Terms of Service

FPK SERVICES LLC
Patient Telehealth Consent, Notices & Acknowledgement Form
BY CLICKING “I ACCEPT,” YOU ACKNOWLEDGE THAT YOU HAVE READ, ACCEPTED, AND AGREED TO BE BOUND BY THIS CONSENT, NOTICE &
ACKNOWLEDGEMENT. IF YOU DO NOT CLICK I ACCEPT, YOU WILL NOT BE ABLE TO USE OR RECEIVE THE TELEHEALTH SERVICES MADE AVAILABLE
BY FPK SERVICES. YOU HEREBY GRANT AGENCY AUTHORITY TO ANY PARTY WHO CLICKS ON THE “I ACCEPT” BUTTON ON YOUR BEHALF.

I agree to receive this health care service provided by health care practitioner(s), affiliated with FPK Services (“Practice”), whom I selected. As a telehealth service, I understand that the health care practitioner(s), providing the identified services to me, which may utilize the FPK Services telehealth platform, is(are) located in (a) location(s) remote from my location.

The scope of services will be at the sole discretion of the health care practitioner(s) treating me, with no guarantee of diagnosis, treatment, or prescription. The health care practitioner(s) will determine whether or not the condition being diagnosed and/or treated or the services being rendered are appropriate for a telehealth encounter.

A telehealth service means that my health care services are provided, as applicable, by practitioner(s) at a distant location using interactive video and/or audio conferencing in real time.

I also understand that:

  • I have the right to withdraw my consent to the use of telehealth in the course of my care at any time.
  • I may have to travel to see a health care practitioner in-person for certain diagnosis and treatment matters.
  • The same confidentiality and privacy protections that apply to my other health care services also apply to these telehealth services.
  • I have access to all of my health and wellness information pertaining to the telehealth services in accordance with applicable laws and regulations.
  • I may need to see an appropriately trained health care professional in-person immediately after the telehealth service if an urgent need arises.
  • My health care information may be shared with other individuals for treatment, payment, and health care operations purposes.
  • Any video feed from the telehealth encounter will not be retained or recorded by Practice.
  • There are alternatives to telehealth, such as visiting a primary care provider, an emergency room, or an urgent care facility; however, I chose to proceed with a telehealth visit at this time.

NOTICE OF PRIVACY PRACTICES AND RELEASE OF MEDICAL INFORMATION

I understand that the laws that protect privacy and the confidentiality of medical information also apply to telehealth, and that no information obtained in the course of the telehealth visit which identifies me will be disclosed to non-covered entities without my written consent. I acknowledge and understand that (i) this is a copy of the Practice “Notice of Privacy Practices”; (ii) this Notice of Privacy Practices is intended to provide information about how Practice and its Providers and contractors may use and/or disclose protected health information about me; (iii) details on Practice’s Privacy Practices can be obtained by contacting the Privacy Officer at 123 W 18TH Street, New York, NY 10011, through the information in this Notice, and with respect to additional information provided to you; (iv) Practice may release information obtained as a result of the telehealth services to my other health care providers, my health care insurer or other payer, [Client], or as otherwise provided in this Practice Notice of Privacy Practices; (v) Practice cannot be responsible for use or re- disclosure of information by third parties; (vi) my personal medical information obtained through my telehealth visit may be communicated to other medical practitioners who may be located in other areas, including out of state; and (vii) my healthcare information may be shared with other individuals for scheduling, billing, treatment or operational purposes, including sharing my information with FPK Services and applicable laboratories or pharmacies.

FINANCIAL RESPONSIBILITY AND ASSIGNMENT OF BENEFITS

I understand that there is a flat fee associated with the telehealth visits provided by Practice, and that this fee must be paid prior to being seen each time I receive telehealth services from Practice. I understand that Practice is unable to file a claim with my insurance company for any telehealth services provided, but that I may attempt to be reimbursed by my insurance company directly by submitting a receipt for my telehealth visit, though reimbursement in part or in full by insurance is not guaranteed.

OTHER ACKNOWLEDGEMENTS

I acknowledge and understand that by agreeing to the telehealth services (i) I authorize FPK Services and Practice to use my email address for health-related messaging purposes and for certain limited marketing purposes; (ii) such marketing and messaging uses shall be limited to communications between and among FPK Services, Practice, and myself; (iii) FPK Services and Practice value patient privacy and do not sell email addresses or use them for purposes other than those outlined herein; (iv) I can revoke this authorization and opt-out of such marketing and messaging uses at any time after receiving my initial email from FPK Services or Practice; (v) I am consenting to allow FPK Services, Practice, or either of their contracted agencies or clients to use the phone number I provided to communicate with me in the case of any outstanding balances on my account(s); and (vi) neither FPK Services nor Practice has conditioned my treatment on the provision of these authorizations. The information provided is correct to the best of my knowledge. I will not hold FPK Services, Practice or its health providers, or either of their employees responsible for any errors or omissions that I may have made in completing this form.

I have read this document carefully, and all my questions were answered to my satisfaction. I hereby consent to participate in the telehealth visit with my selected health care practitioner(s) pursuant to the terms, conditions, standards, and requirements set forth herein or as otherwise provided to me.

If you have any questions or comments about our Terms Of Service, please feel free to contact us at privacy@TreatMyUTI.com or write us at our HQ: 11150 S Wilcrest Dr, Suite 100 Houston, TX 77099.