Telehealth Consent

‍

Effective date: June 24, 2024

‍

‍

INFORMED CONSENT REGARDING USE OF TELEHEALTH

‍

Telehealth or Telemedicine (referred to herein as “Telehealth”) involves the use of electronic communications to enable healthcare providers at different locations to share individual patient medical information for the purpose of improving patient care. Telehealth services also include remote monitoring, tele-pharmacy, prescription refills, appointment scheduling, regional health information sharing, and non-clinical services, such as education programs, administration, and public health. Practice and Providers, as those terms are defined in the Terms and Conditions, may include primary care practitioners, specialists, and/or subspecialists. The information may be used for diagnosis, therapy, follow-up and/or education, and may include any combination of the following: (1) patient medical records; (2) medical images; (3) live two-way audio and video; (4) interactive audio; and (5) output data from medical devices and sound and video files. Electronic systems used may 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. Primary responsibility for your medical care should remain with your local primary care doctor, if you have one. Your primary care doctor should also maintain responsibility for your medical record as well.

‍

BY CLICKING “I AGREE,” CHECKING A RELATED BOX TO SIGNIFY YOUR ACCEPTANCE, USING ANY OTHER ACCEPTANCE PROTOCOL PRESENTED THROUGH THE SERVICE OR OTHERWISE AFFIRMATIVELY ACCEPTING THIS CONSENT, YOU ACKNOWLEDGE THAT YOU HAVE READ, ACCEPTED, AND AGREED TO BE BOUND BY THIS CONSENT. IF YOU DO NOT AGREE TO THIS CONSENT, DO NOT CREATE AN ACCOUNT OR USE THE SERVICE. YOU HEREBY GRANT AGENCY AUTHORITY TO ANY PARTY WHO CLICKS ON THE “I AGREE” BUTTON OR OTHERWISE INDICATES ACCEPTANCE TO THIS CONSENT ON YOUR BEHALF.

‍

IF YOU ARE EXPERIENCING A LIFE-THREATENING SITUATION SUCH AS CONTEMPLATING SUICIDE, CALL 911 OR THE 988 SUICIDE & CRISIS LIFELINE AT 988.

‍

PURPOSE OF THIS FORM. 

‍

The purpose of this consent form (“Consent”) is to provide you with information about telehealth and to obtain your informed consent to the use of telehealth in the delivery of healthcare services to you by physicians, physician assistants, nurse practitioners, and/or health professionals (“Providers”) using the online platforms owned and operated by Brello LLC (“Brello”) and/or its subsidiaries (the “Service”). In this Consent, the terms “you” and “yours” refer to the person using the Service, or in the case of a use of the Service by or on behalf of an individual minor between the ages of thirteen (13) and eighteen (18) or higher age of majority under applicable state law, “you” and “yours” refer to and include (i) the parent or legal guardian who provides consent to the use of the Service by such minor or uses the Service on behalf of such minor, and (ii) the minor for whom consent is being provided or on whose behalf the Service is being utilized.

‍

USE OF TELEHEALTH. 

‍

Telehealth involves the delivery of healthcare services using electronic communications, information technology or other means between a healthcare provider and a patient who are not in the same physical location. Telehealth may be used for diagnosis, treatment, follow-up and/or patient education, and may include, but is not limited to, one or more of the following: electronic transmission of medical records, photo images, personal health information or other data between a patient and a provider; interactions between a patient and provider via audio, video and/or data communications (such as messaging or email communications); use of output data from medical devices, sound and video files. Alternative methods of care may be available to you, such as in-person services, and you may choose an alternative at any time. Always discuss alternative options with your Provider.

‍

ANTICIPATED BENEFITS OF TELEHEALTH.

‍

‍The use of telehealth may have the following possible benefits: making it easier and more efficient for you to access medical care or other services and treatment for the conditions treated by your Provider(s); allowing you to obtain medical care or other services and treatment by Provider(s) at times that are convenient for you; and enabling you to interact with Provider(s) without the necessity of an in-office appointment. 

‍

POTENTIAL RISKS OF TELEHEALTH. 

