Telehealth Informed Consent

Thank you for choosing Jasper Health Services Florida, LLC (“Jasper Health”), Cloud Health Medical Group, PA, Cloud Health Medical Group of California, PC, Cloud Health Medical Group of New Jersey, PC, and Cloud Health Medical Group of Kansas, PA, (collectively “Cloud Health Medical”). You are viewing this form because you have elected to receive services from us.

Services Provided

Besides receiving clinical assessments through telehealth (“Telehealth Services”) provided by our team of providers (including physicians, clinical psychologists, and/or licensed clinical social workers), you may also receive one or more care management services (“Virtual CM Services”) from our team of providers (comprising physicians, clinical psychologists, licensed clinical social workers, clinical staff, and/or auxiliary staff).

Telehealth/Virtual CM Services entail the use of interactive video conferencing equipment and devices, enabling healthcare providers to deliver services remotely. By acknowledging this form, I confirm my understanding of the following:

During the visit, I will not physically be in the same location as my healthcare provider; instead, our interaction will be facilitated through video conferencing technology.
Prior to any involvement of additional Jasper Health and Cloud Health Medical staff or trainees in the visit, I will be informed about their participation and asked for my consent.
Various risks are associated with Telehealth/Virtual CM Services, including potential disruptions due to technology failures, limited emergency response capabilities of the healthcare provider, as well as the risk of interruptions or breaches of confidentiality by unauthorized individuals.
While Jasper Health and Cloud Health Medical take reasonable steps to secure Telehealth/Virtual CM Services, it’s important to recognize that no technology is entirely foolproof, and breaches, although rare, can occur.
There’s a possibility that either myself or my healthcare provider may determine that the video conferencing equipment or connection is inadequate for the visit. In such cases, alternatives such as switching to an approved alternate video conferencing service or making other arrangements may be necessary to continue the visit.
During a Telehealth/Virtual CM Services visit, there’s a chance that certain medical conditions may not be identified which would typically be detected during an in-person consultation.
I retain the right to refuse or discontinue participation in Telehealth/Virtual CM Services at any time. Any such decision will be duly noted in my medical record. However, it’s important to understand that refusal or discontinuation may have implications for future care or treatment at Jasper Health and Cloud Health Medical.
The laws governing the privacy and confidentiality of healthcare information extend to Telehealth/Virtual CM Services. However, it’s noted that certain information may need to be shared with authorized individuals for purposes such as scheduling appointments and billing.
I understand that payment policies for Telehealth/Virtual CM Services may differ from those applicable to in-person visits, and I acknowledge any such distinctions.
I understand that during the telehealth visit, I must be physically located in a state where my provider is licensed, or my provider will not be able to conduct the visit, and it will need to be rescheduled. If I am in a state other than the state I previously provided at the time of my visit, I will tell the provider’s office before the visit to confirm that they can see me.
I have had all my questions about this telehealth service answered to my satisfaction. The risks, benefits, and alternatives to telehealth visits have been shared with me in a language I understand.

Your Care Team

At Jasper Health and Cloud Health Medical, we prioritize a collaborative approach to your care. Your Telehealth/Virtual CM Services are coordinated by a healthcare provider who, along with our clinical social worker and patient/care navigator, will develop your personalized care plan. Our healthcare provider and clinical social worker supervise the care provided by our auxiliary staff.

Upon initiating Telehealth/Virtual CM Services, you will be assigned a dedicated patient/care navigator. This individual will serve as your primary contact point within our organization, ensuring seamless communication and support throughout your care journey.

Telehealth vs. Virtual CM Services

Telehealth encompasses the delivery of comprehensive healthcare services, spanning examination, consultation, diagnosis, and treatment, leveraging electronic communication technologies. This method allows you, the patient, to access care from your healthcare provider regardless of your physical location. Jasper Health and Cloud Health Medical facilitates this service, enabling you to receive care without the need for travel or separate appointments, thereby minimizing wait times typical of in-person visits.

