- IMPORTANT INFORMATION ABOUT YOUR USE OF THE SERVICES
DO NOT USE THE SERVICES FOR EMERGENCY MEDICAL NEEDS. IF YOU EXPERIENCE A MEDICAL EMERGENCY, CALL 9-1-1 IMMEDIATELY.
Alphatelemed.com does not provide any physicians’ or other healthcare providers’ (collectively, “Providers”) services itself. All of the Providers are independent of Alphatelemed.com and merely using the Services to communicate with you. Any information or advice received from a Provider comes from the Provider, and not from Alphatelemed.com. Your interactions with the Providers via the Services are not intended to take the place of your relationship(s) with your regular health care practitioner(s).
NEITHER ALPHATELEMED.COM NOR ANY OF ITS LICENSORS OR SUPPLIERS OR ANY THIRD PARTIES WHO PROMOTE THE SERVICES OR PROVIDE YOU WITH A LINK TO THE SERVICES SHALL BE LIABLE FOR ANY PROFESSIONAL ADVICE YOU OBTAIN FROM A PROVIDER VIA THE SERVICE NOR FOR ANY INFORMATION OBTAINED FROM OUR SERVICES. YOU ACKNOWLEDGE YOUR RELIANCE ON ANY PROVIDERS OR INFORMATION PROVIDED BY THE SERVICES IS SOLELY AT YOUR OWN RISK AND YOU ASSUME FULL RESPONSIBILITY FOR ALL RISK ASSOCIATED THEREWITH.
Alphatelemed.com does not make any representations or warranties about the training or skill of any Providers using the Services. You are ultimately responsible for choosing your particular Provider on the Services. You hereby certify that you are physically located in the State you have entered as your current location on the Services. You acknowledge that your ability to access and use the Services is conditioned upon the truthfulness of this certification and that the Providers you access through the Services are relying upon this certification in order to interact with you. IN
THE EVENT THAT YOUR CERTIFICATION IS INACCURATE, YOU AGREE TO INDEMNIFY ALPHATELEMED.COM AND THE PROVIDERS YOU INTERACT WITH FROM ANY RESULTING DAMAGES, COSTS, OR CLAIMS.
Providers may not utilize the Services to provide fee for service consultations to Medicare or Medicaid beneficiaries. In select circumstances, Providers may utilize the Services to provide consultations to participants in a Medicare Advantage or Managed Medicaid plan. If you provide false or deceptive information regarding your Medicare or Medicaid enrollment status, Alphatelemed.com reserves the right to terminate all current or future use of the Services by you.
III. ACCOUNT ENROLLMENT
To access Providers using the Services, you must first establish an individual user account (“Account”) by providing certain information. You agree that you will not create more than one Account, or create an Account for anyone other than yourself (with the exception of subaccounts established for minor children of whom you are a parent or legal guardian). You agree to provide true, accurate, current, and complete information on the Account enrollment form and to keep this information current and updated as needed.
- PROHIBITED CONDUCT
You may not access or use, or attempt to access or use, the Services to take any action that could harm us or any third party, interfere with the operation of the Services, or use the Services in a manner that violates any laws. For example, and without limitation, you may not:
- transmit any message or information under a false name or otherwise misrepresent your affiliation or the origin of materials you transmit;
- provide information on the enrollment form that is untrue, inaccurate, not current, or incomplete;
- transmit any message or information that is unlawful, libelous, defamatory, obscene, fraudulent, predatory of minors, harassing, threatening, or hateful;
- transmit any message or information that infringes or violates the intellectual property, privacy, or publicity rights of others;
- reproduce, retransmit, distribute, disseminate, sell, publish, broadcast, or circulate content received through the Services to anyone without prior express permission;
- engage in unauthorized spidering, “scraping,” or harvesting of content or personal information, or use any other unauthorized automated means to compile information;
- take any action that imposes an unreasonable or disproportionately large load on our network or infrastructure;
- use any device, software, or routine to interfere or attempt to interfere with the proper working of the Services or any activity conducted on the Services or attempt to probe, scan, test the vulnerability of, or breach the security of any system or network;
- attempt to modify, translate, decipher, decompile, disassemble, reverse-engineer, or create derivative works of any of the software comprising or in any way making up a part of the Services; or
- engage in any other conduct that restricts or inhibits any person from using or enjoying the Services, or that, in our sole judgment, exposes us or any of our users, affiliates, or any other third party to any liability, damages, or detriment of any type.
