K Health Informed Consent for Telehealth Services

Before you give your informed consent to request and receive healthcare services remotely (“Virtual Care Services”), please be aware of how obtaining health services remotely from physicians and other licensed health care professionals (together, the “Providers”) through an online virtual care platform and properties offered by K Health, Inc. (the “Platform”) differs from in-person care. 

The Providers are affiliated with one or more of the following professional entities: Knowledge Health Medical Services, P.C. (NY), Knowledge Health Medical Services, P.C. (NJ), and Preventive Medicine Associates, P.C. (CA) (collectively, “K Health Professional Entities”). If you are connecting with a Provider in NJ or CA, you will be served by the  NJ or CA professional entity, respectively. All other locations will be served by Knowledge Health Medical Services, P.C. (NY). In this Informed Consent, the terms “K Health,” “we”, “us”, or “our” refers to the K Health Professional Entities. The terms “you” and “yours” refer to the patient using the Platform to request Virtual Care Services from Providers. Please read each item carefully.

Expected benefits of Virtual Care Services include improved access to medical care by enabling you to consult with a Provider remotely, more efficient medical evaluation and management, and obtaining the expertise of a Provider who is in a different location from you.   

As with any medical care and treatment, there are potential risks associated with the use of Virtual Care Services.  These risks are rare and may include, but may not be limited to, the following: information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision making by the Provider; delays in medical evaluation and treatment due to deficiencies or failures of the equipment; security protocols could fail, causing a breach of privacy of personal medical information; and, a lack of access to complete medical records could result in adverse drug interactions, allergic reactions, or other errors. There may be other risks to remote care services that are not currently known.

Emergencies

You understand and agree that you should never use the Platform in a medical emergency. You understand and agree that in a medical emergency you should dial 911 or visit an emergency room. Our services are not designed for acute treatment of severe behavioral health systems. In the event you are experiencing emotional distress, please contact the National Suicide Prevention Hotline: Crisis Text Line at 1-800-273-8255, text 988, or text “Home” to 741-741, to obtain immediate assistance.

Service Description

You understand and agree that the Providers provide clinical care services using the Platform as part of an overall primary care practice, however, it is not a remote full-service medical practice. We refer to the Virtual Care Services offered through the Platform and the Platform technology collectively as the “Services”. You understand that your use of the Services is voluntary, and you can withdraw your consent or seek in-person treatment at any time. 

You understand that your use of the Services involves asynchronous and synchronous communications and the electronic transmission of medical information and other data between you and the Provider(s).

You understand and agree that, as part of the Virtual Care visit, you may not be able to select a specific Provider.  

In using the Services, you understand that you will be given your treating Provider’s name and credentials, including whether they are a physician or an advanced practice professional (such as a nurse practitioner). If you are receiving treatment from an advanced practice professional (e.g. a nurse practitioner) and would like to speak to a physician, you may request to speak to a physician, although you understand that there could be a delay in service. 

You understand that state medical licensure laws require that you be seen by a Provider who is licensed to practice in the state where you are located at the time of the Virtual Care Service and therefore you agree and represent that you will use the Virtual Care Services only when you are physically located in the state you reported on the Platform and that you will notify your Provider immediately if you are no longer located in such state at the time of the Virtual Care visit.

You understand and agree that by using the Platform to receive the Services, you will not have an in-person physical examination from the treating Provider that might identify a potentially serious medical condition, and that the absence of an in-person physical examination may affect the Provider’s ability to diagnose any potential condition, disease, or injury. In addition, you understand and agree that any diagnosis you receive may be limited and that the Services are not intended, in all cases, to replace a full medical evaluation or an in-person visit with a health care provider. Your Provider may not be able to diagnose, treat you or identify need for emergency medical care or other treatment, if you require an in-person physical exam or any other test that requires a follow-up visit or if you present with potential symptoms or conditions that we do not treat remotely based on our medical policies and Provider judgment.  In addition, you understand that Providers utilizing the Service may be limited by applicable law, regulations, policies, and standards in prescribing certain medications to you without first conducting an in-person physical examination.

You understand and agree that there is no guarantee that any prescription will be written for you through the Services.  All decisions whether to prescribe are based on the Provider’s independent medical judgment. The Providers do not prescribe U.S. Drug Enforcement Administration controlled substances, such as those containing opioids.  

To the extent a prescription is written for you through the Services, you understand that you  can choose to fill a prescription at a pharmacy of your choice.

You Understand and agree Providers reserve the right to deny care for actual or potential misuse of the Service.

