INFORMED CONSENT TO VIRTUAL CARE SERVICES
November 14, 2023
By clicking "I Agree", I hereby state that I have read, understood, and agree to the following:
- I am over the age of 18. If am under the age of 18 but older than 13, I represent and warrant that my parent or legal guardian authorized to consent on my behalf has read the terms of this Informed Consent to Virtual Care Services (this “Consent”) and accepted them on my behalf.
- I am not under the influence of any medications or other substances that could impair my understanding of the information in this Consent. I have had sufficient time to read and understand the information provided in the SimpliFed Terms of Service regarding virtual care. I have had the opportunity to discuss this Consent with my treating Professional providing virtual lactation consulting and baby feeding support services (“Virtual Care Services”) through SimpliFed. I have been given all of the opportunity I require to ask any and all of my questions, and such questions have been answered to my satisfaction in words I understand.
- I grant my permission for Virtual Care Services to be performed by SimpliFed’s employed and contracted certified lactation counselors, consultants and lactation allies (collectively, my “Professionals” and each, my “Professional”) . I understand that to learn how the Professionals can help me, my Professional may ask about and the Virtual Care Services may consist of the following: a medical history of me and my baby, a virtual, clinical assessment, observation and examination of my breasts and my baby, an assessment of how my baby breastfeeds, the use of breastfeeding aids and equipment, providing helpful hints, recommendations and other educational information to help me reach my breastfeeding goals. I authorize SimpliFed and the Professionals to release the information gained from the Virtual Care Services to my primary care physician(s), health care provider, and insurance company (to assist with claim reimbursement if relevant) unless I specifically object to such release. I understand and agree that the information in this file will be kept for a period that is required by applicable federal and state law.
- I acknowledge and accept that the physical examination portion of the Virtual Care Services, if any, will be delivered wholly virtually through the SimpliFed website located at www.simplifed.com (the “Site”) and/or mobile application (the “App”) in reliance upon video, images, telephone consultations, texts, emails, questionnaire, medical records and/or otherwise. I accept this, with full knowledge, of all potential benefits and consequences from virtual care and deem this method of physical examination appropriate and complete, but I may not, because as with all medical or health care services provided, no results or outcomes can be guaranteed. In fact, as with all medical or health care services provided, I may be subject to virtual care that may cause some harm, including potentially serious harm.
- I understand that a variety of alternative methods of medical care may be available to me, and that I may choose one or more of these at any time. My Professional has explained these alternatives to my satisfaction.
- I acknowledge that, in the exercise of his/her clinical judgment, a Professional may determine: (1) that the nature of my problem is such that it is not professionally appropriate to assist me with that problem through virtual care; or (2) that it may not be lawful for the Professional to diagnose or treat me virtually; or (3) both. Should the Professional make any such determination that they will be unable to assist me virtually, he/she will confer with me about other possible approaches to handling my medical problems, such as referring me to my primary care physician.
- I understand that it is my duty to inform my primary care provider of any electronic interactions regarding my health care that I may have with other health care providers.
- I will provide my Professional and SimpliFed with the names and contact information for other relevant healthcare providers for my baby and me, and my Professional may communicate with them. It is my responsibility to provide accurate information and to keep it updated. I understand that email and text are not secure means of communication, and give my permission for my Professional to send and receive texts and emails that may contain my Personal Health Information (“PHI”).
- I understand that it is my choice to have someone else present during a Virtual Care Services session, and that anyone who sits in on the virtual session will have access to my healthcare information and my confidentiality may not be guaranteed. I understand that if I include any third party on an email or text with SimpliFed I am granting permission for SimpliFed to communicate my health information and that of my baby(ies) with that third party. SimpliFed and/or the Professional will not initiate inclusion of any third party on an email or text. I acknowledge that SimpliFed and/or the Professional is not responsible for any breach of confidentiality made by any person present I invite to be present during a visit, or added by me as a third party.
- I give permission to SimpliFed and/or Professional to photograph of me and/or my baby in furtherance of my care. These photos will not be published without my express consent, but they may be shared with my pediatrician or other healthcare provider that I listed in my client portal.
- I understand that the Professionals I engage with through the Site or App will not prescribe medications to treat my problem and notwithstanding other licenses or qualifications are only engaging with me as a certified lactation counselor or consultant.
- I understand that, if applicable, I may have to pay SimpliFed in advance through a charge to my credit card or other payment method requested before any Virtual Care Services may be rendered by a Professional.
- I understand that virtual care may involve electronic communication of my personal medical information to other medical professionals who may be located in other areas, including out of state. I understand that the laws that protect privacy and the confidentiality of medical information also apply to virtual care, and that no information obtained in receiving virtual care, which identifies me, will be disclosed to researchers or other entities without my consent. I also acknowledge, however, that the security and privacy of electronic communications cannot be guaranteed.
- I understand that I have the right to inspect all information obtained and recorded in the course of a virtual care interaction, including any of my medical records, and may receive copies of this information for a reasonable fee.
- I understand that I have the right to withhold or withdraw my consent to receive Virtual Care Services at any time, without affecting my right to future care or treatment.
- By acknowledging “I AGREE,” I hereby authorize SimpliFed and any Professional performing the Virtual Care Services through the Site or the App to provide care to me virtually in the course of my engagement and treatment, as applicable.
- I agree that my electronic agreement to this Consent is equivalent to the signature of a patient. I understand a copy of this Consent is available by printing this document or by request.
INSURANCE BENEFITS AUTHORIZATION AND ASSIGNMENT
I authorize SimpliFed to release to my insurance company any information required in the course of my examination or treatment. I also authorize (a) any physician, hospital, or clinic to provide details of my history that is applicable to any of the services I will receive through the Site and/or App, including the Virtual Care Services, to SimpliFed, and (b) SimpliFed and its Professionals to share my medical records, including details of my history that is applicable to the Virtual Care Services I will receive, to my insurance company, primary care provider or other specialist provider in a manner consistent with state and federal law, unless I specifically object to such sharing of my medical records.
I hereby assign payment direct to SimpliFed for medical benefits payable for the Services, including the Virtual Care Services. I understand that I am responsible for payment of all Services rendered regardless of insurance coverage.
I agree that my electronic agreement to this Insurance Benefits Authorization and Assignment is equivalent to the signature of a patient. I understand a copy of this Insurance Benefits Authorization and Assignment and this Consent is available by printing this document or by request.