Telehealth Informed Consent

KMG Medical Group

Effective: March 28, 2022 Last Updated: July 18, 2024

Telehealth involves the use of secure electronic communications, information technology, or other means to enable a healthcare provider and a patient at different locations to communicate and share individual patient health information for the purpose of rendering clinical care. This “Telehealth Informed Consent” informs the patient (“patient,” “you,” or “your”) concerning the treatment methods, risks, and limitations of using a telehealth platform.

Services Provided:

Telehealth services offered by KMG Medical Group MO, P.C., KMG Medical Group KS, P.A., KMG Medical Group NJ, P.C. KMG Medical Group TX, P.A., and Michael Karagas, M.D., P.C. d/b/a KMG Medical Group (collectively “KMG Medical Group”), and KMG Medical Group’s engaged providers (our “Providers” or your “Provider”) may include a patient consultation, diagnosis, education, treatment recommendation, prescription, and/or a referral to in-person care, as determined clinically appropriate (the “Services”).

Thirty Madison, Inc. does not provide the Services; it performs administrative, payment, and other supportive activities for KMG Medical Group and the Providers.

Electronic Transmissions:

The types of electronic transmissions that may occur using the telehealth platform include, but are not limited to:

• Appointment scheduling;
• Completion, exchange, and review of medical intake forms and other clinically relevant information (for example: health records; images; output data from medical devices; sound and video files; diagnostic and/or lab test results) between you and your Provider via:
  • asynchronous communications;
  • two-way interactive audio in combination with store-and-forward communications; and/or
  • two-way interactive audio and video interaction;
• Treatment recommendations by your Provider based upon such review and exchange of clinical information;
• Delivery of a consultation report with a diagnosis, treatment, and/or prescription recommendations, as deemed clinically relevant;
• Prescription refill reminders (if applicable);
• Fees assessed for Services and how payments will be rendered; and/or
• Other electronic transmissions, that may include forwarding patient- identifiable information to a third party, for the purpose of rendering clinical care and treatment to you.

Expected Benefits: It can be 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.

Service Limitations: - The primary difference between telehealth and direct in-person service delivery is the inability to have direct, physical contact with the patient. Accordingly, some clinical needs may not be appropriate for a telehealth visit and your Provider will make that determination. - OUR PROVIDERS DO NOT ADDRESS MEDICAL EMERGENCIES. IF YOU BELIEVE YOU ARE EXPERIENCING A MEDICAL EMERGENCY, YOU SHOULD DIAL 9-1-1 AND/OR GO TO THE NEAREST EMERGENCY ROOM. IF YOU ARE CONTEMPLATING SUICIDE, DIAL 9-1-1 OR CALL/TEXT THE NATIONAL SUICIDE PREVENTION LINE AT 988. PLEASE DO NOT ATTEMPT TO CONTACT THIRTY MADISON, INC., KMG MEDICAL GROUP, OR YOUR PROVIDER. AFTER RECEIVING EMERGENCY HEALTHCARE TREATMENT, YOU SHOULD VISIT YOUR LOCAL PRIMARY CARE PROVIDER. - Our Providers are an addition to, and not a replacement for, your local primary care provider. Responsibility for your overall medical care should remain with your local primary care provider, if you have one, and we strongly encourage you to locate one if you do not. Certain Services may be available in-person and you should speak with your Provider to determine the need for in-person Services.

Security Measures: 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. All the Services delivered to the patient through telehealth will be delivered over a secure connection that complies with the requirements of the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”).

Possible Risks: Delays in evaluation and treatment could occur due to deficiencies or failures of the equipment and technologies, or provider availability.

In the event of an inability to communicate as a result of a technological or equipment failure, please contact KMG Medical Group at:

Keeps

833-745-3377

help@keeps.com

Nurx

800-321-6879

support@nurx.co

Cove

877-456-2683

care@withcove.com

Facet

855-658-8855

help@facetcare.com

• In rare events, your Provider may determine that the transmitted information is of inadequate quality, thus necessitating a rescheduled telehealth consult, request to reupload media, or an in-person meeting with your local primary care doctor.
• 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.
• In very rare events, security protocols could fail, causing a breach of privacy of personal medical information.

