Telehealth Medical Consent

Last updated: May 1, 2024

THE INDEPENDENT PROVIDERS DO NOT ADDRESS MEDICAL EMERGENCIES. DO NOT PROCEED WITH TELEMEDICINE SERVICES IF YOU BELIEVE YOU ARE HAVING A MEDICAL EMERGENCY.
 
IF YOU BELIEVE YOU ARE EXPERIENCING A MEDICAL EMERGENCY, YOU SHOULD DIAL 9-1-1 AND/OR GO TO THE NEAREST EMERGENCY ROOM.
 

Introduction

You are reviewing and acknowledging this Telehealth Informed Consent because you are seeking Telemedicine Services utilizing telehealth technologies by Radiant Revival, referred from the SOMA website. This Telehealth Informed Consent does not modify or supersede any Terms of Use, Privacy Policy, or Notice of Privacy Practices of SOMA, rather it supplements these terms and documents.

By completing an intake form and starting a consultation, you consent to Telemedicine Services. You indicate that you have reviewed the risks as described herein of receiving services utilizing telehealth technologies and consent to receiving the services.

SOMA does not provide medical care, treatment, or advice. SOMA refers persons interested in Telemedicine Services to Radiant Revival, who are a collective group of independent medical professionals (the “Providers”).

 

What is Telehealth?

Telehealth involves the delivery of health and wellness services using electronic communications, information technology, or other means between a licensed, certified, or registered healthcare professional at one location and a patient in another location about a clinical matter. Telehealth may be used for diagnosis, treatment, follow-up and/or patient education. These telehealth services may involve various modalities, including asynchronous interactions, real-time (synchronous) video and audio encounters, and interactive audio with store and forward. This “Telehealth Informed Consent” informs the patient (“patient,” “you,” or “your”) concerning the treatment methods, risks, and limitations of utilizing telehealth to meet your health and wellness needs.

 

What are the Possible Benefits of Telehealth?

Benefits of telehealth include being easier and more efficient for you to access health and wellness services. You can obtain health and wellness services at times that are convenient for you without the necessity of an in-office appointment, including follow-up care related to your treatment. If you need follow-up care, please contact Radiant Revival at (970) 650-8050 or contact SOMA to best direct you to a Provider by emailing care@somapeptides.com or calling (888) 818-6543 Mon – Fri 9:00 am PST – 5:00 pm PST.

 

What are the Possible Risks of Telehealth?

Information transmitted to your health professional may not be sufficient to allow for appropriate health or wellness services to meet your particular needs. Some clinical needs may not be appropriate for a telehealth visit and your Provider will make that determination. The technology necessary to interact with your health professional may fail and delay your services. If a technical failure prevents you from communicating with your Providers, you should contact Radiant Revival at (970) 650-8050 or contact SOMA to assist in connecting you with a Provider by emailing care@somapeptides.com or calling (888) 818-6543 Mon – Fri 9:00 am PST – 5:00 pm PST.

In rare events, a lack of access to complete medical records, and/or the quality of transmitted data could result in adverse drug interactions, allergic reactions, and/or other clinical judgment errors. You may stop or decline any on-going Healthcare Services provided by Radiant Revival using telehealth technologies at any time, although you acknowledge that applicable fees may apply if a medical consultation has occurred prior to request to cancel services.

THIRD-PARTY LABORATORY PRODUCTS AND SERVICES

To facilitate certain Healthcare Services, Providers may require that you complete diagnostic test(s). These diagnostic tests are provided by third-party laboratories, and neither SOMA nor your Provider(s) can guarantee the accuracy or reliability of these tests. These laboratory tests can provide false negative, false positive, or inconclusive results that could impact your Provider(s) ability to correctly diagnose or treat your medical conditions. A failure or defect of these tests could also impact your Provider(s) ability to correctly diagnose or treat your medical conditions.

