This Informed Consent Agreement applies to all products and services I have selected under the terms of my agreement with Civic Telehealth, LLC (“Civic”). The terms of this Informed Consent Document are different from, and in addition to, the provisions of Civic’s Terms of Use, https://civictelehealth.com/terms-of-use/, and its Privacy Policy, https://civictelehealth.com/privacy-policy/.  It is also different from, and in addition to, agreements I have made with DialCare, through which Civic provides many of its services and products.

Privacy

The laws that protect privacy and confidentiality of medical information in general also apply to Civic’s services, including remote monitoring and telehealth. Except as provided by law, no information obtained in the use of Civic’s services that identifies me will be disclosed to researchers or others without my authorization.

Communication: I understand that clinicians or staff I communicate with through Civic may send me messages. These messages may contain information important to my health or healthcare or both. It is my responsibility to monitor these messages. I agree that all communication will pertain to my health condition(s). I understand that asking for advice on behalf of another person violates the agreement I have with Civic. Neither Civic nor clinicians available to me through Civic assume any responsibility for health information or services used by persons other than me, or for information about me that is erroneous or incomplete.

Civic’s Limitations 

I understand that Civic is neither a health care provider of any type nor an insurer, health maintenance organization, or other underwriter of health care services.

Civic serves adults, not children. I am an adult, and I understand I am not to, and I will not, utilize Civic’s services for a child or children.

Civic’s services are provided by independent clinicians not employed by or under the control of Civic. They are independent health professionals utilizing their own independent professional judgment and acting within their scopes of their respective licenses. Their services are not intended to and do not replace those of my own primary care physicians, mental health professionals, or specialists. Physicians, nurses, behavioral health, and other health care professionals I communicate with through Civic are solely responsible for the professional advice and treatment rendered to me, and Civic disclaims any liability with respect to their work. 

I understand that it is impossible to list every possible risk, consequence, and benefit of Civic’s services. 

Consultation times are not guaranteed. 

I agree to accurately represent my location, city and state when requesting a clinical consult. Civic’s services may not be available in all states, and certain methods of telehealth consultations (e.g., phone, texting) may not be available in some jurisdictions per state law.

I will provide accurate answers to inquiries about my health. If I am inaccurate, I know that the risk increases significantly that my providers, or individuals acting on their behalf, might make a mistake or mistakes that are harmful to my health.

By signing this form, I acknowledge that, after getting a thorough explanation, I understand the following about each aspect of Civic Telehealth’s services:

Remote Monitoring Program

I have decided to engage in a remote monitoring program. I give permission for my health care provider to be contacted about the results of my monitoring, if needed. 

For and during a pilot monitoring program, I will receive both remote monitoring devices and the associated monitoring services at no cost to me, but I will be charged if I elect to continue the service thereafter.  

I am the only one that may use my remote monitoring devices.

Systems, including cellular services and other equipment, can break down at times. I accept the risk that, as a result, my monitoring could be interrupted, and data important to my care could be missed.

I may expect to benefit from the use of remote monitoring, but no results can be guaranteed or assured.

The devices I will receive will be in good working condition. I understand, however, that their function cannot be guaranteed, and even well-designed devices can sometimes provide erroneous data.

I have the right to withhold or withdraw my authorization for the use of both remote monitoring devices and monitoring itself at any time, without prejudice to my ability to seek care afterwards elsewhere. 

Civic utilizes recognized ranges for vital signs and other biological parameters when monitoring my data. Should I or my health care providers have questions, I or they may contact the Monitoring Center. At my provider’s request, Civic will customize ranges and parameters for me.

This is NOT AN EMERGENCY RESPONSE SERVICE AND IS NOT MONITORED 24/7.  I WILL NOT USE IT IN AN EMERGENCY.  If I have, or I think I may be having an emergency, I will call 911 immediately. 

In the event that I am unable to be reached by phone, I authorize Civic to contact my emergency contacts or my health care provider for unstable or concerning measurements during my monitoring period.

Urgent Care Telemedicine and Behavioral Health Services

I have decided to engage in telehealth, either for urgent care or for behavioral health or both. I give permission for my health care provider to be contacted about the results of my care, if needed. 

Civic’s services, including remote monitoring, telehealth, and behavioral health consultations available through Civic are NOT SUITABLE for emergencies or other health problems requiring in-person care. If I am facing a medical emergency, or I think I might be, or if instructed to do so by a clinician available to me through Civic, I will immediately dial “911” or seek in-person treatment.

For and during a pilot telehealth program, I will be eligible to receive urgent care at no cost to me, but I will be charged $80 for behavioral health services I elect to access. I also understand that, if I elect to continue either service thereafter, I will be charged.  

I agree to have my medical or behavioral health history and other diagnostic and medical/dental documentation reviewed by a clinician or clinicians available to me through Civic. I acknowledge that virtual care is not always suitable for every kind of health problem; some must be evaluated in person. I acknowledge that clinicians available to me through Civic may be unable to diagnose my condition, may choose not to treat my condition, or may choose not to prescribe a medication for my condition. Civic plays no role in making any of these decisions. Clinicians available to me through Civic do not prescribe DEA controlled substances, non-therapeutic drugs and certain other drugs that may be harmful because of their potential for abuse.

