I have read, or someone has read and explained to me, the information provided by Central Outreach Wellness Center t/d/b/a HepCMyWay.com (“COWC”) regarding the transmission of Hepatitis C, other STIs and the purposes, potential uses, limitations, complications and benefits of Hepatitis C medication.
I have read, or someone has read and explained to me, the information provided by COWC regarding the policies and procedures for telemedicine treatment of Hepatitis C, including but not limited to, the telemedicine procedures for the provision of Hepatitis C testing and Hepatitis C medication.
I understand and acknowledge that telemedicine services provided by COWC, are limited to Hepatitis C and other STIs treatment, including the provision of Hepatitis C testing, Hepatitis C medication and are only available to residents of Ohio and Pennsylvania. I hereby represent and certify that I am either a resident of the State of Ohio or a resident of the Commonwealth of Pennsylvania and am of legal age and competence to obtain the COWC services.
I have read, or someone has read and explained to me, the Terms of Service and Disclaimer located on the website www.HepCMyWay.com and I consent to the terms and conditions contained therein.
I understand and acknowledge that telemedicine involves the use of electronic communications to enable healthcare providers at different locations to share my medical information for the purpose of improving patient care. Providers may include primary care practitioners, specialists, and/or sub-specialists. I acknowledge that the information may be used for diagnosis, therapy, follow-up and/or education, and may include any of the following: Patient medical records, Medical images, Live two-way audio and video, Output data from medical devices and sound and video files
I understand that patient care other than for Hepatitis C will not be provided by COWC. I may choose COWC or other health care providers to provide follow-up care for Hepatitis C. Upon patient’s consent, COWC will forward the medical records to the patient’s identified primary care provider or other health care providers, or refer the patient as appropriate. COWC may provide prescriptions for Hepatitis C and a diagnosis and treatment plan as appropriate.
I understand and acknowledge that the expected benefits of telemedicine are: (1) Improved access to medical care by enabling me to remain in my home while my healthcare provider consults and obtains test results at distant/other sites. (2) More efficient medical evaluation and management. (3) Obtaining expertise of a specialist.
I understand and acknowledge that there are potential risks associated with the use of telemedicine. These risks include, but are not limited to:
In rare cases, the healthcare provider may determine that the transmitted information is of inadequate quality, thus necessitating a face-to-face meeting with the patient, or at least a rescheduled telemedicine consult;
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 cases, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors.
I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine, and that no information obtained in the use of telemedicine, which identifies me, will be disclosed to researchers or other entities without my written consent.
I understand that I have the 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 care or treatment.
I understand the alternatives to telemedicine consultation as they have been explained to me, and in choosing to participate in a telemedicine consultation, I understand that some parts of the exam involving physical tests may be conducted by way of at-home testing kits, or at a testing facility, at the direction of a healthcare provider.
I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured.
I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. Others may also be present during the consultation other than healthcare providers in order to operate the communications equipment. The above-mentioned people will maintain confidentiality of the information obtained. 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/physical examination that are personally sensitive to me; (2) ask non-medical personnel to leave the telemedicine examination room; and/or (3) terminate the consultation at any time.
I have read this document carefully, and understand the risks and benefits of a telemedicine consultation and have had my questions regarding the procedure explained and I hereby give my informed consent to participate in a telemedicine consultation under the terms described herein, including but not limited to telemedicine examination and remote testing and treatment for Hepatitis C, including all examinations and tests relating to Hepatitis C medications.
I have read, or someone has read and explained to me, the process for complaints related to healthcare services provided via telemedicine by COWC. I understand that all complaints related to telemedicine shall be submitted in writing to COWC at 127 Anderson Street, Suite 101, Pittsburgh, PA 15212. I consent to COWC contacting me via the telemedicine procedures currently used by COWC, email, text message, and/or Facebook messenger in the event additional patient consent is needed for additional healthcare procedures or testing.