Informed Consent to Receive Remote Healthcare from The New York and Presbyterian Hospital, Cornell University for Weill Cornell Medicine, and/or The Trustees of Columbia University in the City of New York for Columbia University Irving Medical Center (collectively the “Consortium”) and its affiliated entities and Providers.

Remote Healthcare

Remote Healthcare Services (“Service”) provides evaluation, diagnosis, consultation, and treatment using an interactive audio and video telecommunications system that permits real-time communication between you and your provider.

DO NOT USE THIS SITE FOR EMERGENCY MEDICAL NEEDS.

If you are experiencing a medical emergency, call 911 immediately.

You acknowledge that your ability to access and use the Service is conditioned upon the truthfulness of this certification and that the Providers you access are relying upon this certification in order to interact with you.

In the event that your certification is inaccurate, you agree to indemnify the healthcare providers you interact with from any resulting damages, costs, or claims.

I UNDERSTAND:

• Remote Healthcare visits are clinical visits, rules and confidentiality apply.
• I have the right to withhold or withdraw my consent for the use of Remote Healthcare at any time, without affecting my right to future care or treatment.
• If I am a parent/legal guardian engaging Remote Healthcare services on behalf of a minor child or person who lacks capacity to provide consent, I will consent and be present for the visit and I further understand that special circumstances may apply.
• I will be informed of the clinical staff, involved in my care, present during my Remote Healthcare service.
• The laws that protect privacy and the confidentiality of medical information also apply to Remote Healthcare, and that no information obtained in the use of Remote Healthcare which identifies me will be disclosed to researches or other entities without my consent.
• I have the right to request copies of my health information, including records of my Remote Healthcare visit, and receive copies of this information, in accordance with applicable federal and state law, for a reasonable fee.
• My insurance carrier may have access to my medical records for payment and/or quality assurance.
• My insurance may be billed for the Remote Healthcare service and I will be responsible for the copay, co-insurance, deductible, and other patient responsibility.
• My health information may be shared by my Providers with other medical providers, who may be located in other areas including out of state, by electronic or other means, in order to improve my medical care.
• My Provider will determine whether or not the condition being diagnosed and/or treated is appropriate for a Remote Healthcare encounter via the Service.
• If my Provider determines that the Remote Healthcare services do not adequately address my medical needs, my Provider may require an in-person medical evaluation. In the event the Remote Healthcare session is interrupted due to a technological problem or equipment failure, alternative means of communication may be implemented, or an in-person medical evaluation may be necessary.

DISCLAIMERS

Access to the service and the information contained therein is provided "as is" and "as available" without any warranty of any kind, express or implied.

Without limiting the foregoing, neither my Provider nor any organization with whom my Provider is affiliated for the provision of Remote Healthcare warrants that access to the service will be uninterrupted or error-free, or that defects, if any, will be corrected; nor does it make any representations about the accuracy, reliability, currency, quality, completeness, usefulness, performance, security, legality or suitability of the service or any of the information contained therein.

You expressly agree that your use of the service and your reliance upon any of its contents is at your sole risk.

AGE REQUIREMENTS

I hereby certify that I am at least 18 years of age and/or am legally qualified and able under the laws of my state to make medical decisions on my own behalf, or on behalf of my minor child or the adult person on whose behalf I have requested this visit, if applicable.

I acknowledge that my ability to access and use Remote Healthcare services, and information is conditional upon the truthfulness of my certification of age.

GEOGRAPHIC RESTRICTIONS

I hereby certify that I am located in an eligible service area and agree to only interact with a Provider through Remote Healthcare services, while I am present in that service area.

I acknowledge that my ability to access and use these services is conditional upon the truthfulness of the certifications I make at the time of accessing a Provider, and that the Providers I access are relying upon this certification in order to interact with me.

PATIENT CONSENT TO THE USE OF REMOTE HEALTHCARE

For additional information regarding your Platform account and electronic communications please refer to Connect Terms of Service.

PRIVACY POLICY

The Notice of Privacy Practices covers the Organization’s standards and procedures, but the Patient is responsible for communicating with the provider from a private location and for security of the electronic device you use for such communications in order to protect patient privacy.

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