‍

‍While the use of telehealth in the delivery of healthcare can provide potential benefits, there are also potential risks associated with the use of telehealth and other technology. These potential risks include, but may not be limited to the following: the quality, accuracy or effectiveness of the healthcare services you receive from your Provider could be limited; technology, including the Service, may contain bugs or other errors, including ones which may limit functionality, produce erroneous results, render part or all of such technology, including the Service, unavailable or inoperable, produce incorrect records, transmissions, data or content, or cause records, transmissions, data or content to be corrupted or lost; failures of technology may also impact your Provider(s) ability to correctly diagnose or treat your condition; the inability of your Provider(s) to conduct certain tests or assess vital signs in-person may in some cases prevent the Provider(s) from providing a diagnosis or treatment or from identifying the need for emergency medical care or treatment for you; your Provider(s) may not able to provide treatment for your particular condition and you may be required to seek alternative care or emergency care services; delays in medical evaluation/treatment could occur due to unavailability of your Provider(s) or deficiencies or failures of the technology or electronic equipment used; the electronic systems or other security protocols or safeguards used could fail, causing a breach of privacy of your medical or other information; data stored and communicated electronically (e.g., e-mail communications) may be more susceptible to unintended disclosure of protected health information to third parties; given regulatory requirements in certain jurisdictions, your Provider(s) diagnosis and/or treatment options, especially pertaining to certain prescriptions, may be limited; a lack of access to all of your medical records may result in adverse drug interactions or allergic reactions or other judgment errors.

‍

LIFE THREATENING AND OTHER EMERGENCY SITUATIONS; FOLLOW-UP CARE. 

‍

‍If you are experiencing a life-threatening situation such as contemplating suicide, call 911 or the 988 Suicide and Crisis Lifeline at 988.

‍

If the situation is an emergency, call 911. In some situations, telehealth is not an appropriate method of care. If you require immediate or urgent care, you must cease use of the Services immediately and seek care at an emergency room facility or other provider equipped to deliver urgent or emergent care. Providers may not respond promptly to communications you submit through the Service. If you are not experiencing an emergency or do not require immediate or urgent care, you may communicate with Providers through use of the secure message service in the Service. If a technical failure prevents you from communicating with your Provider(s) through the Service, you should email us at info@brellohealth.com or call the following number: Phone: 1-888-273-5561 (M-F 9AM – 5PM CT).

‍

DATA PRIVACY AND PROTECTION. 

‍

‍The electronic systems used in the Service will incorporate network and software security protocols to protect the privacy and security of your information and will include measures to safeguard data against intentional or unintentional corruption. Personal information that identifies you or contains protected health information will not be disclosed to any third party without your consent, except as authorized by law for the purposes of consultation, treatment, payment/billing, certain administrative purposes, and as required by law to disclose to other persons and agencies certain information obtained during the provision of health services (e.g., danger to self or others; mandatory reporting of child, elder, or vulnerable adult abuse) or as otherwise set forth in your Provider's Notice of Privacy Practices. See Terms and Conditions and Privacy Policy for what constitutes protected health information.  Use of the Service may include email communications to and from you that may include your protected health information. You understand that Brello does not and cannot guarantee, and is not responsible for, the security or privacy of the services you use to receive communications, including for example your email service provider.

‍

LABORATORY PRODUCTS AND SERVICES. 

‍

Certain healthcare services provided to you by Providers via the Service may require that you complete an at-home diagnostic test. These diagnostic tests are provided by third-party laboratories, and neither Brello, nor your Provider(s) can guarantee the accuracy or reliability of these tests. These laboratory tests can provide false negative, false positive, or inconclusive results that could impact your Provider(s) ability to correctly diagnose or treat your medical conditions. A failure or defect of these tests could also impact your Provider(s) ability to correctly diagnose or treat your medical conditions. Brello cannot guarantee, nor is Brello responsible for, the accuracy of any at-home diagnostic test provided by third-party laboratories.

‍

MODIFICATIONS AND AMENDMENTS.

‍

‍This Telehealth Consent may change from time to time. If such changes are made, they will be effective immediately, and we will notify you by a notice posted on our website’s home page of the changes that have been made. If you disagree with the changes that have been made, you should cease all use of our Site. Your continued use after a change to this Agreement has been posted constitutes your acceptance of this Agreement as modified by such changes. We may terminate or amend this Telehealth Consent for any reason and at any time without notice to you. If you are concerned about the terms of this Telehealth Consent, you should read them each time before you use the Site. Any questions or concerns should be brought to our attention by sending an e-mail to info@brellohealth.com, and providing us with information relating to your concern.

‍

YOUR ACKNOWLEDGMENTS. 

