DO NOT USE THIS SERVICE IF YOU MAY BE EXPERIENCING A MEDICAL EMERGENCY. In an emergency situation, please call 911 or go to the nearest emergency room.

Please carefully review this Telehealth Consent, which is intended to inform you of what you can expect in connection with the travel medicine services provided to you via telehealth technologies by Travel Guard Care CA, P.C., Travel Guard Care PLLC, and Travel Guard Care NJ, LLC (collectively the “Medical Group,” “we,” “our,” or “us”).

By clicking “I accept”, “I agree”, or similar when the option is presented to you, or by accessing or receiving travel medicine services from the Medical Group, you consent to receive the services via telehealth technologies.

YOUR TELEHEALTH PROVIDER’S CREDENTIALS. If you have any questions about your provider’s credentials, please direct them to your telehealth provider.

IMPORTANT INFORMATION REGARDING YOUR TREATMENT BY TELEHEALTH PROVIDERS, INCLUDING POTENTIAL RISKS AND BENEFITS. The Medical Group offers travel medicine services through various types of healthcare providers, including [physicians, nurses, and equivalent licensed professionals], via telecommunications technology (also referred to as “telehealth”). The services provided may also include chart review, appointment scheduling, health information sharing, and non-clinical services, such as patient education. 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. There are various benefits associated with telehealth services, including improved access to care by enabling you to remain in your home while the provider consults with you, more efficient care evaluation and management, and obtaining expertise of a specialist as appropriate. Possible risks include delays in evaluation and treatment due to deficiencies or failures of the equipment and technologies, and in rare events, our provider may determine that the transmitted information is of inadequate quality, thus necessitating a rescheduled telehealth consult or a meeting with your local primary care doctor.

At times, your provider may seek supervision or consultation with other Medical Group or non-Medical Group providers regarding your treatment or to enhance the services being provided to you. All team members are required to comply with laws regarding the privacy and confidentiality of your health information. Exceptions to confidentiality exist in certain situations, including: threat of serious harm to self or others; reasonable suspicion of abuse or neglect of a child, or abuse, neglect, or exploitation of an incapacitated or dependent adult; court order and/or subpoena; permission from you or your parent or guardian (i.e. voluntary release signed by you or your parent or guardian); during supervisory consultations or consultations between treating providers; information shared with an insurance company to collect payments; and as otherwise permitted or required by law.

FINANCIAL RESPONSIBILITY AND ASSIGNMENT OF BENEFITS. the Medical Group does not accept commercial health insurance plans and is not enrolled with federal or state health care programs, such as Medicare and Medicaid. By choosing to receive telehealth services from the Medical Group, you are specifically choosing to obtain products and services on a cash-pay basis outside of any commercial health insurance plan or federal or state health care program, and you are solely responsible for the costs of any services or products provided to you by the Medical Group. In the event any collection action is necessary to collect amounts you owe to the Medical Group, you agree to pay all expenses associated with such action, including but not limited to, collection agency fees and attorneys’ fees. If you are a federal health program beneficiary, you agree that neither you or the Medical Group will submit a claim for reimbursement to any federal or state healthcare program for the costs of the services and products provided to you through the Services.

TREATMENT AND CONFIDENTIALITY OF MINORS. In accordance with state laws, consent for treatment of a minor can only be authorized by a current legal guardian for the minor.

By clicking “I accept”, “I agree”, or similar when the option is presented to you, or by accessing or receiving telehealth services from the Medical Group, you acknowledge that you understand and agree to the following:

1. You acknowledge that you have read and understand this Telehealth Consent, have been given an opportunity to ask questions, have had your questions answered to your satisfaction, and you hereby consent to receiving services from the Medical Group via telehealth technologies. You understand that the Medical Group and its providers offer telehealth-based medical services, but that these services do not replace the relationship between you and your primary care doctor. You also understand it is up to your providers practicing through the Medical Group to determine whether or not your specific clinical needs are appropriate for a telehealth encounter.
2. If you are consenting on behalf of a minor, you represent that you are the parent or legal guardian of the minor and have legal authority to make healthcare decisions on behalf of the minor.
3. You understand that alternatives to telehealth services, such as in-person services, are available to you. In choosing to participate in telehealth services, you understand that some parts of the services involving tests may be conducted by individuals at your location, or at a testing facility, at the direction of your Medical Group provider (e.g., labs or bloodwork).
4. You understand that you may expect the anticipated benefits from the use of telehealth in your care, but that no results can be guaranteed or assured.
5. You understand that you will not be prescribed any narcotics, nor is there any guarantee that you will be given a prescription at all.
6. You understand that telehealth may involve electronic communication of your personal medical information to other health practitioners who may be located in other areas, including out of state.
7. You understand that federal and state law requires health care providers to protect the privacy and the security of health information. You understand that the Medical Group will implement reasonable safeguards designed to prevent the unauthorized use or disclosure of your health information.
8. You understand that your healthcare information may be shared with other individuals and third-party contractors for scheduling and billing purposes. Persons may be present during the consultation other than your Medical Group provider in order to operate the telehealth technologies. You further understand that you will be informed of their presence in the consultation and thus will have the right to: (a) omit specific details of your medical history/examination that are personally sensitive to you; (b) ask non-medical personnel to leave the telehealth examination; and/or (c) terminate the consultation at any time.
9. You consent to the Medical Group and third parties who work on behalf of the Medical Group (including Travel Guard Services, LLC) using and disclosing of your health information, including your Highly Confidential Information, for purposes of treatment, payment, health care operations. “Highly Confidential Information” means information about substance use disorder treatment, mental health diagnoses and treatment, HIV/AIDS testing or treatment or status, communicable or blood borne diseases, sexually transmitted diseases, and any other type of information that is given special privacy protection under state or federal laws.
10. You consent to the Medical Group and Travel Guard Services, LLC using all telephone numbers and email addresses you provide to communicate with you by telephone (including cell phone), text, email, or any automated or prerecorded messages. You acknowledge that text messages, phone calls and emails may be unencrypted and carry some risk that the information in the messages, including information about your health, could be read by an unauthorized person. You may opt-out of text messages by following the instructions in the text message.
11. You understand that there is a risk of technical failures during the telehealth encounter beyond the Medical Group’s control. You agree to hold the Medical Group harmless for delays in evaluation or for information lost due to such technical failures.
12. You understand that if you participate in a consultation, that you have the right to request a copy of your medical records which will be provided to you at reasonable cost of preparation, shipping and delivery.
13. You understand that you have the right to withhold or withdraw your consent to the use of telehealth services in the course of your care at any time, without affecting your right to future care or treatment. You understand that you may suspend or terminate use of the telehealth services at any time for any reason or for no reason. You understand that if you are experiencing a medical emergency, your Medical Group provider is not able to connect you directly to any local emergency services.
14. You acknowledge that you have read and you understand the disclosures set forth next to the state in which you are located at the time of the telehealth encounter, as set forth in the “State-Specific Disclosures” section below.

STATE-SPECIFIC DISCLOSURES. The following disclosures apply to patients located in the states listed below and participating in a telehealth consultation with the Medical Group that provides services in that state:

Alaska: You understand your primary care provider may obtain a copy of your records of your telehealth encounter. (Alaska Stat. § 08.64.364).

Arizona: You understand that all medical records resulting from a telemedicine consultation are part of your medical record. (A.R.S. § 12-2291.)

Colorado: You are informed that if you want to register a formal complaint about a provider, you should file at https://dpo.colorado.gov/FileComplaint.

Connecticut: You understand that your primary care provider may obtain a copy of your records of your telehealth encounter, and that you can revoke your consent at any time. (Conn. Gen. Stat. Ann. § 19a-906).

D.C.: You have been informed of alternate forms of communication between you and a physician for urgent matters. (D.C. Mun. Regs. tit. 17, § 4618.10).

Georgia: You have been given clear, appropriate, accurate instructions on follow-up in the event of needed emergent care related to the treatment. (Ga. Comp. R. & Regs. 360-3-.07(7)).

Iowa: You have been informed that if you want to register a formal complaint about a provider, you should visit the medical board’s website, here: https://medicalboard.iowa.gov/consumers/filing-complaint 

Idaho: You have been informed that if you want to register a formal complaint about a provider, you should visit the medical board’s website, here: https://elitepublic.bom.idaho.gov/IBOMPortal/AgencyAdditional.aspx?Agency=425&AgencyLinkID=650Il

Illinois: You have been informed that if you want to register a formal complaint about a provider, you should visit the Illinois Division of Professional Regulation at https://www.idfpr.com/admin/DPR/DPRcomplaint.asp

Indiana: As a Medicaid patient, you have the right to choose between an in-person visit or telehealth visit. You have been informed that if you want to register a formal complaint about a provider, you should visit the medical board’s website, here: https://www.in.gov/attorneygeneral/2434.htm.

Kansas: You understand that if you have a primary care provider or other treating physician, the person providing telemedicine services must send within three business days a report to such primary care or other treating physician of the treatment and services rendered to you during the telemedicine encounter. (Kan. Stat. Ann. § 40-2,212(2)(d)(2)(A)). You understand that the complaint process may be found here: http://www.ksbha.org/complaints.shtml

Kentucky: You have been informed that if you want to register a formal complaint about a provider, you should visit the medical board’s website, here: https://kbml.ky.gov/grievances/Pages/default.aspx

Louisiana: You understand the role of other health care providers that may be present during the consultation other than the telehealth provider. (46 La. Admin. Code Pt XLV, § 7511).

Maine: You have been informed that if you want to register a formal complaint about a provider, you should visit the medical board’s website, here: https://www.maine.gov/md/discipline/file-complaint.html

Maryland: Regarding audiologists, speech language pathologists, and hearing aid dispensers, you recognize the inability to have direct, physical contact with the patient is a primary difference between telehealth and direct in-person service delivery. The knowledge, experiences, and qualifications of the consultant providing data and information to the provider of the telehealth services need not be completely known to and understood by the provider. The quality of transmitted data may affect the quality of services provided by the provider. Changes in the environment and test conditions could be impossible to make during delivery of telehealth services. Telehealth services may not be provided by correspondence only. (Md. Code Regs. 10.41.06.04). You have been informed that if you want to register a formal complaint about a provider, you should visit the medical board’s website, here: https://www.mbp.state.md.us/forms/complaint.pdf.