 

Patient Acknowledgments

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

  1. You have reviewed this Telehealth Informed Consent, and understand there are risks, limitations, and benefits of utilizing telehealth.
  2. You understand that the electronic nature of the telehealth services means that there is a greater risk to the privacy of my health information.
  3. In some cases, my Provider may be a nurse practitioner or physician assistant and not a physician.
  4. Persons may be present during the telehealth visit other than my Provider in order to operate the telehealth technologies and/or for language translation assistance, if requested. If another person is present during the telehealth visit, I will be informed of the individual’s presence and his or her role.
  5. I understand that information I provide as part of any telehealth offering is viewed as accurate, true, and complete.
  6. I understand that in certain instances, and in compliance with applicable law, my Provider may determine that it is appropriate to provide my Healthcare Services asynchronously via store-and-forward technology. In such instances, my Provider and I will communicate electronically and not via telephone or video. I agree that if my provider makes that determination, I would like to receive Healthcare Services in this manner.
  7. I understand that there is no guarantee that I will be given a prescription and that the decision of whether a prescription is appropriate will be made in the professional judgment of my Provider. I understand that while the use of telehealth may provide benefits to me, no such benefits or specific results can be guaranteed, and my condition may not improve.
  8. I understand there is a risk of technical failures during the telehealth encounter beyond the control of SOMA and my Provider(s). I AGREE TO HOLD HARMLESS SOMA AND ITS EMPLOYEES, CONTRACTORS, AGENTS, DIRECTORS, MEMBERS, MANAGERS, SHAREHOLDERS, OFFICERS, REPRESENTATIVES, ASSIGNS, PREDECESSORS, AND SUCCESSORS, INCLUDING ADONIS HEALTH AND ITS EMPLOYEES, CONTRACTORS, AGENTS, DIRECTORS, MEMBERS, MANAGERS, SHAREHOLDERS, OFFICERS, REPRESENTATIVES, ASSIGNS, PARENTS, PREDECESSORS, AND SUCCESSORS FOR DELAYS IN EVALUATION OR FOR INFORMATION LOST DUE TO SUCH TECHNICAL FAILURES.
  9. I understand that certain diagnostic testing services, including laboratory products and services offered to support the Healthcare Services of Providers, may contain defects, including ones which may limit functionality or produce erroneous results, any or all of which could limit or otherwise impact the quality, accuracy and/or effectiveness of the medical care or other services that I receive from my Provider(s).
  10. I understand I may need to seek other resources for my other health needs. There is no guarantee that I will be approved for treatment by a Provider. My Provider reserves the right to deny care for any reason if, in the professional judgment of my Provider, the provision of the services, including when provided via telehealth is not medically or ethically appropriate. I understand that the Providers, and not SOMA, are responsible for the quality and appropriateness of the care they render to me and make all decisions regarding clinical care in their independent discretion without the influence of SOMA.
  11. I understand that I have the opportunity to discuss the use of telehealth, including the Healthcare Services, with my Provider(s), including the benefits and risks of such use and the alternatives to the use of telehealth. I have the right to withdraw my consent to the use of telehealth in the course of my care, without prejudice to any future care or treatment and without risking the loss or withdrawal of any health benefits to which I am entitled, but I understand that the Providers who provide Healthcare Services do not offer in-person treatment.

 

Additional State-Specific Disclosures

The following disclosures apply to users participating in a telehealth visit as required by the states listed below:

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: https://medicalboard.iowa.gov/consumers/filing-complaint.

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: https://kbml.ky.gov/grievances/Pages/default.aspx.

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: https://www.maine.gov/md/complaint/file-complaint.

New York

I have been informed that to get information regarding your rights and how to report professional misconduct, I should visit here: https://www.health.ny.gov/professionals/doctors/conduct.

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: https://www.oregon.gov/omb/investigations/pages/how-to-file-a-complaint.aspx.

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: https://health.ri.gov/complaints/.

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: http://www.healthvermont.gov/health-professionals-systems/board-medical-practice/file-complaint; or Board of Osteopathic Examiners can be found at: https://sos.vermont.gov/opr/complaints-conduct-discipline/

Wyoming

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: http://wyomedboard.wyo.gov/consumers/file-a-complaint.