‍

‍By clicking “I Agree”, checking a related box to signify your acceptance, using any other acceptance protocol presented through the Service or otherwise affirmatively accepting this consent, you are agreeing and providing your consent with respect to the following:

‍

Healthcare services, including telehealth, are provided to you by Practice and Providers, not Brello, via the Service. In some cases, your treating Provider may be a nurse practitioner or physician assistant and not a physician, and you agree to be treated by non-physician providers, if applicable, by using the Service. Certain technology, including the Service, may be used while still in a beta testing and development phase, and before such technology is a final and finished product. Technology used to deliver care, including the Service, may contain bugs or other errors, including ones which may limit functionality, produce erroneous results, render part or all of such technology unavailable or inoperable, produce incorrect records, transmissions, data or content, or cause records, transmissions, data or content to be corrupted or lost, any or all of which could limit or otherwise impact the quality, accuracy and/or effectiveness of the medical care or other services that you receive from your Provider(s). Certain diagnostic testing services, including laboratory products and services offered through the Service, may contain defects, including ones which may limit functionality or produce erroneous results, any or all of which could limit or otherwise impact the quality, accuracy and/or effectiveness of the medical care or other services that you receive from your Provider(s). The delivery of healthcare services via telehealth is an evolving field and the use of telehealth or other technology in your medical care and treatment from Provider(s) may include uses of technology different from those described in this Consent or not specifically described in this Consent. No potential benefits from the use of telehealth or other technology or specific results can be guaranteed, including any laboratory testing results or related diagnosis or treatment by your Provider(s). Your condition may not be cured or improved, and in some cases, may get worse. There are limitations in the provision of medical care or other services and treatment via telehealth and technology, including the Service, and you understand you may not be able to receive diagnosis and/or treatment through telehealth for every condition for which you seek diagnosis and/or treatment. There are potential risks to the use of telehealth and other technology, including but not limited to the risks described in this Consent. You have the opportunity to discuss and ask questions regarding the use of telehealth, including the Service, with your Provider(s), including discussing the benefits and risks of such use and the alternatives to the use of telehealth. Your continued use of the Service confirms that all of your questions related to your medical care and the telehealth services have been answered to your satisfaction and you agree to not utilize the Service if you have any outstanding questions or concerns. You understand that there will be no recording of any online treatment sessions by your Provider(s) or you. Your Provider(s) will assess your medical condition and, in their sole discretion, may determine it is medically appropriate to diagnose and/or treat your condition via telehealth and whether you maintain sufficient knowledge and skills in the use of technology appropriate to diagnosing and/or treating your condition via telehealth. By continuing to use the Service, you concur with your Provider’s medical assessment and agree to receive a diagnosis and/or treatment via telehealth technology. You have the right to withdraw your consent to the use of telehealth in the course of your care, without prejudice to any future care or treatment and without risking the loss or withdrawal of any health benefits to which your entitled, but you understand that the Providers who utilize the Service do not offer in-person treatment. Any withdrawal of your consent will be effective upon receipt of written notice to your Providers, except that such withdrawal will not have any effect on any action taken by Brello or your Provider(s) in reliance on this Consent before each received your written notice of withdrawal. Any withdrawal of your consent will not affect any other provision of this Consent, and you will continue to be bound by this Consent. You understand that the use of the Service involves electronic communication to and from you of your personal medical information in connection with the provision of telehealth services, including through email. You understand that it is your duty to provide Brello and your Provider(s) truthful, accurate and complete information, including all relevant information regarding care that you may have received or may be receiving from healthcare providers including emergency contact information for your local healthcare providers. You understand that each of your Provider(s) will assess your medical condition and, in their sole discretion, may determine it is medically appropriate to diagnose and/or treat your condition using telehealth technology, including the Service. By continuing to use the Service, you concur with your Provider’s medical assessment and consent and agree to receive a diagnosis and/or treatment via telehealth technology. You understand that each of your Provider(s) may determine in their sole discretion that your condition is not suitable for diagnosis and/or treatment using telehealth technology, including the Service, and that you may need to seek care and treatment from a specialist or other healthcare provider, outside of such telehealth technology. Brello has a commercial and financial relationship with Southend Pharmacy and Practice, the entity that employs or contracts with your Provider. You are free to obtain your medical examination from another healthcare provider that is not associated with Brello. Brello will use its pharmacy partner, Southend Pharmacy, or its successor, to fulfill your order directly to your door. You are free to obtain your prescription from any pharmacy of your choice by contacting our support team. Prescriptions may be filled by and transferred between any pharmacy partners on your behalf. You must pay the full amount of the costs associated with use of the Service, including any prescription you may receive, and you will not attempt to submit a claim to Medicare, any other federal payor, or any state or private insurer.

‍

If you have a concern about a medical professional, you may contact the Medical Board in your state regarding your concerns. 

Special Notice to California Clients. Physicians and midwifes are licensed and regulated by the Medical Board of California. To confirm a license or file a complaint, go to www.mbc.ca.gov or call (800) 633-2322.

‍

‍