Violations of system or network security may result in civil or criminal liability. We may investigate and work with law enforcement authorities to prosecute users who violate the Terms. We may suspend or terminate your access to the Services for any or no reason at any time without notice.
- PAYMENT AUTHORIZATION
By providing a credit card or other payment method accepted by Alphatelemed.com (“Payment Method”), you are expressly agreeing that we are authorized to charge to the Payment Method any fees for your use of the Services, together with any applicable taxes. Please note that Alphatelemed.com may not receive complete information from your health insurance plan, if applicable, regarding the applicable co-pay due from you for your consultation. As such, you may be billed more than once with respect to a consultation to account for additional co-pay amounts due, if any. Should you choose not to enter your health plan billing details, you elect to be seen as self-pay, thereby waiving health plan claim submission.
You agree that authorizations to charge your Payment Method remains in effect until you cancel it in writing, and you agree to notify Alphatelemed.com of any changes to your Payment Method. You certify that you are an authorized user of the Payment Method and will not dispute charges for the Services that correspond to consultation fees or the co-payment required by your health plan. You acknowledge that the origination of ACH transactions to your account must comply with applicable provisions of U.S. law. In the case of an ACH transaction rejected for insufficient funds, Alphatelemed.com may at its discretion attempt to process the charge again at any time within 30 days.
When scheduling a visit with a Provider using the Services, you will be required to provide a Payment Method. If you choose to cancel your scheduled appointment, you must do so at least 24 hours in advance of the scheduled appointment time. Should you choose to cancel your scheduled appointment within 24 hours of the scheduled appointment time, Operator may assess a reservation fee.
You acknowledge and agree that fees for consultations may increase at any time.
- INTELLECTUAL PROPERTY RIGHTS
The Services are protected under the copyright laws of the United States and other countries. All copyrights in the Services are owned by us or our third-party licensors to the full extent permitted under the United States Copyright Act and all international copyright laws. You may not publish, reproduce, distribute, display, perform, edit, adapt, modify, or otherwise exploit any part of the Services without our written consent.
All rights in the product names, company names, trade names, logos, service marks, trade dress, slogans, product packaging, and designs of the Services, whether or not appearing in large print or with the trademark symbol, belong exclusively to Alphatelemed.com or its licensors and are protected from reproduction, imitation, dilution, or confusing or misleading uses under national and international trademark and copyright laws. The use or misuse of these trademarks or any materials, except as authorized herein, is expressly prohibited, and nothing stated or implied on the Services confers on you any license or right under any patent or trademark of Alphatelemed.com, its affiliates, or any third party.
VII. PASSWORD SECURITY
You are solely responsible for the security of your username and password, and for any use of the Services using your username and password. You should not share your username or password with any third party or allow any third party to access the Services using your username and password. You agree to notify us if you have any reason to believe that your username or password has been lost, compromised, or misused in any way. We reserve the right to revoke or deactivate your username and password at any time.
VIII. WEBSITE AND THIRD-PARTY CONTENT
Other than information received directly by you from Providers, the content on the Services should not be considered medical advice. You should always talk to an appropriately qualified health care professional for diagnosis and treatment, including information regarding which medications or treatment may be appropriate for you. NONE OF THE CONTENT ON THE SERVICES REPRESENTS OR WARRANTS THAT ANY PARTICULAR MEDICATION OR TREATMENT IS SAFE, APPROPRIATE, OR EFFECTIVE FOR YOU. Alphatelemed.com does not recommend or endorse any specific tests, providers, medications, products, or procedures.
