: (1) a review of health records, images, and/or test results via asynchronous communications; (2) live two-way interactive audio and video; (3) interactive audio with store and forward; or (4) output data from medical devices and sound and video files.
The electronic communication systems we use 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.
- Improved access to care by enabling you to remain in your home while the Medical Group’s provider consults and obtains test results at distant/other sites.
- More efficient care evaluation and management.
- Obtaining expertise of a specialist as appropriate.
- Delays in evaluation and treatment could occur due to deficiencies or failures of the equipment and technologies.
- In rare events, our provider may determine that the transmitted information is of inadequate quality, thus necessitating a rescheduled telehealth consult or a meeting with your local primary care doctor.
- In very rare events, security protocols could fail, causing a breach of privacy of personal medical information.
- In rare events, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors.
- If you need to receive follow-up care, assistance in the event of an adverse reaction to the treatment, please contact your provider by sending a message to your care team. In the event of an inability to communicate as a result of a technological or equipment failure, please contact your provider at (310) 299-7373, or by email at email@example.com.
- Our providers do not address urgent cases or medical emergencies. If you believe you are experiencing a medical emergency, you should dial 9-1-1 and/or go to the nearest urgent care center or emergency room. After receiving urgent healthcare treatment, you should visit your primary care doctor.
- Our providers will respond to messages within 24 business hours (business hours are 9:00am EST to 5:00 PST, Monday through Friday, excluding holidays).
- Our providers are an addition to, and not a replacement for, your primary care physician. Responsibility for your overall medical care should remain with your local primary care doctor, if you have one, and we are unable to treat you if you do not.
- Sustain does not offer in-person consultation.
By checking the box associated with "Informed Consent", you acknowledge that you understand and agree with the following:
- I give my informed consent to the use of telehealth by the Providers
- I have read the above information and have had an opportunity to ask questions
- I understand the benefits and risks of receiving telehealth services
- I understand that the Provider may determine in his or her sole discretion that my condition is not suitable for treatment using telehealth, and that I may need to seek medical care and treatment in-person or from an alternative source
- I understand that the Providers offer telehealth-based medical services, but that these services do not replace the relationship between me and my primary care doctor.
- 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 affecting my right to future care or treatment. I understand that I may suspend or terminate use of the telehealth services at any time for any reason or for no reason.
- I understand that if I am experiencing a medical emergency, that I will be directed to dial 9-1-1 immediately and that the Providers are not able to connect me directly to any local emergency services.
- I understand that while the use of telehealth may provide potential benefits to me, as with any medical care service no such benefits or specific results can be guaranteed.
- I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. Persons may be present during the consultation other than the provider in order to operate the telehealth technologies. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history/examination that are personally sensitive to me; (2) ask non-medical personnel to leave the telehealth examination; and/or (3) terminate the consultation at any time.
- I understand there is no guarantee that I will be given a prescription.
- I agree and authorize my Provider to share information regarding the telehealth exam with other individuals for treatment, payment, and health care operations purposes.
- I agree and authorize the Providers to release information regarding the telehealth exam to Sustain, Dr Nancy, Nancy P Rahnama MD, APC, and its affiliates.
I have read this document carefully, and understand the risks and benefits of the telehealth consultation and have had my questions regarding the procedure explained and I hereby give my informed consent to participate in a telehealth consultation under the terms described herein.