Telehealth agreement

Telehealth services offered by Innovative Care Florida, P.A. (“Group”), and the Group’s engaged providers (our “Providers” or your “Provider”) may include a patient consultation, diagnosis, treatment recommendation, prescription, and/or a referral to in-person care, as determined clinically appropriate (the “Services”). Your Provider will be licensed in the state where you are located at the time of your consultation, or otherwise meet a professional licensure exception under applicable state law, and will establish a provider-patient relationship in accordance with the laws and rules in the applicable state.

Eve Adam Health LLC does not provide the Services; it performs administrative, payment, and other supportive activities for Group and our Providers.

The types of electronic transmissions that may occur using the telehealth platform include, but are not limited to:

• Completion of medical intake forms;
• Exchange and review of patient medical intake forms, health records, images, diagnostic and/or lab test results via asynchronous communications;
• Delivery of a consultation report;
• Prescription refill reminders; and/or
• Other electronic transmissions for the purpose of rendering clinical care to you.

Improved access to care by enabling you to remain in your preferred location while your Provider consults with you. Our telehealth services are available 24 hours a day, 7 days a week.

Convenient access to follow-up care. If you need to receive non-emergency follow-up care related to your treatment, please contact your Provider by directly sending a message through your patient user account.

More efficient care evaluation and management. Our Physicians and agents work Monday – Friday 9am – 5pm. Any electronic consultations, messages or emails sent after 5pm or weekends will be reviewed the next working day. You may experience some delay during the Covid-19 pandemic.

The primary difference between telehealth and direct in-person service delivery is the inability to have direct, physical contact with the patient. Accordingly, some clinical needs may not be appropriate for a telehealth visit and your Provider will make that determination.

OUR PROVIDERS DO NOT ADDRESS MEDICAL EMERGENCIES. IF YOU BELIEVE YOU ARE EXPERIENCING A MEDICAL EMERGENCY, YOU SHOULD DIAL 9-1-1 AND/OR GO TO THE NEAREST EMERGENCY ROOM. PLEASE DO NOT ATTEMPT TO CONTACT EVE ADAM HEALTH LLC, GROUP, OR YOUR PROVIDER. AFTER RECEIVING EMERGENCY HEALTHCARE TREATMENT, YOU SHOULD VISIT YOUR LOCAL PRIMARY CARE PROVIDER.

Our Providers are an addition to, and not a replacement for, your local primary care provider. Responsibility for your overall medical care should remain with your local primary care provider, if you have one, and we strongly encourage you to locate one if you do not.

Group does not have any in-person clinic locations.

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. All the Services delivered to the patient through telehealth will be delivered over a secure connection that complies with the requirements of the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”).

Delays in evaluation and treatment could occur due to deficiencies or failures of the equipment and technologies, or provider availability.

In the event of an inability to communicate as a result of a technological or equipment failure, please contact the Group at +1 (646) 905-0239

In rare events, your Provider may determine that the transmitted information is of inadequate quality, thus necessitating a rescheduled telehealth consult or an in-person meeting with your local primary care doctor.

In very rare events, security protocols could fail, causing a breach of privacy of personal medical information.

I further acknowledge and understand the following:

1. Prior to the telehealth visit. With the next available provider from the Group, I will be given my Provider’s credentials.
2. If I am experiencing a medical emergency, I will be directed to dial 9-1-1 immediately and my Provider is not able to connect me directly to any local emergency services.
3. I may elect to seek services from an independent medical group with in-person clinics as an alternative to receiving telehealth services.
4. I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time without affecting my right to future care or treatment.
5. Federal and state law requires health care providers to protect the privacy and the security of health information. I am entitled to all confidentiality protections under applicable federal and state laws. I understand all medical reports resulting from the telehealth visit are part of my medical record.
6. Group will take steps to make sure that my health information is not seen by anyone who should not see it. Telehealth may involve electronic communication of my personal health information to other health practitioners who may be located in other areas, including out of state.
7. Dissemination of any patient identifiable images or information from the telehealth visit to researchers or other educational entities will not occur without my affirmative consent.
8. There is a risk of technical failures during the telehealth visit beyond the control of the Group. I AGREE TO HOLD HARMLESS GROUP AND ITS EMPLOYEES, CONTRACTORS, AGENTS, DIRECTORS, MEMBERS, MANAGERS, SHAREHOLDERS, OFFICERS, REPRESENTATIVES, ASSIGNS, PARENTS, PREDECESSORS, AND SUCCESSORS FOR DELAYS IN EVALUATION OR FOR INFORMATION LOST DUE TO SUCH TECHNICAL FAILURES.
9. In choosing to participate in a telehealth visit, I understand that some parts of the Services involving tests (e.g., labs or bloodwork) may be conducted at another location such as a testing facility, at the direction of my Provider.
10. Persons may be present during the telehealth visit other than my Provider in order to operate the telehealth technologies. If another person is present during the telehealth visit, I will be informed of the individual’s presence and his/her role.
11. My Provider will explain my diagnosis and its evidentiary basis, and the risks and benefits of various treatment options.
12. I have the right to request a copy of my medical records and I understand upon my affirmative consent my medical records will be forwarded directly to my local primary care provider or other designated health care provider of record. I can request to obtain or send a copy of my medical records by contacting the group on customercare@eveadam.com. A copy will be provided to me at a reasonable cost of preparation, shipping and delivery. I understand that proof of my ID will be requested for this purpose.
13. It is necessary to provide my Provider a complete, accurate, and current medical history. I understand that I can log into my “Eve Adam Patient Profile area at any time to access, amend, or review my health information.
14. There is no guarantee that I will be issued a prescription and that the decision of whether a prescription is appropriate will be made in the professional judgement of my Provider. If my Provider issues a prescription.
15. There is no guarantee that I will be treated by a Group provider. My Provider reserves the right to deny care for potential misuse of the Services or for any other reason if, in the professional judgment of my Provider, the provision of the Services is not medically or ethically appropriate.

The following consents apply to patients accessing Group’s website for the purposes of participating in a telehealth consultation as required by the states listed below:

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

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

Indiana: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here:
https://www.in.gov/attorneygeneral/consumer-protection-division/consumer-complaint/

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

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

Oklahoma: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here:

Oklahoma Board of Medical Licensure and Supervision:
http://www.okmedicalboard.org/complaint;

Oklahoma Board of Osteopathic Examiners:
https://www.ok.gov/osboe/faqs.html;

Texas: I 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.

VermontI have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here:

Vermont Board of Medical Practice:
http://www.healthvermont.gov/health-professionals-systems/board-medical-practice/file-complaint

Vermont Board of Osteopathic Examiners:
https://sos.vermont.gov/opr/complaints-conduct-discipline