Nebraska: If you are a Medicaid recipient, you retain the option to refuse the telehealth consultation at any time without affecting your right to future care or treatment and without risking the loss or withdrawal of any program benefits to which the patient would otherwise be entitled. All existing confidentiality protections shall apply to the telehealth consultation. You shall have access to all medical information resulting from the telehealth consultation as provided by law for access to your medical records. Dissemination of any patient identifiable images or information from the telehealth consultation to researchers or other entities shall not occur without your written consent. You understand that you have the right to request an in-person consult immediately after the telehealth consult and you will be informed if such consult is not available. (Neb. Rev. Stat. Ann. § 71-8505; 471 Neb. Admin. Code § 1-006.05). You have been informed that if you want to register a formal complaint about a provider, you should visit: https://dhhs.ne.gov/Pages/Complaints.aspx

New Hampshire: You understand that the telehealth provider may forward your medical records to your primary care or treating provider. (N.H. Rev. Stat. § 329:1-d).

New Jersey: You understand you have the right to request a copy of your medical information and you understand your medical information may be forwarded directly to your primary care provider or health care provider of record, or upon your request, to other health care providers. (N.J. Rev. Stat. Ann. § 45:1-62).

Ohio: You understand that the telehealth provider may forward your medical records to your primary care or treating provider. Ohio Admin. Code 4731-11-09(C).

Oklahoma: You have been informed that if you want to register a formal complaint about a provider, you should visit the medical board’s website, here: http://www.okmedicalboard.org/complaint.

Board of Osteopathic Examiners can be found at: https://www.ok.gov/osboe/faqs.html

Rhode Island: If you use e-mail or text-based technology to communicate with your provider, then you understand the types of transmissions that will be permitted and the circumstances when alternate forms of communication or office visits should be utilized. You have also discussed security measures, such as encryption of data, password protected screen savers and data files, or utilization of other reliable authentication techniques, as well as potential risks to privacy. You acknowledge that your failure to comply with this agreement may result in the telehealth provider terminating the relationship. (Rhode Island Medical Board Guidelines).

South Carolina: You understand your medical records may be distributed in accordance with applicable law and regulation to other treating health care practitioners. (S.C. Code Ann. § 40-47-37).

South Dakota: You have received disclosures regarding the delivery models and treatment methods or limitations. You have discussed with the telehealth provider the diagnosis and its evidentiary basis, and the risks and benefits of various treatment options. (S.D. Codified Laws § 34-52-3).

Tennessee: You understand that you may request an in-person assessment before receiving a telehealth assessment if you are a Medicaid recipient.

Texas: You understand that your medical records may be sent to your primary care physician. (Tex. Occ. Code Ann. § 111.005). You 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 

Utah: You understand (i) any additional fees charged for telehealth services, if any, and how payment is to be made for those additional fees, if the fees are charged separately from any fees for face-to-face services provided in combination with the telehealth services; (ii) to whom your health information may be disclosed and for what purpose, and have received information on any consent governing release of your patient-identifiable information to a third-party; (iii) your rights with respect to patient health information; (iv) appropriate uses and limitations of the site, including emergency health situations. You understand that the telehealth services meets industry security and privacy standards, and comply with all laws referenced in Subsection 26-60-102(8)(b)(ii). You were warned of: potential risks to privacy notwithstanding the security measures and that information may be lost due to technical failures, and agree to hold the provider harmless for such loss. You have been provided with the location of telehealth company’s website and contact information. You were able to select your provider of choice, to the extent possible. You were able to select your pharmacy of choice, to the extent possible. Your are able to a (i) access, supplement, and amend your patient-provided personal health information; (ii) contact your provider for subsequent care; (iii) obtain upon request an electronic or hard copy of your medical record documenting the telemedicine services, including the informed consent provided; and (iv) request a transfer to another provider of your medical record documenting the telemedicine services. (Utah Admin. Code r. 156-1-603).

Virginia: You acknowledge that you have received details on security measures taken with the use of telemedicine services, such as encrypting date of service, password protected screen savers, encrypting data files, or utilizing other reliable authentication techniques, as well as potential risks to privacy notwithstanding such measures; You agree to hold harmless the Medical Group for information lost due to technical failures; and you provide your express consent to forward patient-identifiable information to a third party. (Virginia Board of Medicine Guidance Document 85-12).

Vermont: You understand that you have the right to receive a consult with a distant-site provider and will receive one upon request immediately or within a reasonable time after the results of the initial consult.

You have been informed that if you want to register a formal complaint about a provider, you should visit the medical board’s website, here: http://www.healthvermont.gov/health-professionals-systems/board-medical-practice/file-complaint; Board of Osteopathic Examiners can be found at: https://www.sec.state.vt.us/professional-regulation/file-a-complaint-employer-mandatory-reporting.aspx