Telehealth Consent
Effective Date: 3/1/2025
This Telehealth Consent (“Consent”) explains how telehealth services are provided by Rebecca Martel, APRN, FNP-BC (doing business as “Certicare”) and your rights and responsibilities when receiving telehealth services. By acknowledging or signing this form (electronically or otherwise), you consent to receive healthcare services via telehealth from Certicare’s licensed healthcare providers (“Providers”).
1. Definition of Telehealth
1.1 Telehealth Services
Telehealth involves the delivery of healthcare services using electronic communications, such as secure messaging, forms, video, audio, and other digital tools, instead of in-person visits. Interactions may be synchronous or asynchronous. Our Providers may consult with you, diagnose, treat, and potentially prescribe medication (if appropriate and legally permissible) through these digital communications.
1.2 Asynchronous Modality
Certicare offers asynchronous telehealth services, which means you may complete forms and communicate with Providers via secure messaging. You understand that asynchronous telehealth can have certain limitations, including the inability to see or hear you in real time. These limitations may affect the Provider’s ability to fully diagnose or treat certain conditions.
2. Nature and Limitations of Telehealth
2.1 Potential Benefits
- Access to care if you cannot travel to an office.
- More convenient and flexible scheduling.
- Reduced time away from work or family.
2.2 Potential Risks
- Telehealth may not provide the same level of information as an in-person visit, which could affect diagnosis or treatment.
- Delays or disruptions in communication due to technical failures (e.g., internet issues).
- In rare cases, security protocols could fail, causing a breach of privacy or personal medical information.
2.3 Appropriateness of Telehealth
- Our Providers will determine if your condition is suitable for evaluation and treatment through a telehealth visit.
- You may need an in-person evaluation or emergency care if your condition appears severe or complicated.
3. Services Provided
3.1 Scope of Practice
- Certicare’s telehealth services focus on mild illnesses and stable chronic conditions.
- We do not serve patients on Medicaid or Medicare, and we do not provide emergency or crisis services.
- We do not provide certain types of documentation, such as insurance claims, disability, or workers’ compensation paperwork.
3.2 Prescriptions
- Certcare does not dispense medications directly.
- Any prescriptions issued by our Providers will be filled by an independent pharmacy; you are responsible for any medication costs.
3.3 Referrals
If your condition cannot be adequately addressed via telehealth, Certicare or its Providers may refer you to another healthcare professional or instruct you to seek in-person care.
4. Patient Eligibility and Responsibilities
4.1 Age and Location
- You certify that you are at least 18 years of age and located in a U.S. state where Certicare has a licensed Provider.
- You agree to provide accurate information regarding your current location and state of residence.
4.2 No Emergencies
- You understand that telehealth with Certicare is not appropriate for emergency or life-threatening conditions.
- In a medical emergency, call 911 or go to the nearest emergency department.
4.3 Truthful and Accurate Information
You agree to provide complete, accurate, and current health information through the forms and questions provided. If you withhold or falsify information, it may impact the quality of care you receive.
5. Privacy and Confidentiality
5.1 Protected Health Information (PHI)
- Your personal health information is confidential and protected by federal and state privacy laws, including HIPAA.
- We use secure software and encryption to protect your information, but no electronic communication system is entirely without risk.
5.2 Privacy Policy
Please review our Privacy Policy for details on how we collect, use, disclose, and protect your information. By consenting to telehealth, you also agree to the terms of our Privacy Policy.
6. Technology Requirements
6.1 Electronic Communications
- Telehealth visits may occur through secure messaging and forms provided by Certicare or third-party vendors like Typeform.
- You are responsible for the security of your own devices and internet connection.
6.2 Possible Technical Issues
You understand that technical problems may occur. You agree to promptly inform Certicare’s support team at 518-254-8905 or support@certicare.org if you experience any technical difficulties that prevent you from completing your telehealth visit.
7. Risks, Benefits, and Alternatives
7.1 Acknowledgment of Risks
- You acknowledge that telehealth may be limited by the Provider’s inability to conduct certain physical examinations or tests.
- You acknowledge there is a small risk of unauthorized access due to the nature of electronic communications.
7.2 Potential Benefits
- Telehealth allows for convenient access to care and may prevent unnecessary travel.
- It can provide more immediate access to a Provider for certain conditions.
7.3 Alternatives
- An alternative to telehealth is an in-person visit at a traditional healthcare setting.
- You have the right to refuse or withdraw consent for telehealth at any time without affecting your right to future care or treatment.
8. Financial Responsibility
8.1 Service Fees
You acknowledge and agree to pay the fees for telehealth services as outlined on Certicare.org or in communications provided by Certicare. These fees do not include the cost of prescribed medications or other treatments.
8.2 Refunds
- Refunds are only provided if (i) Certicare cannot provide services (e.g., no licensed Provider in your state), or (ii) you cancel before the evaluation.
- Once an evaluation by a Provider has taken place, no refund will be issued.
9. Right to Withdraw Consent
You may withdraw your consent to receive telehealth services at any time by contacting Certicare at support@certicare.org or calling 518-254-8905. Withdrawing consent will not affect any action taken before your withdrawal, including any diagnoses or prescriptions that have already been issued. However, withdrawing consent may limit your ability to receive further telehealth services from Certicare.
10. Consent to Telehealth
By clicking “I Agree,” signing electronically, or otherwise indicating your acceptance of this Telehealth Consent:
- You acknowledge that you have read or had this form read to you.
- You understand the risks, benefits, and alternatives of telehealth.
- You consent to receive telehealth services from Certicare and its Providers.
- You understand that you can ask questions at any time and can request a copy of this Consent.
11. Contact Information
- Address:
Certicare
418 Broadway #4220
Albany, NY 12207 - Customer Support:
- Phone: 518-254-8905
- Email: support@certicare.org
