TELEHEALTH CONSENT FORM

The following Telehealth Consent Form applies to all services provided by Bliv Wellness LLC to users and patients through services and subscriptions. In order to communicate and share specific patient health information for the goal of providing clinical treatment, telehealth entails using secure electronic communications, information technology, or other means to enable a health care professional and a patient in different locations. This "Telehealth Consent Form" describes the confidentiality of information provided through telehealth services, information protection, potential risks, electronic communications made through telehealth services, limitations of the telehealth service, as well as patient/user statements.

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1. CONFIDENTIALITY

Laws that protect the privacy and confidentiality of health and health care information also apply to telehealth/telemedicine. Information obtained during telehealth/telemedicine services that identifies the user or patient will not be provided to any third party without the user's or patient's consent, except for purposes of treatment, education, billing and healthcare operations. By agreeing to use Bliv Wellness LLC telehealth/telemedicine services, the user/patient consents to Bliv Wellness LLC sharing protected health information with certain third parties as further described in Bliv Wellness LLC' privacy policy. By using Bliv Wellness LLC services, the user or patient expressly consents to Bliv Wellness LLC obtaining, using, storing and disclosing to necessary third parties’ information about the user or patient, including images, as necessary to provide the telehealth/telemedicine services.

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2. DATA PROTECTION

We will use network and software security protocols in the electronic communication systems we use to protect the confidentiality of patient identification and image data. These protocols will also include safeguards to protect the data and ensure its integrity against malicious or unintentional corruption. The Health Insurance Portability and Accountability Act of 1996's ("HIPAA") criteria for secure connections will be followed for all telehealth services supplied to the patient.

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3. ELECTRONIC TRANSMISSIONS:

The types of electronic transmissions that may occur when using our telehealth services and platform include, but are not limited to:

• Appointment scheduling
• Online consultations
• Exchange and review of clinically relevant information (e.g., medical records; images; sound and video files, diagnostic and/or laboratory test results, etc.) between you and your Medical Provider.
• Treatment recommendations by your Medical Provider based on such review and exchange of clinical information.
• Delivery of a consultation report with a diagnosis, treatment and/or prescription recommendations, as deemed clinically relevant.
• Prescription of medications 
• Other electronic transmissions for the purpose of providing the services described in our terms and conditions and website.

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4. POTENTIAL RISKS

The following risks may occur when using Bliv Wellness LLC telemedicine services:

• There may be delays in diagnosis and treatment as a result of equipment and technological shortcomings, breakdowns, or supplier accessibility.
• Rarely, your medical provider might find that the data sent was of poor quality, in which case the telehealth consultation would need to be rescheduled or an in-person encounter would be necessary.
• Very rarely, security procedures may go wrong and expose the confidentiality of sensitive health information.

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5. SERVICE LIMITATIONS 

The inability to make direct physical contact with the patient is the main distinction between telehealth and direct in-person service delivery. As a result, your Provider will decide if certain clinical needs are appropriate for a telemedicine visit.

OUR SERVICES ARE NOT meant to be used in the case of medical emergencies. YOU SHOULD CALL THE EMERGENCY LINES OR GO TO THE NEAREST EMERGENCY SERVICES IF YOU THINK YOU ARE EXPERIENCING A MEDICAL EMERGENCY.

Our Providers are an addition to, not a replacement for, your main care doctor. Your neighborhood primary care physician, if you have one, should continue to be in charge of your general medical care, and if not, we firmly advise that you get one.

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6. PATIENT OR USER STATEMENTS

I further acknowledge and understand the following:

• No patient identifiable photographs or data from the telehealth encounter will be given to researchers or other educational entities without my express agreement.
• There is an outside chance that a technical issue will arise during the telehealth session. I agree to indemnify and hold harmless Bliv Wellness LLC and its employees, contractors, agents, directors, members, managers, shareholders, officers, representatives, assigns, parents, predecessors and successors from any loss or damage caused by such technical failures. 
• Individuals other than the Medical Provider may be present during telehealth visits to operate the telehealth technologies. If another person is present during the telehealth visit, the patient will be informed of the person's presence and role.
• In accordance with the services offered by Bliv Wellness LLC, my healthcare practitioner will describe my diagnosis, treatment, and the evidence behind it, as well as the advantages and disadvantages of the various treatment alternatives..
• The issuance of a prescription is not guaranteed, and the Medical Provider's professional judgment will be used to determine whether a prescription is appropriate for a patient or user. The patient may select the pharmacy of his or her choosing if the doctor issues a prescription. The user or patient is aware that no prescription for a controlled substance will be made.
• There is no assurance that the patient or user will see a doctor from Bliv Wellness LLC. If, in the expert opinion of the Medical Provider, the supply of services is not medically or ethically suitable, Bliv Wellness LLC has the right to refuse care for potential service misuse or for any other reason.  

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7. CONTACT

If you have questions or concerns about this Telehealth Consent Form, please contact us through our contact page or through the information below.

Bliv Wellness LLC.

info@blivwell.com

888-859-2882

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Pharmacy Contact:

RedRock Pharmacy

450 South 900 East, Suite 150, SLC, UT 84102              

(801) 433-9500