Telehealth Informed Consent and Agreement

Telehealth Informed Consent and Agreement

Zeus Men’s Health, a Professional Corporation

 

BY CLICKING “I AGREE,” CHECKING A RELATED BOX TO SIGNIFY YOUR ACCEPTANCE, USING ANY OTHER ACCEPTANCE PROTOCOL PRESENTED THROUGH THE SERVICE OR OTHERWISE AFFIRMATIVELY ACCEPTING THIS CONSENT, YOU ACKNOWLEDGE THAT YOU HAVE READ, ACCEPTED, AND AGREED TO BE BOUND BY THIS CONSENT. IF YOU DO NOT AGREE TO THIS CONSENT, DO NOT CREATE AN ACCOUNT OR USE THE SERVICE

 

Introduction

Telehealth involves the use of electronic communications to enable healthcare providers to evaluate, diagnose, consult, treat, and educate patients remotely. Telehealth includes video calls, phone consultations, secure messaging, and other digital communication methods.

Purpose

The purpose of this form is to obtain your informed consent to participate in telehealth services. Your participation in telehealth is voluntary, and you have the right to withdraw consent at any time without affecting your access to future care.

Nature of Telehealth Services

Telehealth services may include, but are not limited to:

• Medical evaluations and diagnosis
• Treatment recommendations
• Prescription of medication when appropriate
• Follow-up consultations
• Health education and counseling

Benefits of Telehealth

• Increased access to healthcare services
• Convenience of receiving care from home or another location
• Reduced travel time and associated costs
• Faster access to specialists or consultations

Risks of Telehealth

• Limitations of virtual examinations compared to in-person visits
• Potential for technical failures (e.g., poor internet connection, software issues)
• Possible unauthorized access due to security vulnerabilities, despite efforts to maintain confidentiality
• Delayed treatment due to lack of physical examination

Confidentiality & Security

Telehealth consultations will be conducted using secure, HIPAA-compliant technology to protect your privacy. However, there is always a risk of data breaches. You are encouraged to conduct telehealth sessions in a private, secure location to maintain confidentiality. (Please see separate privacy policy for details regarding this policy)

Patient Responsibilities

• Ensure you have a stable internet connection or phone service
• Use a private and secure location for telehealth sessions
• Accurately disclose medical history, symptoms, and concerns
• Follow the healthcare provider’s instructions for treatment and follow-up
• Notify your provider if you experience any adverse effects from treatment

Financial Responsibility

Telehealth services may be covered by your insurance provider, but coverage may vary. It is your responsibility to verify with your insurance company whether telehealth services are included in your plan. If not covered, you may be responsible for any out-of-pocket costs.

Open Payments Notice

For informational purposes only, a link to the federal Centers for Medicare and Medicaid Services Open Payments web page is provided here. The federal Physician Payments Sunshine Act requires that detailed information about payment and other payments of value worth over ten dollars ($10) from manufacturers of drugs, medical device, and biologics to physicians and teaching hospitals be made available to the public. 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.

 

Use of Third-Party Laboratories

Our website partners with third-party laboratories for certain medical tests and analyses. While we strive to work with reputable laboratories, we do not own, operate, or control these third-party entities. As such, we are not responsible for any inaccuracies in test results, laboratory errors, or any issues arising from their services. Any concerns regarding laboratory testing should be directed to the respective laboratory provider.

Use of Third-Party Pharmacies

Our website also partners with third-party pharmacies for medication fulfillment. While we strive to work with reputable pharmacies, we do not own, operate, or control these entities. As such, we are not responsible for compounding errors, inconsistent delivery of medications, late delivery of medications, or pharmacy errors. If you experience any serious or life-threatening reactions or adverse effects to a medication, call 911 immediately.

Licensed Telemedicine providers at Zeus Men’s Health, A professional corporation: 

Haad Mahmood, MD

Type: Physician and surgeon

License Number A132056

Emergency Situations

Telehealth is not appropriate for medical emergencies. IF YOU ARE EXPERIENCING A LIFE-THREATENING SITUATION SUCH AS CONTEMPLATING SUICIDE, CALL 911 OR THE 988 SUICIDE & CRISIS LIFELINE AT 988.

Consent and Acknowledgment

By signing this form, I acknowledge that:

1. I have read and understood this Telehealth Informed Consent Form.
2. I understand the risks and benefits associated with telehealth.
3. I understand that I can withdraw my consent at any time.
4. I understand that telehealth is not a substitute for emergency care.
5. I understand that the website uses third-party laboratories and that the website is not responsible for any laboratory errors or inaccuracies.
6. I understand that the website uses third-party pharmacies and that the website is not responsible for any pharmacy errors, medication delivery issues, or compounding errors.

 

 By using this service, you agree to receive healthcare and mental health services through telehealth technology—which may involve nurse practitioners, physician assistants, or licensed mental health professionals, rather than physicians. Because the telehealth technology is still evolving and may be in a beta phase, there is a possibility of technical issues (such as bugs or errors) that could affect the quality or accuracy of the care and services you receive.

Telehealth may not be suitable for all medical conditions, and there is no guarantee of specific benefits or results. Your provider will decide whether telehealth is appropriate for diagnosing or treating your condition. You have the right to discuss any concerns, benefits, and risks of telehealth with your provider, as well as to explore other options. You can withdraw your consent for telehealth services at any time, but the providers on this service do not offer in-person care. Any withdrawal of consent will not affect care already provided under the previous consent.

You understand that using this service involves electronic communication (e.g., email) of your personal and medical information. It is your responsibility to provide accurate and complete information, including details about any other healthcare or mental health treatment you have received or are receiving. If, at any point, your provider decides your condition is unsuitable for telehealth, you may need to seek in-person care or see a specialist. By continuing to use the service, you accept your provider’s decision to treat you via telehealth.