Thank you for your interest in receiving telehealth services from TRIBECA PEDIATRICS, PLLC (Tribeca). Tribeca currently offers real-time, remote telehealth visits to established patients, for certain medical conditions, through products and services offered by Zoom Video Communications, Inc. The Zoom Video Communications Platform (Platform) permit live video chatting between Tribeca and the parents and guardian. Tribeca offers telehealth services that use live video chatting function.
Consent
- I understand that Tribeca will make available telehealth services, whether the Platform or any other technology, based on Tribeca’s independent professional determinations, and that Tribeca may deem certain conditions not appropriate for telehealth services. For example, telehealth services are not the same as an in-person visit, and a health care provider using telehealth technologies does not have access to all of the information that is obtained during an in-person examination. This means that in some cases the information transmitted through the Platform, including in light of my child’s condition, may not be sufficient to allow for appropriate medical decision making, and so the telehealth service will not be provided by Tribeca, even if I request the service. I agree to accept any decision by my health care provider to not provide telehealth services at any given time, and I agree to immediately discontinue receiving telehealth services if I determine or believe that it is not appropriate or safe to continue receiving the services.
- I UNDERSTAND THAT TELEHEALTH SERVICES ARE NOT APPROPRIATE FOR MEDICAL EMERGENCIES, LIFE- THREATENING CONDITIONS, OR OTHER URGENT MEDICAL MATTERS. I AGREE THAT FOR ALL URGENT OR EMERGENCY MATTERS I WILL IMMEDIATELY CALL 911 OR GO TO AN URGENT CARE CENTER OR TO AN EMERGENCY ROOM AT A HOSPITAL.
- I understand there are potential risks to using any telehealth technology that relies upon the Internet and personal mobile devices, such as Internet service interruptions, mobile device malfunctions, data security incidents, and other technical difficulties, and there are no guarantees that the operation of the Platform will be uninterrupted or error free.
- I understand and agree that Zoom Video Communications, not Tribeca, is solely responsible for the functionality and operation of its Platform, including with respect to malfunctions, service interruptions, returns, warranties and related matters.
- I understand that use of the Platform for telehealth services will be subject to the terms and conditions of the mobile phone carrier and data usage plans in which I participate, including that charges may apply.
- I understand that Tribeca’s regular financial and scheduling policies apply to Tribeca’s telehealth services, including, for example, Tribeca’s Office and Financial Policy. I ALSO UNDERSTAND THAT Tribeca’s TELEHEALTH SERVICES MAY NOT, IN WHOLE OR IN PART, BE COVERED BY MY HEALTH INSURANCE POLICY OR HEALTH PLAN. I further understand that as consistent with applicable laws and the policies of my health insurance policy or health plan, I will be responsible to pay Tribeca for all Tribeca telehealth services not covered by my health insurance policy or health plan, and it is my responsibility to understand my coverage. IF YOUR CARRIER DOES NOT COVER TELEMEDICINE SERVICES, YOU WILL BE RESPONSIBLE FOR THE $95 SELF-PAY FEE.
- I understand that use of the Platform for telehealth services requires that I am located within New York State, New Jersey, or California.
I have read and fully understand these terms of service. I have had the opportunity to ask my doctor and other Allied health professionals questions about this Consent Form and the telehealth services offered by Tribeca. The risks, benefits, and alternatives to telehealth services have been discussed with me in a manner that I understand, and my questions have been answered to my satisfaction.
I hereby consent to and authorize Tribeca to provide these telehealth services, as Tribeca deems medically necessary, and I acknowledge that no guarantees have been made to the results that may be obtained.