You understand and agree that the health and medical information you provide through the Platform may be the only source of information used by Providers during the course of your evaluation and treatment through the Platform, and that such Providers may not have access to any other health information held by your previous medical providers (e.g., allergies, drug reactions, etc.)  if they are not affiliated with the K Health Professional Entities or be able to otherwise confirm the health information you inform them about. Such lack of access to your prior medical history or ability to perform an in-person examination, may result in negative health outcomes. 

Any care that you receive is based on your symptoms and other information you provide or upload to the Platform or your Provider(s) and care team. You certify that the information, including your geographic location, you provide using the Platform is true, accurate, and complete, and may serve as the basis of any diagnosis and treatment by your Provider. You understand and agree that the Providers you access through the Platform are relying upon this certification in order to interact with you.   You understand and agree that if you provide false, misleading, or incomplete information to a Provider, it may have a negative effect on your treatment and your health. 

You understand and agree that you need to be responsive to ongoing requests for information from your Provider(s) and care team, including but not limited to completion of ongoing assessments about your symptoms and side effects during your treatment, and to consent to access to prior medical information, including your prescription history. If you are not responsive to these requests for information, you understand that you cannot be considered to be under the care of the Provider and/or that the Provider may refuse to treat you (or continue to treat you, as applicable). You understand that a variety of alternative methods of medical care may be available to you, and that you may decide to stop using the Services and choose one or more of these alternative modes of care at any time. 

You understand that the Provider that you consult with may have a financial interest in organizations to which they refer, including K Pharmacy LLC.  You may choose any organization to obtain health care services. 

When receiving Services from a Provider, you may be required to upload a copy of your identification card (e.g. drivers’ license, state ID) and a self-photograph (“selfie”) for verification purposes, location purposes, evaluation and treatment purposes and healthcare operation purposes.  

You understand and agree that as part of the verification process, our service providers may utilize biometric measurements and analysis to compare the image obtained from your ID and selfie. Such biometric measurements will be deleted once they are no longer required.

Nature of Electronic Services

You understand that the electronic nature of the Service means that there is a greater risk to the privacy of your electronic health information relative to receiving in-person care. For information about the privacy and security practices as well as our information sharing practices, please read the K Health’s  Privacy Policy and our Joint Notice of Privacy Practices.

You understand that information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical or health-care decision making by the Provider. 

You understand and agree that, due to emergencies, scheduling, technological difficulties, and other circumstances, we cannot warrant or otherwise guarantee, that you will have access to the Services, including to the Providers, and that technical and other failures could lead to loss of information, delays in medical evaluation, treatment and failure to obtain needed treatment. You hereby release and hold harmless the Providers, K Health and their service providers, agents and representatives for such delays and failures.

You understand that if you are experiencing technical difficulties through the Platform, you may email [email protected].

In accordance with all applicable data privacy laws, you hereby authorize the release of your medical records or other information necessary for treatment, care coordination, processing, billing and collecting payment for Services you received, which may include communication with your Sponsor Organization, and for other purposes relating to healthcare operations as further described in our Joint Notice of Privacy Practices. You understand that such release of your medical records and information may include parties that are out of the state in which you were provided with the Services.

You understand and agree that we will share your information with K Health, Inc. and other third party vendors in order to provide you with the Services. 

You understand, agree, and expressly consent to K Health obtaining, using, storing, and disseminating to necessary third parties, information about you, as necessary to provide Services through the Platform. Any sharing of your information will be done in accordance with all applicable data privacy laws.  

You understand and agree that, for so long as you continue to receive Services, you authorize K Health and its Providers to access your past medical information, including your prescription history, from pharmacies that have filled prescriptions, other healthcare providers, and medical data aggregators of such information to allow for the Providers to use this information for your treatment purposes.  

In addition, you hereby authorize the release of information identifying you as a patient, your medical records and/or other information to health information exchanges or similar organizations (“HIE”) that allow K Health, your Providers and other health care providers, insurers and other third parties to electronically access and share your medical information via the HIE. 

You may opt out from such participation, subject to applicable law, by sending an email to [email protected].  If you opt out, K Health Professional Entities will exclude your medical records from the HIEs in which K Health participates.  If you opt out, we will not share information about your Services, except we may share or may have shared information about your Services prior to you opting out. Your request to opt out is not immediate; upon receiving your request to opt out, there will be a reasonable time period for us to process your request.

You understand that under applicable state laws, Providers may be required to report suspicions of child abuse, neglect, statutory rape, domestic violence, and sexual assault. In addition, if your Provider believes that you may be a danger to yourself or others, then your Provider may need to share information with your emergency contact or send care to you by calling 911, other emergency services or initiating a welfare check. You hereby release and hold harmless K Health and Providers for Provider’s good faith compliance with state mandatory reporting laws and good faith emergency contacts.