During your telehealth appointment, our healthcare provider may engage in discussions regarding your mental health, medical history, and personal health information utilizing interactive video, audio, and telecommunication technologies.

It’s worth noting that our Virtual CM Services may not be classified as telehealth by certain insurance providers. Consequently, they may not be subject to identical billing, location, and supervision restrictions as conventional telehealth services.

Benefits of Telehealth and Virtual CM Services

Telehealth offers numerous advantages, such as the ability to access healthcare services wherever there is internet connectivity, including the convenience of your own home. With telehealth, the waiting period for an in-person appointment is significantly reduced, sparing you from prolonged delays. Additionally, telehealth eliminates the need for extensive travel to access specialized care that might not be locally available.

Our Virtual CM Services extend further support beyond clinical visits, providing ongoing assistance without necessitating travel for in-person appointments.

Possible Risks of Telehealth and Virtual CM Services

As with any mental health and/or medical treatment, there are potential risks associated with the use of Telehealth/Virtual CM Services. While Jasper Health and Cloud Health Medical assess that the likelihood of encountering these risks is minimal, it’s important to acknowledge their existence.

These risks may encompass, but are not limited to, the following:

Due to Jasper Health and Cloud Health Medical not having access to your entire mental health or medical records, failure to disclose your complete mental health and/or medical history—including diagnoses, treatments, and medications/supplements—to your healthcare provider could result in adverse outcomes.
Telehealth/Virtual CM Services are NOT emergency services and your Personal Data (as defined in the Jasper Health Privacy Policy) WILL NOT BE MONITORED 24/7. If you think you are experiencing a mental health emergency, SEEK SERVICES IN YOUR AREA IMMEDIATELY. If you think you are experiencing a medical emergency, CALL 911 IMMEDIATELY.

THE CARE YOU RECEIVE WILL BE AT THE SOLE DISCRETION OF THE HEALTHCARE PROVIDER WHO IS TREATING YOU, WITH NO GUARANTEE DIAGNOSIS OR TREATMENT.

This Telehealth Informed Consent is valid during my entire treatment with Jasper Health and Cloud Health Medical. If I would like to withdraw consent, I must do so prior to receiving any further services by emailing us at [email protected]. I have the right to withdraw my consent to participate in the services at any time, and my withdrawal of consent will not affect my right to future care or treatment. I understand that declining or withdrawing consent may limit my services and may not allow for the full benefits of the Services. I acknowledge that such a decision may entail consequences, and I recognize the importance of discussing any concerns or inquiries with my healthcare provider.

Communication and Follow-up

I acknowledge the significance of maintaining open and honest communication with my healthcare provider. I agree to furnish accurate and comprehensive information regarding my medical history, current medications, allergies, and any other pertinent details. Furthermore, I understand the importance of adhering to any post-treatment instructions provided and attending follow-up appointments as advised.

Authorization for Medical-Decision Making

I hereby authorize Jasper Health and Cloud Health Medical, along with its healthcare providers, to make essential medical decisions on my behalf in the event that I am unable to do so. I entrust these decisions to be made based on their professional judgment and in accordance with relevant laws and regulations.

Choice of Pharmacy Services

By using the Telehealth/Virtual CM Services and receiving a prescription, I have the option to select the pharmacy through which I wish to fulfill my prescription. By providing consent, I authorize Jasper Health and Cloud Health Medical to share and disclose all pertinent information, including information provided by me, health care records, and other relevant health care and personal details (such as my name, location, and demographic information), with the pharmacy of my choice. This facilitates the provision of pharmacy services and ensures seamless fulfillment of my prescription.

Your Rights and Acknowledgements

I understand that my personal mental health and/or medical information may be shared with others in compliance with Jasper Health Notice of Privacy Practices and regulations or laws in the state or territory in which I’m located. Further, Telehealth/Virtual CM Service may involve electronic communication of my personal mental health and/or medical information to remote mental health practitioners who may be located outside of my state.

