Tele-Health Consent

DO NOT USE THIS SERVICE FOR EMERGENCY MEDICAL CONDITIONS OR NEEDS. IF YOU ARE CURRENTLY EXPERIENCING A MENTAL HEALTH OR OTHER MEDICAL EMERGENCY, IMMEDIATELY CALL 911.
If you are considering suicide or thinking about taking an action that may cause harm or danger to you or to others, you must immediately call 911. If you are considering suicide, we urge you to call the National Suicide Prevention Hotline at 1-800-273-TALK (8255).

Only use our service if you’ve read this information and subsequently made an informed decision that our service is right for you. If you have any questions, please send us a message through our help center at support@dollarmomclub.com

By signing and/or opting to agree to this form, I understand and agree with the following:

Telehealth/Telemedicine (“telehealth”) involves the use of electronic communications to enable Authorized Providers at different locations to share individual patient medical information for the purpose of improving patient care. I consent to receive treatment via telehealth from Beleaf LLC DBA Dollar Mom Club Authorized Providers. Authorized Providers may include primary care practitioners, specialists and/or subspecialists, nurse practitioners, registered nurses, medical assistants, and other healthcare providers who are part of my clinical care team. In addition to myself and the members of my clinical care team, I may choose to have my family members, caregivers, or other legal representatives or guardians join and participate in the telehealth service, and I may agree to share my personal information with such family members, caregivers, legal representatives, or guardians if I choose to have them join in my telehealth services. The information may be used for diagnosis, therapy, follow-up and/or education.

Telehealth/Telemedicine requires transmission, via Internet or tele-communication device, of health information, which may include:

Progress reports, assessments, or other intervention-related documents; and

Videos, pictures, text messages, audio, and any digital form of data

The laws that protect the privacy and confidentiality of health and care information also apply to telehealth. Information obtained during telehealth services that identify me will only be provided to someone with consent, except for purposes of treatment and healthcare operations. By agreeing to use the telehealth services, I am consenting to the sharing of my protected health information with certain third parties as more fully described in Beleaf LLC DBA Dollar Mom Club’s Privacy Policy. I understand and expressly consent to Beleaf LLC DBA Dollar Mom Club obtaining, using, storing, and disseminating to necessary third parties, information about me, as necessary to provide the telehealth services and as specified in the Privacy Policy.

I understand that I must check the Website for messages because this is the way that the Authorized Provider will communicate important information to me. I understand that if I do not check the Website regularly, then my care may be delayed.

I understand that if I have any questions relating to my care that are not urgent, I can message the Authorized Provider through the Website. I understand that the Authorized Provider may not review and respond to my messages until the next business day depending on when the message was sent.

Telehealth sessions may not always be possible. Disruptions of signals or problems with the Internet’s infrastructure may cause broadcast and reception problems (e.g., poor picture or sound quality, dropped connections, audio interference) that prevent effective interaction between the Authorized Provider, participant, patient, or care team.

I hereby release and hold harmless Beleaf LLC DBA Dollar Mom Club and all members of my care team from any loss of data or information due to technical failures associated with the telehealth service. I understand and agree that the health information I provide at the time of my telehealth service may be the only source of health information used by the Authorized Provider during my evaluation and treatment at the time of my telehealth visit, and that such Authorized Provider may not have access to my full medical record or information.

For more details about how Beleaf LLC DBA Dollar Mom Club protects and uses your health information see our Privacy Policy.

I understand that I will be given information about tests, treatments, and procedures, as applicable, including the benefits, risks, possible problems or complications, and alternate choices for my medical care through the telehealth visit.

I have the right to withhold or withdraw consent to the use of telehealth services at any time and revert to traditional in-person clinic services. I understand that if I withdraw my consent for telehealth, it will not affect any future services or care benefits to which I am entitled.

I hereby consent to the use of telehealth in the provision of care and the above terms and conditions.