In addition, you agree to the following in connection with the Service:

  1. Data, chat text, audio, video, and/or digital photos may be recorded;
  2. Details of your medical information may be discussed with you and the Providers via the Service using electronic technology, including chat, audio, video, and/or graphics technology;
  3. Virtual examination of you may take place; and
  4. Medical personnel and non-medical technical personnel may join the visit, virtually, to aid in delivery of medical care to you or for the purpose of improving the Service.

Payments

You may be required to provide your credit card details and payment authorization prior to your visit with a Provider.  You understand that if you do not provide your credit card information and applicable payment authorization,  your visit may be canceled.

You understand that, except as explicitly stated otherwise, the fees paid to K Health cover only the professional services provided by these entities and do not cover (i)  cost of medication (unless explicitly stated otherwise), (ii) any ancillary services; (iii) any services provided by any party other than your Provider; (iv) hospital services, emergency room visits, or urgent care facility visits; (v) appointments with other providers or specialists referred to you by a Provider; (vi) radiology; (vii) lab tests; and (viii) durable medical equipment  (collectively, the “Excluded Services”).  You understand and agree that your Provider is not responsible for any medical or other bills incurred for any Excluded Services, even if your Provider has referred you for such services.  If your Provider makes an outside referral, you should contact your insurance provider to check your coverage for such referred service.

To the extent that you receive the Services pursuant to our agreement with your Sponsor Organization (as defined in the K Health Terms of Service) , you understand and hereby authorize your insurance benefits be paid directly to the applicable K Health Affiliated Entity.  You acknowledge that it is your responsibility to understand the benefits and limitations on benefits under your insurance or health plan and the applicable arrangement (to the extent any) with the K Health Professional Entities and  to contact your insurance carrier/health plan if you have questions. 

You understand and agree that although we may bill your Sponsor Organization for services you receive from our affiliated Providers, you will be responsible for payment for any amount not paid by your  Sponsor Organization, or your insurance plan and/or benefit program, as permitted by applicable law. Further, you accept that you are financially responsible for all co-payments or deductibles as dictated by your insurance plan and benefit program. You understand that it is your responsibility to arrange and pay for any follow-up care that the Provider recommends you receive.  You agree to promptly pay any owed amounts for which you responsible. If your account is referred to an attorney or collection agency for collection, you agree to pay actual attorney’s fees and collection expenses. All delinquent accounts shall bear interest at the legal rate, unless prohibited by law.

Membership

If you are enrolled in our Membership Plan(s) (as defined by the K Health Terms of Service), you understand that we are not an insurance company and any Membership Plan offered does not meet any individual health mandate that may be required by federal law.  You further understand that this document is not a health insurance plan or policy, a health benefit plan nor a discount medical plan as otherwise described by applicable laws and that  it only pertains to a limited set of services provided by the Providers.  You further understand and agree and acknowledge that: (i) if you are uninsured you may still be subject to tax penalties under the Patient Protection and Affordable Care Act for failing to obtain insurance; and (ii) that our Membership Plans have exclusions as further described in the K Health Terms of Service. If you are a Medicare or Medicaid enrollee or insured by other health insurance plans, you may be entitled to receive similar digital healthcare services from a provider enrolled in Medicare or your state’s Medicaid program or other arrangements, as applicable, at little or no cost to you. 

If you are enrolled in our Membership Plan, you understand and agree to be bound by the terms of the Plan and the terms set forth in the K Health Terms of Service .  as may be revised from time to time.   

If you are enrolled in our Membership Plan, your membership is effective upon your acceptance of this document and continues for the same duration as your initial Membership Plan.  Your Membership Plan will be automatically renewed unless you provide us with notice of at least 48 hours to the end of the applicable Membership Term of your wish to not renew your Membership Plan.  By enrolling to our Membership Plan and providing us with your payment information, you authorize us (without notice to you, unless required by applicable law) to automatically renew your membership periods and collect the membership fees and any taxes, using any payment method we have on record for you.

We may terminate or suspend your use of the Service at any time and without prior notice, if Company believes that you have violated or acted inconsistently with the letter or spirit of this document or the Terms of Service.  Upon any such termination, your right to use the Service will immediately cease, and we may, without liability to you or any third party, immediately deactivate or delete your user name, password, and account, and all associated materials, without any obligation to provide any further access to such materials; however, we will provide you with access to any of your health records in our possession that were generated as a result of the Services in accordance with applicable legal, ethical, and professional obligations.