I have the same privacy rights via telehealth that I would have during an in-person visit.
I understand that no results can be guaranteed or assured—I may not achieve the anticipated benefits of the services.
I understand that a variety of alternative methods of mental health and/or medical care may be available to me, and that I may choose one or more of these at any time.

I understand that some information submitted to Jasper Health and Cloud Health Medical may be part of my health record, and I may or may not have the right to review and receive copies of certain health records that pertain to me. For more information on my right to access my health records, please contact us at [email protected].

Financial Responsibility

I acknowledge that standard charges may apply for the Telehealth/Virtual CM Services provided. I understand I may receive services from multiple healthcare providers, and I acknowledge that each healthcare provider involved in my care may bill separately for their services rendered. I agree to promptly address any questions or concerns regarding billing with the billing department or the respective healthcare provider’s office. I am responsible for any copayments, coinsurance, deductibles, or other fees as specified in my insurance plan. Payment is expected at the time services are rendered, unless alternative arrangements have been agreed upon in advance. Additionally, I am accountable for any services not covered by my insurance, including those deemed experimental, investigational, or exceeding benefit limits, as determined by my insurance plan.

Jasper Health and Cloud Health Medical will submit claims to my insurance carrier on my behalf. However, it is my responsibility to ensure the accuracy and currency of all insurance information provided at the time of service. In cases where insurance coverage cannot be verified, full payment may be required upfront.

Outstanding balances not covered by insurance are to be settled within 30 days of receiving a statement. Failure to address outstanding balances beyond 90 days may result in collections action, unless prior payment arrangements have been established. Patients are liable for any fees associated with collection efforts, including but not limited to, collection agency and legal fees.

Assignment of Benefits

By signing this document, I agree to assign benefits payable for eligible claims to the physician or other healthcare provider responsible for electronically submitting my claims to my insurance payer. I further authorize my insurance payer to issue payments directly to Jasper Health and Cloud Health Medical, the physician, or other healthcare provider. This assignment encompasses insurance benefits payable for both current and future services.

In the event that my claim(s) are declined or not covered by the insurer/plan administrator, I understand that I remain responsible for payment to the physician or other healthcare provider for any services rendered and/or supplies provided.

If you are a federal health program beneficiary, you agree that neither you, Cloud Health Medical, the affiliated physician practices, or any of the health care organization(s) or provider(s) with whom Cloud Health Medical partners with to provide health care and pharmacy services to you 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.

Guarantor Agreement

I understand and agree that:

I—or the person signing or guaranteeing payment for me (Guarantor)—am responsible for any charges not covered by my insurance, for any reason.

I can ask for an estimate of the charges based on the Jasper Health or Cloud Health Medical pricelist (“chargemaster”) in effect at the time of service. This estimate may need to be prepared and mailed to me. It will only be an estimate. Actual costs may vary.

Jasper Health or Cloud Health Medical may bill my insurance for me. But Jasper Health or Cloud Health Medical may also ask me to pay in full in advance, unless Jasper Health or Cloud Health Medical agrees with my insurance company or other payer not to do this.

I may be billed by Jasper Health or Cloud Health Medical.

I am responsible for all charges and that this agreement covers all Jasper Health and Cloud Health Medical accounts, including, but not limited to those for doctors, nurse practitioners, physician assistants, principal illness navigators, and licensed clinical social workers. Should my bill be sent for collection, I will pay any costs that may result, including attorney’s fees, court costs, and collection agency fees associated with the collection process.

Jasper Health or Cloud Health Medical and its providers, affiliates, agents and contractors, including debt collectors, may call or text my cell or home phone using any type of artificial or pre-recorded voice or auto-dialer technology for any purpose, including billing and collections.

Jasper Health and Cloud Health Medical may access my consumer credit report to help collect what I owe or to see if I am eligible for financial aid or charity care.

Signature

By signing this document, I agree that I have read and understand the terms above, and that I understand the risks and benefits of telehealth. By accepting these terms, I give my informed consent to receive telehealth care under these terms.