Healthcare LDMTS Agreement

HEALTHCARE LDMTS AGREEMENT

This Healthcare LDMTS Agreement ("Agreement") establishes the terms under which Long-Distance Medical Telehealth Services ("LDMTS") will be provided by the healthcare provider identified below to the patient identified below. By completing and signing this Agreement, Patient consents to telehealth evaluation, treatment, and related administrative activities as described herein, and acknowledges the limits, risks, and conditions of such services.

Parties and Effective Date

Effective Date:

Scope of LDMTS

Provider shall deliver telehealth services including live interactive audio and video consultation, remote monitoring, and store-and-forward transmission of medical data where appropriate. Telehealth services may include initial evaluation, follow-up care, medication management, and coordination with other healthcare professionals. Telehealth services do not replace emergency care; for urgent or emergency situations, Patient must seek immediate in-person emergency services.

Patient Information

Insurance Information

Medical History and Current Health Status

Consent to Telehealth Services

Patient authorizes Provider to provide LDMTS as described in this Agreement. Patient acknowledges that telehealth involves the use of electronic communications to enable Provider to deliver care at a distance. Patient understands that telehealth may include transmission of medical information, images, and other data necessary for diagnosis, treatment, follow-up and care coordination.

Risks and limitations include, but are not limited to: technical failures beyond Provider control; limited ability to perform physical examinations; reduced fidelity of transmitted images or data; and delays or interruptions. There is no guarantee that telehealth care will be equivalent to in-person care for all conditions. Patient accepts these limitations and agrees to follow Provider instructions regarding when in-person evaluation is required.

Patient has the right to withdraw consent at any time by providing written notice to Provider. Withdrawal of consent will not affect the lawfulness of care provided prior to receipt of revocation.

Privacy, Security and HIPAA Authorization

Provider will use reasonable administrative, technical, and physical safeguards to protect the privacy and security of protected health information exchanged in connection with telehealth. However, Patient acknowledges that no method of electronic communication is completely secure and that breaches may occur. Patient further authorizes Provider to disclose medical information to other treating providers, payers, or health information exchanges as necessary for treatment, payment, and healthcare operations.

Authorization Expiration Date:

Fees, Billing and Insurance

Patient is responsible for fees for telehealth services not covered by insurance. Provider will bill Patient or Patient's insurer as indicated below. Patient must verify benefits with their insurer and is responsible for co-payments, co-insurance, deductibles, and any services denied by insurance.

Technical Requirements and Patient Responsibilities

Patient is responsible for ensuring they have a compatible device, reliable internet connection, and a private environment suitable for clinical discussion. Patient agrees to inform Provider of any change in contact information, medical status, or technology access that may affect delivery of telehealth services.

Emergency Protocols

Telehealth is not appropriate for emergencies. If Patient experiences an emergency or life-threatening condition during or between telehealth visits, Patient must call emergency services or proceed to the nearest emergency facility. Provider will attempt to contact Patient's emergency contact as necessary.

Termination, Revocation, and Amendment

Either party may terminate this Agreement for any reason upon written notice. Patient may revoke any authorizations provided herein in writing; revocation will not affect disclosures or actions already taken in reliance on prior authorization. Provider may amend terms of telehealth services subject to notice to Patient as required by law.

Representations, Warranties and Liability

Patient represents that responses to clinical intake and medical history questions are accurate to the best of Patient's knowledge. Provider will exercise professional clinical judgment in the provision of LDMTS. To the extent permitted by law, Provider's liability for any claims arising from telehealth services is limited to direct damages and shall exclude punitive, consequential, and incidental damages.

Governing Law and Dispute Resolution

This Agreement shall be governed by the laws of the state in which Provider is licensed, except to the extent preempted by applicable federal law. Any dispute arising from this Agreement shall be resolved through negotiation and, if necessary, non-binding mediation prior to initiating litigation, unless emergency injunctive relief is required.

Acknowledgment and Certification

By signing below, Patient certifies that they have read and understand this Agreement, that all information provided is true and correct, that Patient consents to receive LDMTS as described, and that Patient has had the opportunity to ask questions and receive answers regarding the nature, benefits, and risks of telehealth services.

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