Text Messages, Push Notifications and Emails

You agree to receive electronic communications from your Providers, K Health and their affiliates, agents, representatives, suppliers and service providers, including but not limited to email communications, push notification, calls (including automated calls) and SMS text messages (including automated messages) about services we provide and your care. For example, you may be notified by e-mail, push notification and SMS when you have an upcoming visit, new information is available for you on the Platform, if you have outstanding tasks information regarding your billing information and charges, or the availability of new or additional services. This means that any person with access to your e-mail or phone (including technology providers) will be able to see the notice. While the e-mail, push or SMS message may ask you to log in to your account to retrieve the detailed information, you need to understand that the email, push notification or SMS will disclose that you have a relationship with us and an activity or a particular task or need for follow up on the Platform. Accordingly, it will be your responsibility to use an email address and a phone number that provides you with the level of confidentiality you desire. 

You can opt-out of from receiving emails, calls and text messages by contacting customer service at [email protected], replying STOP to any such message, and for push notifications, through your device settings.  You acknowledge that opting out may impact your ability to use certain features of the Service. If you wish to withdraw your consent to receive future electronic communications, you must unsubscribe from each service you consented to hereunder in order to completely withdraw from electronic communications.  Any withdrawal of your consent to electronic communications will be effective only after there has been a reasonable period of time to process such withdrawal request.

Upon your request, you may receive a paper copy of any communication that was provided to you electronically.  If you would like a paper copy of any such communication, please email [email protected]  There will be no charge for any paper copy.

All communications in either electronic or paper format from us to you will be considered to be in writing.  You should print or download a copy of this Informed Consent and any other electronic communication that is important to you for your records.

Your consent to receive communications relating to the Service in electronic form may also include, but shall not be not limited to:  (i) any initial disclosure statement or agreement governing your access to or use of the Service ; (ii) any disclosure statement or agreement required by federal, state, provincial, territorial, or local law, including any disclosure or agreement pursuant to the federal Health Insurance Portability and Accountability Act (iii) any notice, alert, or letter regarding your access to or use of the Service; (iv) any other disclosures, notices, or communications in connection with the Service.

You acknowledge that by clicking on the “I Agree,” “Register,” “Continue,” or any similar button provided in connection with this Informed consent, you are indicating your intent to sign up for electronic communications, and that such action shall constitute your signature.

For additional information regarding your Platform account and electronic communications please refer to K Health, Inc. Terms of Service

You acknowledge and agree that (i) your consent is being provided in connection with a transaction affecting interstate commerce that is subject to the federal Electronic Signatures in Global and National Commerce Act; and (ii) you and the Providers, and their affiliates, agents, representatives, suppliers, and service providers, intend that the Act apply to the fullest extent possible to validate the ability to conduct business and communicate with you by electronic means.

You further understand and agree that:

  • You are at least eighteen (18) years of age.
  • You will be located at the time of your visit(s) in the state you identified during registration, and, that you will notify your Provider immediately if you are no longer located in such a state at the time of your Virtual Care visit.
  • You have read and understood the information above, including the benefits, risks and limitations of using the Platform for the Services and agree to the use of the Services to examine, consult, diagnose, or treat you.
  • No assurances or guarantees have been made concerning the outcome and/or results of any medical treatment or services provided by our Providers or otherwise related to the Service.
  • Our Providers may determine that our clinical services are not appropriate for some or all of your treatment needs and may determine not to provide Services to you through the Platform.
  • This Informed Consent will become a part of your medical record;
  • You have the right to access your medical information created during use of the Services or to have the medical information forwarded to a third-party or alternative provider, including but not limited to your primary care provider.
  • If you are providing consent to treat a minor under the age of 18, you hereby swear and declare that you are the parent or legal guardian of the minor listed below and that there are no court orders preventing you from granting this Consent to provide Services to the minor. 
  • We have the right to discontinue Services to you at any time and for any reason subject to applicable law and professional standards.

You acknowledge that by clicking on the “I Agree,” “Register,” “Continue,” or any similar button provided in connection with this Informed consent, you carefully reviewed this document, understand the risks associated of the use of telehealth in the medical care and treatment provided to me by the Providers, and give your informed consent to all consents and terms of this Informed Consent.

Additional State Specific Consents and Notices  – Applicable to patients accessing the Service within state specified below

California

Open Payments Notice

For informational purposes only, a link to the federal Centers for Medicare and Medicaid Services (CMS) Open Payments web page is provided below. 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 devices, 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.