The Services may provide links to third-party content. You acknowledge and agree that we are not responsible for the availability of such third-party content, and we do not control, endorse, sponsor, recommend, or otherwise accept responsibility for such content. Use of any linked third-party content is at the user’s own risk.
- CONSENT TO SERVICES
The Service respects and upholds patient confidentiality with respect to protected health information as outlined by the Health Insurance Portability and Accountability Act (“HIPAA”), and, subject to HIPAA regulations, will obtain express patient consent prior to sharing any patient-identifiable information to a third party for purposes other than treatment, payment or health care operations. In addition, by clicking the “AGREE” button you are authorizing Providers to release your contact information to Alphatelemed.com solely in order for Alphatelemed.com to provide you with information about additional clinical services or general wellness. You may opt out of receiving such information by contacting us at privacy@Alphatelemed.com.com. Finally, when using the Service you may be asked if you would like to share certain PHI collected by Apple Health with Alphatelemed.com. By clicking on “SYNC” you are authorizing Alphatelemed.com to collect and Providers to utilize such PHI.
By clicking the “AGREE” button, you also acknowledge the importance of providing a record of your clinical encounters via the Services to your primary care provider. At the end of your consultation, you will have the option to send this record to your primary care provider via email and we encourage you to do so.
- CONSENT FOR TREATMENT PERFORMED
We are providing this information on behalf of Providers:
Telemedicine involves the use of communications to enable health care providers at sites remote from patients to provide consultative services. Providers may include primary care practitioners, specialists, and/or subspecialists. The information may be used for diagnosis, therapy, follow-up and/or education, and may include live two-way audio and video and other materials (e.g., medical records, data from medical devices).
The communications systems used will incorporate reasonable security protocols to protect the confidentiality of patient information and will include reasonable measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption. At the end of each encounter, the patient will be provided an encounter summary, which may be kept for the patient’s records and may be shared with the patient’s local primary care or other provider, as appropriate.
Anticipated Benefits of Telemedicine
- Improved access to medical care by enabling a patient to remain at his or her home or office while consulting a clinician.
- More efficient medical evaluation and management.
Possible Risks of Telemedicine
As with any medical procedure, there are potential risks associated with the use of telemedicine. Provider believes that the likelihood of these risks materializing is very low. These risks may include, without limitation, the following:
- Delays in medical evaluation and consultation or treatment may occur due to deficiencies or failures of the equipment.
- Security protocols could fail, causing a breach of privacy of personal medical information.
- Lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other negative outcomes.
By accepting these Terms, you acknowledge that you understand and agree with the following:
- I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine; I have received the HIPAA Notice which explains these issues in greater detail.
- I understand that telemedicine may involve electronic communication of my personal medical information to medical practitioners who may be located in other areas, including out of state.
- 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 others (including health care providers and health insurers) for treatment, payment, and healthcare operations purposes. Psychotherapy notes are maintained by clinicians but are not shared with others, while billing codes and encounter summaries are shared with others and with me. If I obtain psychotherapy from Provider, I understand that my therapist has the right to limit the information provided to me if in my therapist’s professional judgment sharing the information with me would be harmful to me.
- I further understand that my healthcare information may be shared in the following circumstances:
- a) When a valid court order is issued for medical records.
- b) Reporting suspected abuse, neglect, or domestic violence.
- c) Preventing or reducing a serious threat to anyone’s health or safety.
Patient Consent to the Use of Telemedicine
I have read and understand the information provided above, and understand the risks and benefits of telemedicine, and by accepting these Terms I hereby give my informed consent to participate in a telemedicine visit under the terms described herein.
