The purpose of this form is to provide you with information about telehealth and to obtain your informed consent for a telehealth consultation with Peak Medical Group, P.C. or another medical practice affiliated with Peak Health Global, Inc. (collectively, “Peak Medical Group”). If you so consent, a Peak Medical Group telehealth provider (“Provider”) will use telehealth technology to deliver healthcare services to you. This service is not to be used for urgent or emergency consultations. Nor is it a replacement for primary care services.
Nature Of Telehealth: Telehealth is the use of electronic information and communication technologies to enable a healthcare provider and a patient at different locations to share medical information, including, for example, for the purpose of evaluation and consultation regarding certain healthcare screening results. The delivery of healthcare via telehealth allows the patient and provider to establish a relationship, much as they would during a traditional face-to-face appointment. For example, your telehealth encounter may include interaction through and with the use of some of the following technologies: synchronous video (e.g. videoconferencing) and/or asynchronous technology, such as store-and-forward technology to exchange medical data and secure messaging portal communication.
Benefits & Risks: The benefits of telehealth include improved access to health services and care, including the expertise of specialists and consultants who may not otherwise be available to you. There are potential risks to using telehealth technology, including interruptions to the connection, images and other information transmitted may not be clear enough to be useful for the consultation, unauthorized access, and technical difficulties. However, either the Provider or you can discontinue your telehealth visit if the telehealth technologies are not adequate for the situation or if the information obtained via telehealth was not sufficient or if telehealth is inappropriate for any reason. Other potential risks to using telehealth services include breach of privacy of protected health information due to security breaches or failures, as well as adverse drug interactions, allergic reactions, complications, or other errors due to a patient’s failure to provide complete medical information or records.
Alternatives: Alternative methods of care, such as in-person services, may be available to you. You may choose an alternative at any time.
Your Privacy Rights: The Provider uses security protocols to protect the confidentiality of your patient health information. Personal information that identifies you or contains protected health information will not be disclosed to any third party without your consent, except as permitted or authorized by law for the purposes of consultation, treatment, payment/billing, and certain administrative purposes.
Follow-Up Care; Emergencies: The Provider does not provide primary care services. If a technical failure prevents you from communicating with the Provider, or if you believe telehealth will not provide sufficient safety and quality, you should contact us as indicated below. In the event of an urgent health issue or concern, you must seek care in-person, at a facility or provider equipped to deliver urgent or emergent care. IF THE SITUATION IS AN EMERGENCY, YOU MUST CALL 911.
Phone: (650) 753-8292
Hours of Operation: Monday to Friday, 9am - 6pm PST (except federal holidays)
By signing this form, I understand that telehealth involves the use of electronic information and communication technologies by a healthcare provider to deliver services to a patient when the patient is located at a different site than the provider, and I hereby consent to the Provider(s) delivering health care services to me via telehealth.
I understand that telehealth technology will be used in connection with my screening, assessment or management and have been given the opportunity to ask questions regarding the technology. I understand that this visit will not be the same as an in-person visit due to the fact that I will not be in the same physical location as the Provider, who will be at a distant site. I further understand that the Provider will determine whether telehealth is appropriate for me at this time. I understand that I may benefit from telehealth, but that results cannot be guaranteed. I further understand that my telehealth visit will involve review of my medical data for screening, assessment or management purposes, and that I am responsible for any follow-up with my primary care provider or another specialist regarding any results, concerns, or abnormalities that may be identified based on my screening, assessment or management by the Provider.
The provider will inform me who will be present at the Provider’s location during the telehealth service, and I have the right to exclude anyone from being present, if I so choose. I understand that the laws that protect privacy and the confidentiality of medical information also apply to telehealth. In addition, a summary of my visit may also be sent to my primary care provider of record in order to facilitate continuing care. I understand that I have the right to inspect and obtain copies of all information received and recorded during any telehealth session, subject to the policies of the providers involved in my care. I may be charged a fee for copies of records in accordance with applicable laws.
I understand that I have the right to withhold or withdraw my consent to the use of telehealth at any time, without affecting my right to future care. I may revoke my consent orally or in writing at any time by contacting Peak Medical Group or the Provider.
For purposes of this informed consent, I understand and agree that accepting THIS TELEHEALTH AUTHORIZATION SHALL CONSTITUTE AND IS MY ELECTRONIC SIGNATURE.
If you're in emotional distress, here are some resources for immediate help:
National Suicide Prevention Hotline:
Call or text: 988
Crisis Text Line:
Text Home to 741-741
Peak Health Global Inc. is a platform that provides services to affiliated psychiatric medical practices which are independently owned and operated, and in no way owns, directs, or controls the mental healthcare clinicians providing care. Peak Health Global, Inc. in no way or form provides, sells, or endorses the possession, usage, or distribution of any illegal substances.