Risks, Consequences, and Benefits: I understand that it is not possible to list every possible risk or benefit of telehealth, and that not every risk can be avoided nor every benefit realized. I know there are risks from telemedicine consultations, including, but not limited to, the following:

1. loss of records from failure of electronic equipment;
2. power failures with interruption of communication;
3. invasion of electronic records by outsiders (hackers);
4. technological errors that can affect communication and the provision of health care services; and
5. misdiagnosis and therefore improper care where a diagnosis hinges on methods not available through telemedicine, such as palpation or percussion. Palpation is a diagnostic technique in physical examinations where healthcare professionals use their hands to touch, press, and feel body tissues, organs, and structures. Percussion is another physical examination technique involving tapping body surfaces with fingers to produce sounds that reveal the density, size, and position of underlying structures, or to detect fluid/air accumulation.
6. System break-downs. I understand that systems, including those used in virtual urgent or behavioral health care, can break down at times. I accept the risk that, as a result, my care could be interrupted, and data important to my care could be missed.

I understand there are also potential benefits of telehealth consultations, such as:

1. increased availability of health care;
2. availability of real-time data and information; 
3. ease and convenience of receiving health care; and
4. reduced in-person contact with health providers and their patients during epidemics or pandemics.

Medical Records: I agree to the entry of my medical records into Civic’s computer database and understand that reasonable measures have been taken to safeguard my medical information, but no computer or phone system is totally secure.

Rights: I understand that I have all the following rights with respect to telemedicine consultations, both urgent care and behavioral health:

1. Free Choice. I have the right to withhold or withdraw my consent to a telemedicine consultation at any time without affecting any right to future care or treatment I may have or risking the loss or withdrawal of any benefits to which I would otherwise have been entitled.
2. Access to Information. I have the right to request a copy of all medical information transmitted during a telehealth consultation, and to have such records sent to my primary care physician or to anyone else of my choosing.
3. Communications. I understand that, by having my consent to telehealth consultations, the clinicians available to me through Civic may communicate medical information concerning me to physicians and other health care practitioners and others located in other parts of my state/jurisdiction or outside my state/jurisdiction as needed to facilitate consultation and follow up.
4. Consent. I understand the information provided and I consent to treatment by a clinician available to me through Civic. I agree that as long as this consent is in force (has not been revoked) clinicians available to me through Civic may provide health care services to me via telemedicine without my needing to grant further consent.

Pharmaceuticals

Through Civic, I have access to a wide array of prescription medications at discounted fees. Civic does not guarantee, however, that it can make every medication I am prescribed available to me at a discount or at all. In particular, Civic’s pharmaceutical program does not permit the filling of prescriptions for controlled substances. Nor does every pharmacy honor Civic’s discounted prescription arrangement with me. I know I can access a list of all pharmacies participating in the program on the DialCare website.

The discounted prescriptions I can obtain through Civic are not limited to those written by clinicians available to me through Civic. Regardless of the identity or affiliation of the prescriber, however, Civic plays no role in selecting medications for me, nor is it competent to do so. All such prescriptions are the responsibility of the prescribers who write these prescriptions for me. Civic disclaims responsibility for the consequences of taking any medication prescribed for me.

Laboratory Services

Though Civic, I can get access to a wide array of lab tests on a discounted basis. Civic does not make all such tests available, however, nor does every clinical lab honor the discounted arrangement Civic has established. I know I can access a list of laboratories that collaborate with Civic in providing discounted services on the DialCare website.

I understand that Civic does not itself order lab tests, nor is it competent to do so. I may select my own test or rely on my healthcare professionals to order for me. Civic does not try to interpret laboratory data, either, nor is it competent to do so. For such interpretation, I will ask the professional who ordered my lab test for me or my own provider. Civic disclaims responsibility for all tests ordered or interpreted for me.

Durable Medical Equipment (DME)

Through Civic, I understand I have access to a wide array of durable medical equipment (DME). Not every device is available through Civic, however, nor does every DME Supplier honor Civic discounts. I know I can access a list of DME and DME suppliers available to me on the DialCare website. I understand that Civic plays no role in determining that I need DME, nor, if so, what kind(s). Civic disclaims responsibly for any consequences of my using DME.

Eye Care

Civic makes refraction services available to me as well as discounted eyewear. I understand that refraction determines how light bends (refracts) in my eye, permitting determination of my prescription for eyeglasses or contact lenses. Civic itself plays no role in measuring my visual acuity nor in writing prescriptions for corrective lenses. The eye professionals available to me through Civic make all such determinations, and they are neither employed by nor under the control of Civic. Civic disclaims all responsibility for all such determinations.

Hearing Care

Civic makes hearing aids available to me at a discount. Civic itself plays no role in measuring my hearing acuity nor in writing prescriptions for hearing aids, however. The hearing professionals available to me through Civic make all such determinations, and they are neither employed by nor under the control of Civic. Civic disclaims all responsibility for all such determinations.

Health Advocate

Civic makes the services of Health Advocate available to those participating in its pilot program, and once that is completed, will make it available to members as well. As its name suggests, Health Advocate exists to assist me in non-clinical matters, such as finding providers in various fields, helping me get appointments there, advising me about various aspects of my health insurance coverage, and sometimes in helping me convince my health insurer to cover a service or product. I understand that Health Advocate may not always be able to find a provider in my area in a specialty I need, and may not always be able to convince my health insurance company to cover a product or service I need. I agree to assist Health Advocate in its efforts, as by making myself available to answer questions and providing documents it may need to give me advice and information.

Consent

I have read and understand this document. All my questions have been answered to my satisfaction in language I understand. At the time of my signing, I am not under the influence of alcohol or of any other drug that could make it harder for me to understand this document. 

In the event that I cannot be reached by phone, I authorize Civic to contact my emergency contacts or my health care provider(s) for unstable or concerning information learned about from my use of Civic’s services.

I give permission to the clinicians available to me through Civic to perform the medical services that the clinician may deem necessary.