- DISCLAIMER OF WARRANTIES; LIMITATION OF LIABILITY
YOUR USE OF THE SERVICES IS AT YOUR OWN RISK. THE SERVICES ARE PROVIDED “AS IS” WITHOUT WARRANTIES OF ANY KIND, EITHER EXPRESS OR IMPLIED, INCLUDING WITHOUT LIMITATION WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, OR OTHER VIOLATION OF RIGHTS. WE DO NOT WARRANT THE ADEQUACY, CURRENCY, ACCURACY, LIKELY RESULTS, OR COMPLETENESS OF THE SERVICES OR ANY THIRD-PARTY SITES LINKED TO OR FROM THE SERVICES, OR THAT THE FUNCTIONS PROVIDED WILL BE UNINTERRUPTED, VIRUS-FREE, OR ERROR-FREE. WE EXPRESSLY DISCLAIM ANY LIABILITY FOR ANY ERRORS OR OMISSIONS IN THE CONTENT INCLUDED IN THE SERVICES OR ANY THIRD-PARTY SITES LINKED TO OR FROM THE SERVICES. SOME JURISDICTIONS MAY NOT ALLOW THE EXCLUSION OF IMPLIED WARRANTIES, SO SOME OF THE ABOVE EXCLUSIONS MAY NOT APPLY TO YOU.
IN NO EVENT WILL WE, OR OUR PARENTS, SUBSIDIARIES, AFFILIATES, LICENSORS, SUPPLIERS AND THEIR DIRECTORS, OFFICERS, AFFILIATES, SUBCONTRACTORS, EMPLOYEES, AGENTS, AND ASSIGNS BE LIABLE FOR ANY DIRECT OR INDIRECT, SPECIAL, INCIDENTAL, CONSEQUENTIAL OR PUNITIVE DAMAGES, LOST PROFITS, OR OTHER DAMAGES WHATSOEVER ARISING IN CONNECTION WITH THE USE OF THE SERVICES, ANY INTERRUPTION IN AVAILABILITY OF THE SERVICES, DELAY IN OPERATION OR TRANSMISSION, COMPUTER VIRUS, LOSS OF DATA, OR USE, MISUSE, RELIANCE, REVIEW, MANIPULATION, OR OTHER UTILIZATION IN ANY MANNER WHATSOEVER OF THE SERVICES OR THE DATA COLLECTED THROUGH THE SERVICES, EVEN IF ONE OR MORE OF THEM HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH DAMAGES OR LOSS. BECAUSE SOME JURISDICTIONS DO NOT ALLOW THE EXCLUSION OR LIMITATION OF INCIDENTAL OR CONSEQUENTIAL DAMAGES, ALPHATELEMED.COM’S LIABILITY IN SUCH JURISDICTIONS SHALL BE LIMITED TO THE MAXIMUM EXTENT PERMITTED BY LAW.
YOU AGREE THAT YOUR SOLE REMEDY FOR ANY CLAIM ARISING OUT OF OR CONNECTED WITH THE SERVICES WILL BE TO CEASE USING THE SERVICES.
YOU ACKNOWLEDGE AND AGREE THAT ALPHATELEMED.COM IS NOT ENGAGED IN THE PRACTICE OF MEDICINE AND THAT ALPHATELEMED.COM IS NOT DETERMINING APPROPRIATE MEDICAL USE OF THE SERVICES. ALPHATELEMED.COM, ITS LICENSORS, SUPPLIERS, AND ALL THIRD PARTIES WHO PROMOTE THE SERVICES OR PROVIDE YOU WITH A LINK TO THE SERVICES EXPRESSLY DISCLAIM ANY AND ALL LIABILITY RESULTING FROM THE DELIVERY OF HEALTHCARE VIA THE SERVICE, INCLUDING BUT NOT LIMITED TO LIABILITY FOR MEDICAL MALPRACTICE.
YOU AGREE TO INDEMNIFY, DEFEND AND HOLD US AND OUR PARENTS, SUBSIDIARIES, AFFILIATES, LICENSORS, SUPPLIERS AND THEIR DIRECTORS, OFFICERS, AFFILIATES, SUBCONTRACTORS, EMPLOYEES, AGENTS, AND ASSIGNS HARMLESS FROM AND AGAINST ANY AND ALL LOSS, COSTS, EXPENSES (INCLUDING REASONABLE ATTORNEYS’ FEES AND EXPENSES), CLAIMS, DAMAGES AND LIABILITIES RELATED TO OR ASSOCIATED WITH YOUR USE OF THE SERVICES AND ANY ALLEGED VIOLATION BY YOU OF THESE TERMS. WE RESERVE THE RIGHT TO ASSUME THE EXCLUSIVE DEFENSE OF ANY CLAIM FOR WHICH WE ARE ENTITLED TO INDEMNIFICATION UNDER THIS SECTION. IN SUCH EVENT, YOU SHALL PROVIDE US WITH SUCH COOPERATION AS WE REASONABLY REQUEST.