Patient Acknowledgments:

I further acknowledge and understand the following:

1. Prior to the telehealth visit, I will be given an opportunity to connect with a Provider and review the Provider’s credentials or elect to visit with the next available Provider from KMG Medical Group, and given that Provider’s credentials.

2. I understand that I may be asked to provide my identification and confirm my physical location prior to or during the telehealth visit.

3. If I am experiencing a medical emergency, I will be directed to dial 9-1-1 and/ or 9-8-8 immediately, and my Provider is not able to connect me directly to any local emergency services.

4. I may elect to seek services from a medical group with in-person clinics as an alternative to receiving telehealth services.

5. 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.

6. Federal and state law requires health care providers to protect the privacy and the security of health information. I am entitled to all confidentiality protections under applicable federal and state laws. I understand all medical reports resulting from the telehealth visit are part of my medical record.

7. KMG Medical Group will take steps to make sure that my health information is not seen by anyone who should not see it. Telehealth may involve electronic communication of my personal health information to other health practitioners who may be located in other areas, including out of state. I consent to KMG Medical Group using and disclosing my health information for purposes of my treatment (e.g., prescription information) and care coordination, to receive reimbursement for the services provided to me, and for KMG Medical Group’s health care operations.

8. Dissemination of any patient-identifiable images or information from the telehealth visit to researchers or other educational entities will not occur without my consent unless authorized by state or federal law.

9. There is a risk of technical failures during the telehealth visit beyond the control of KMG Medical Group and will hold the provider and KMG Medical Group harmless for such loss.

10. In choosing to participate in a telehealth visit, I understand that some parts of the Services involving tests (e.g., labs or bloodwork) may be conducted by third-party laboratories at another location such as a testing facility, at the direction of my Provider and neither KMG Medical Group nor my 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. .

11. Persons may be present during the telehealth visit other than my Provider who will be participating in, observing, or listening to my consultation with my Provider (e.g., in order to operate the telehealth technologies). If another person is present during the telehealth visit, I will be informed of the individual’s presence and his/her/their role.

12. My Provider will explain my diagnosis and its evidentiary basis, and the risks and benefits of various treatment options.

13. I understand that by creating a treatment plan for me, my Provider has reviewed my medical history and clinical information and, in my Provider’s professional assessment, has made the determination that the Provider is able to meet the same standard of care as if the health care services were provided in-person when using the selected telehealth technologies, including but not limited to, asynchronous store-and-forward technology.

14. I have the right to request a copy of my medical records. I can request to obtain or send a copy of my medical records to my primary care or other designated health care provider by contacting KMG Medical Group at: medicalrecords@thirtymadison.com or I can log into my account and go to your Account Profile and request it in a message. A copy will be provided to me at a reasonable cost of preparation, shipping, and delivery.

15. It is necessary to provide my Provider a complete, accurate, and current medical history. I understand that I can log into my account and go to my Account Profile or reach out to medicalrecords@thirtymadison.com at any time to access, amend, or review my health information. I understand that if I fail to comply, that may result in termination of the patient-provider relationship.

16. There is no guarantee that I will be issued a prescription and that the decision of whether a prescription is appropriate will be made in the professional judgment of my Provider. If my Provider issues a prescription, I have the right to select the pharmacy of my choice.

17. There is no guarantee that I will be treated by a KMG Medical Group Provider. My Provider reserves the right to deny care for potential misuse of the Services or for any other reason if, in the professional judgment of my Provider, the provision of the Services is not medically or ethically appropriate.

Additional State-Specific Consents: The following consents apply to patients accessing KMG Medical Group’s website for the purposes of participating in a telehealth consultation as required by the states listed below:

Alaska: 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 and the nursing board website, here.

California: I have been informed or the following notice:

The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. It can be found at https://openpaymentsdata.cms.gov.

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.

Indiana: 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.

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 (or, alternatively, by accessing this URL in my browser: 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; Or, the Maine Board of Osteopathic Licensure’s website, here.

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.

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.

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; Or, the Vermont Board of Osteopathic Examiners’ website, here.

Patient Informed Consent I acknowledge that I have carefully read, understand, and agree to the terms of this “TELEHEALTH INFORMED CONSENT” and consent to receive the Services.