Notice to Patients

Medical doctors are licensed and regulated by the Medical Board of California. For more information, please visit: http://www.mbc.ca.gov or contact tel:8006332322. 

Nurse practitioners are licensed and regulated by the Board of Registered Nursing. For more information, please visit: http://www.rn.ca.gov or contact tel:9163223350 

 By clicking Accept below, you understand that (i) physicians are licensed and regulated by the Medical Board of California, and (ii) Nurse Practitioners are regulated by the Board of Registered Nursing of California.

Connecticut, Ohio, Utah, and Texas- If you would like your medical records to be forwarded to another provider, please include the name and contact information in a message to your Provider.Florida – Each provider is a physician licensed by the Florida Board of Medicine or the Florida Board of Osteopathic Medicine.  Each Provider’s hours are variable.

Georgia

NOTICE CONCERNING COMPLAINTS

You have the right to file a grievance with the Georgia Composite Medical Board, concerning the physician, staff, office, and treatment received. You should send a written complaint to the board. You should be able to provide the physician or practice name, the address, and the specific nature of the complaint. Complaints or grievances may be reported to the Board at the following address or telephone number:

Georgia Composite Medical Board
Attn: Complaints Unit
2 Martin Luther King Jr. Drive SE
11th floor, East Tower
Atlanta, GA 30334
(404) 656-3913
www.medicalboard.georgia.gov

Iowa– You understand and agree that if you want to register a formal complaint about a Provider, you can visit the medical board’s  website (https://medicalboard.iowa.gov/consumers/filing-complaint).

Idaho– You understand and agree that if you want to register a formal complaint about a Provider, You can visit the medical board’s website (https://elitepublic.bom.idaho.gov/IBOMPortal/AgencyAdditional.aspx?Agency=425&AgencyLinkID=650).

Indiana– You understand and agree that if you want to register a formal complaint about a Provider, you can visit the medical board’s website or the Consumer Protection Division Office of the Indiana Attorney General (https://www.in.gov/attorneygeneral/consumer-protection-division/consumer-complaint/).  

Kansas – Notice to Patients – Required Signage for K.A.R. 100-22-6 Prepared by the State Board of Healing Arts April 5, 2007: It is unlawful for any person who is not licensed under the Kansas Healing Arts Act to open or maintain an office for the practice of the healing arts in Kansas.  Services are provided by a person who is licensed to practice the healing arts in Kansas. Questions and concerns regarding this professional practice may be directed to:  KANSAS STATE BOARD OF HEALING ARTS 800 SW Jackson, Lower Level – Suite A, Topeka, Kansas 66612 — PHONE: (785) 296-7413 TOLL FREE: 1(888) 886-7205 FAX: (785) 368-7102: www.ksbha.org.

Kentucky– You understand and agree that if you want to register a formal complaint about a provider, you can visit the medical board’s website (https://kbml.ky.gov/grievances/Pages/default.aspx).

Louisiana – In addition to any informed consent and right to privacy and confidentiality pursuant to state and federal law or regulations, you shall be informed of the relationship between the Provider, you and the respective role of any other health care provider with respect to the management of your care and treatment; and you may decline to receive Services and may withdraw from such care at any time. 

Maine- You understand and agree that if you want to register a formal complaint about a Provider, you can visit the medical board’s website (https://www.maine.gov/md/complaint/file-complaint).

Oklahoma–  You understand and agree that if you want to register a formal complaint about a provider, you should visit the medical board’s website, here (https://www.okmedicalboard.org/complaint); or, the Oklahoma Board of Osteopathic Examiners’ website (https://osboe.us.thentiacloud.net/webs/osboe/register/#/complaint-form).

Oregon– You understand and agree that if you want to register a formal complaint about a Provider, You can visit the medical board’s website (https://www.oregon.gov/omb/investigations/Pages/How-to-File-a-Complaint.aspx)

Rhode Island–  You understand and agree that if you want to register a formal complaint about a Provider, You can visit the medical board’s website (https://ohic.ri.gov/consumer-protection).

Texas– NOTICE CONCERNING COMPLAINTS – Complaints about physicians, as well as other licensees and registrants of the Texas Medical Board, including physician 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 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 sitio web en www.tmb.state.tx.us.

Vermont: You understand and agree that if you want to register a formal complaint about a Provider, You can visit the medical board’s website (https://www.healthvermont.gov/systems/medical-practice-board); Or, the Vermont Office of Professional Regulation’s website (https://sos.vermont.gov/opr/complaints-conduct-discipline/).

Wisconsin– You have the right to request and receive information within a reasonable period of time after your request the fees charged for a health care service, diagnostic test, or procedure provided by K Health.