XIII. CHOICE OF LAW AND FORUM
The Services are intended for use by residents of the United States. We do not intentionally provide access to the Services to individuals located outside the United States. You agree that your access to and use of the Services will be governed by and will be construed in accordance with the laws of the Commonwealth of Massachusetts without regard to principles of conflicts of laws. You agree that any claim or dispute against us arising out of or relating to the Services must be resolved by a federal district court located in Boston, Massachusetts, unless agreed upon by all parties.
These Terms constitute the entire agreement between you and us, superseding any prior or contemporaneous communications and proposals (whether oral, written or electronic) between you and us. In the event any provision of these Terms is held unenforceable, it will not affect the validity or enforceability of the remaining provisions and will be replaced by an enforceable provision that comes closest to the intention underlying the unenforceable provision. You agree that no joint venture, partnership, employment, or agency relationship exists between you and us as a result of these Terms or your access to and use of the Services.
Our failure to enforce any provisions of these Terms or respond to a violation by any party does not waive our right to subsequently enforce any terms or conditions of the Terms or respond to any violations. Nothing contained in these Terms is in derogation of our right to comply with governmental, court, and law enforcement requests or requirements relating to your use of the Services or information provided to or gathered by us with respect to such use.
CURRENT PROCEDURAL TERMINOLOGY (“CPT”)
CPT Copyright © 2016 American Medical Association. All rights reserved.
Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. Applicable FARs/DFARs restrictions apply to government use.
CPT is a registered trademark of the American Medical Association.
Copyright ©2008-2014 Vidyo, Inc. This product includes Vidyo Software Libraries which are covered by one or more issued or pending United States patents, as more fully detailed on the Patent Notice page of Vidyo’s website http://www.vidyo.com/about/patent-notices/, as well as issued and pending international patents.
If you are see a provider while you are located in California, please be advised that medical doctors are licensed and regulated by the Medical Board of California (800-633-2322; www.mbc.ca.gov).
I hereby certify that I am physically in my current state (you will select this state on the next page), and agree to only interact with a physician through Online Care Services while I am present in this state. I acknowledge that my ability to access and use these services is conditional upon the truthfulness of the certifications I make at the time of accessing a provider and that the Providers I access are relying upon this certification in order to interact with me.
I hereby certify that I am at least 18 years of age and am qualified under the laws of my state to make medical decisions on my own behalf. I acknowledge that my ability to access and use the Alphatelemed.com.com system and information is conditional upon the truthfulness of my certification of age.
Informed Consent to Services Performed by Alphatelemed.com (Alpha Healthcare Services and Solutions LLC DBA Alphatelemed.com).
Hello, and Welcome! This document contains important information about our telehealth/telemedicine services and policies. Please read the following closely and raise any questions you may have with your provider prior to signing.
What is Telehealth?
Telehealth involves the use of two-way, telecommunications technology, such as video-chat, whereby a clinician renders healthcare services from one location to a patient who is located at another location. Such clinicians may include physicians, counselors, nurse practitioners, therapists, and others. Telehealth services may include diagnosis, consultation, treatment, counseling services, education, care coordination, and other healthcare services.
Benefits & Risks
The provision of services via telehealth technology presents risks that may arise, despite reasonable efforts on the part of Alphatelemed.com. However, there are also key benefits to telehealth services. We encourage you to consider these risks and benefits before agreeing to receive services through us.
· Improved access to services by enabling the patient to connect with clinicians remotely from the comfort of the patient’s home
· Eliminating transportation barriers
· Eliminating or shortening appointment wait times
· Improved access to care through the availability of a wide range of experts
· Increased capacity of clinicians to devote time to patients
· More efficient care management and care coordination
· Increased efficiency and convenience of use—including online scheduling and communication with counselors
· Improved team treatment model through virtual collaboration
· Improved psychosocial and satisfaction outcomes for patients
· Providing an alternative to in-person interaction for patients who otherwise might be resistant to seeking in-person care in a clinic setting
· In rare cases, information transmitted through telecommunications technology may not be sufficient to allow for appropriate clinical decision-making.
· Delays in clinical evaluation and treatment could occur due to deficiencies or failures of the equipment or connections.
· In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information.
· You compromise your own confidentiality if you do not place yourself in a private area.
Alternatives to Alphatelemed.com
If you prefer not to receive services virtually, Alphatelemed.com may be able to provide you with an opportunity to receive in-person services, depending on availability, or we may refer you to a different provider.
Privacy and Security
Alphatelemed.com DOES NOT provide emergency healthcare services. If, at any time, you believe you are experiencing a medical emergency or other health-related crisis, call 911 or go to the nearest emergency room. If you experience suicidal thoughts or plans to harm yourself, you may also contact your local crisis center or call the National Suicide Prevention Lifeline at 1.800.273.TALK (8255) for free, 24/7 hotline support.
Alphatelemed.com provides non-emergency, telehealth and in-person services by scheduled appointment. Our clinicians are not available on a 24-hour basis and may not be available on demand. If an Alphatelemed.com clinician determines that your healthcare needs are outside of scope of our practice, we are legally obligated to refer you to another provider.
Alphatelemed.com has a strict “No Recording” policy. You may not record any of your sessions, whether they take place in person or via telehealth, without your provider’s consent.
By signing this consent form, I acknowledge and agree that I have read and understood the above disclosures. I further understand and agree that:
- I have the option to withhold my consent to receive services at this time or to withdraw this consent at any time, including at any point during an appointment, without affecting my right to future care, treatment, or risking the loss or withdraw of any program benefits to which I would otherwise be entitled.
- I may expect the anticipated benefits from the use of telemedicine in my care but that no results can be guaranteed or assured.
- I will not record any visits with my provider, whether they take place in person or via telehealth.
- There are potential risks associated with telehealth services, including, but not limited to, the possibility, despite reasonable efforts on the part of Alphatelemed.com and its clinicians, that the transmission of my personally identifiable information could be disrupted or distorted by technical failures; the transmission of my personally identifiable information could be intercepted by unauthorized persons; and/or the electronic storage of my personally identifiable information could be accessed by unauthorized persons. Although Alphatelemed.com takes steps to ensure the confidentiality and privacy of virtual communications, these actions, in whole or in part, cannot guarantee the security of online transmissions. I am solely responsible for ensuring the privacy of my surroundings when receiving services from Alphatelemed.com.
- If my Alphatelemed.com clinician believes I would be better served by another type or means of services (e.g., in-person services), I may be referred to a provider of such services in my area.
- There are potential risks and benefits associated with any form of healthcare services and that, despite my efforts and the efforts of my clinician, my condition may not improve and, in some cases, may worsen.
- There are alternative means of accessing Alphatelemed.com services, and I may choose one or more of these alternatives at any time. Alphatelemed.com has explained the available alternatives to my satisfaction.
- It is my responsibility to ensure the privacy and security of Alphatelemed.com information or records stored on or accessible by any device I may use in the course of receiving Alphatelemed.com services (e.g., computer, smartphone).
- Neither I nor my attorney will call on my clinician to testify in court or at any other legal or administrative proceeding.
I am free to refuse services at any time, and I have the right to terminate treatment at any time.
I understand that I will not conduct video visits while driving or any unsafe location. It is illegal and dangerous. The provider cannot conduct the appointment in any unsafe environment.
I understand I will provide a physical address in Virginia and P.O. are not acceptable for Telehealth/Telemedicine practice.
Authorization and Consent for Treatment:
Assignment of Benefits and Authorization to Release Medical Information
I authorize and understand that payment of benefits under Medicare, Medicaid, and/or any other insurance company, will be made on my behalf to the provider, for services furnished to me by that provider. I authorize any holder of my medical information to release it to Alphatelemed.com division of Alpha Healthcare Services and Solutions LLC, the Health Care Financing Administration, listed insured and/or agents of the company and/or the listed responsible person(s), any information needed to determine these benefits or the benefit for the related services. In the event that my insurance plan is out of the to Alphatelemed.com division of Alpha Healthcare Services and Solutions LLC network, or if I am a self-pay patient, assignment of benefits may not apply. I certify that the information I have reported with my insurance coverage and demographics is correct.
I permit a copy of this authorization to be used in place of the original. This authorization may be revoked by either me or my insurance company at any time in writing.
As a component of my care, I understand and agree that Alphatelemed.com division of Alpha Healthcare Services and Solutions LLC may contact me using phone calls, text messages to my landline or calls and emails sent to my mobile device. These communications may notify me of test results, treatment recommendations, outstanding balances, or any other communication from the medical group.
Patient Financial Obligation Agreement:
I understand and agree that all applicable co-payments and deductibles are due at the time of service. I agree to be financially responsible and make full payment for all charges not covered by my insurance company. I authorize my insurance benefits be paid directly to Alphatelemed.com for services rendered. I authorize representatives of Alphatelemed.com to release pertinent medical information to my insurance company when requested or to facilitate payment of a claim.
All visits are by appointment only:
Unless your follow-up appointment has been scheduled for you during your session, it is your responsibility to schedule (and reschedule as necessary) follow-up appointments through the patient portal. Outside of exceptional circumstances, where you are unable to access the patient portal or use email, please do not call the clinic for appointment inquiries, changes, or cancellations.
Cancellations and rescheduling of follow-up appointments should be made at least 24 business hours in advance by calling or texting. Failure to do so will result in additional charges as follows:
No Show/late cancellation (less than 24 hours in advance): $50 fee self/pay not billable to insurance.
If your provider at Alphatelemed.com prescribe a controlled medication, you must read and agree to the following policy. Controlled medicine can be dangerous and habit forming. These medicines must be taken only as prescribed by your doctor. Please read this consent and agreement thoroughly and ask any questions you may have.
If you are in agreement and fully understand the benefits and risks of the medications, sign and date below:
• I understand that the medication I am being prescribed may cause addiction, but my provider feels it is necessary for treatment of my condition. My provider has explained to me the potential risks, the potential short and long term side effects; the risk of drug interactions and over-sedation; the risk of misuse
and overdose. I accept these risks.
• I agree to take this medication only as prescribed by my provider.
• I agree to attend all scheduled appointments with my provider, NP or Medical Assistant.
• I understand that refills will not be given early.
• I will not obtain controlled substances from any other providers unless authorized by my primary prescriber, because it may be considered illegal to obtain controlled substances from multiple providers. • I understand that these medications are for my personal use only.
• I understand that it is illegal, and can be reported to the police, to give or sell my medication to others. • I agree to not use any illegal substances, including but not limited to marijuana, cocaine, or any other “street drugs”.
• I understand that it is illegal for me to use medications that are not prescribed to me.
• I understand that I am responsible for my own medication. Lost or stolen medication will not be replaced.
• I give up the right to privacy protections with regard to my prescription for controlled substances. The provider or his staff may talk with other providers, pharmacists or family members to confirm appropriate medication use.
• I agree to submit to random drug screening tests when ordered by my provider, and I will be responsible for payment for the tests.
• If requested of me, I agree to bring my medication bottle(s) to the office for the purpose of a pill count.
• I understand that I may obtain my controlled substances from only one pharmacy and it will be in VIRGINIA, and I agree to update my provider’s office of any changes in the pharmacy I use.
• I understand these medications may interfere with my ability to drive and/or operate heavy machinery.
• I understand this agreement is entered the date it is signed and completed.
• I have reviewed this Informed Consent and Treatment Agreement for Controlled Substances. I understand it and continue to agree to honor the Agreement. I understand that failure to do so may result in my discharge from this medical practice.