DO NOT USE THIS SERVICE IF YOU MAY BE EXPERIENCING A MEDICAL EMERGENCY. In an emergent situation, you can: (i) call 911; or (ii) go to the nearest emergency room; (iii) contact your local crisis center; (iv) if applicable, call the National Suicide Prevention Lifeline (1-800-272-8255); or (v) if applicable, contact the Crisis Text Line (text “GO” to 741-741).
We are pleased you have chosen Beam Healthcare S.C. and its associated medical practices (collectively, “Group”) and their affiliated health care providers (“Providers”) for your telehealth needs. This document is intended to inform you of what you can expect of your Provider in terms of his or her credentials and in connection with your treatment via telehealth. After you have carefully read this document and had an opportunity to have your questions answered, certain state laws mandate that you must sign and date it before commencing services.
Your Provider’s credentials were made available to you before scheduling an appointment. If you have any questions about these credentials, please direct them to your telehealth Provider.
The Group offers treatment by various types of healthcare providers via telecommunications technology (also referred to as “telehealth”). Our Providers include physicians, nurses, and equivalent licensed professionals. The services provided may also include chart review, remote prescribing, appointment scheduling, refill reminders, health information sharing, and non-clinical services, such as patient education. The electronic communication systems we use will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption. There are various benefits associated with telehealth services, including improved access to care by enabling you to remain in your home while the provider consults with you, more efficient care evaluation and management, and obtaining expertise of a specialist as appropriate. Possible risks include delays in evaluation and treatment could occur due to deficiencies or failures of the equipment and technologies, and in rare events, our provider may determine that the transmitted information is of inadequate quality, thus necessitating a rescheduled telehealth consult or a meeting with your local primary care doctor.
In accordance with state laws, consent for treatment of a minor can only be authorized by a current legal guardian for the minor. If the parents of a minor are separated, treatment is provided to the minor only with the written consent of both parents. If the parents of the minor are divorced, consent for treatment of the minor may be given by the parent authorized to make medical decisions for the minor. If a court of law has ordered that medical decisions for the minor are to be made jointly by the minor’s parents, then consent of both parents is required for treatment of the minor. In the case of minors, as defined by state law, parents may request information about their child’s diagnosis or treatment. While release of this information will be provided, it is best that the process be a collaborative one involving the minor, parent, and clinician in order to maintain the rapport established between the minor and clinician since rapport is vital to treatment success. Therefore, unless there is a safety concern, the minor would be consulted about the disclosure and encouraged to share the information with the parent first in order to establish better communications within the family structure.
You or the entity sponsoring your receipt of our telehealth services, as applicable, are responsible for the cost of all professional fees associated with your use of our telehealth services, which may change from time to time, and the cost of any medications or supplies prescribed by the Group Provider as well as any equipment provided by the Group, including but not limited to peripheral equipment for use in engaging with the telehealth technology.
By checking the box associated with “Informed Consent”, you acknowledge that you understand and agree with the following:
Teams by Beam only offers services in select states at this time. For a complete list, please visit our homepage.
Alaska: I understand my primary care provider may obtain a copy of my records of my telehealth encounter. (Alaska Stat. § 08.64.364).
Arizona: I understand that all medical records resulting from a telemedicine consultation are part of my medical record. (A.R.S. § 12-2291.)
Colorado: I am informed that if I want to register a formal complaint about a Provider, I should file at https://dpo.colorado.gov/FileComplaint.
Connecticut: I understand that my primary care provider may obtain a copy of my records of my telehealth encounter, and that I can revoke my consent at any time. (Conn. Gen. Stat. Ann. § 19a-906).
D.C.: I have been informed of alternate forms of communication between me and a physician for urgent matters. (D.C. Mun. Regs. tit. 17, § 4618.10).
Georgia: I have been given clear, appropriate, accurate instructions on follow-up in the event of needed emergent care related to the treatment. (Ga. Comp. R. & Regs. 360-3-.07(7)).
Iowa: I have been informed that if I want to register a formal complaint about a Provider, I should visit the medical board’s website, here: https://medicalboard.iowa.gov/consumers/filing-complaint
Idaho: I have been informed that if I want to register a formal complaint about a Provider, I should visit the medical board’s website, here: https://elitepublic.bom.idaho.gov/IBOMPortal/AgencyAdditional.aspx?Agency=425&AgencyLinkID=650
Illinois: I have been informed that if I want to register a formal complaint about a provider, I should visit the Illinois Division of Professional Regulation at https://www.idfpr.com/admin/DPR/DPRcomplaint.asp
Indiana: I have been informed that if I want to register a formal complaint about a Provider, I should visit the medical board’s website, here: https://www.in.gov/attorneygeneral/2434.htm.
Kansas: I understand that if I have a primary care provider or other treating physician, the person providing telemedicine services must send within three business days a report to such primary care or other treating physician of the treatment and services rendered to me during the telemedicine encounter. (Kan. Stat. Ann. § 40-2,212(2)(d)(2)(A). I understand that the complaint process may be found here: http://www.ksbha.org/complaints.shtml
Kentucky: I have been informed that if I want to register a formal complaint about a Provider, I should visit the medical board’s website, here: https://kbml.ky.gov/grievances/Pages/default.aspx
Louisiana: I understand the role of other health care providers that may be present during the consultation other than the telehealth provider. (46 La. Admin. Code Pt XLV, § 7511).
Maine: I have been informed that if I want to register a formal complaint about a Provider, I should visit the medical board’s website, here: https://www.maine.gov/md/discipline/file-complaint.html
Maryland: Regarding audiologists, speech language pathologists, and hearing aid dispensers, I recognize the inability to have direct, physical contact with the patient is a primary difference between telehealth and direct in-person service delivery. The knowledge, experiences, and qualifications of the consultant providing data and information to the provider of the telehealth services need not be completely known to and understood by the provider. The quality of transmitted data may affect the quality of services provided by the provider. Changes in the environment and test conditions could be impossible to make during delivery of telehealth services. Telehealth services may not be provided by correspondence only. (Md. Code Regs. 10.41.06.04). I have been informed that if I want to register a formal complaint about a Provider, I should visit the medical board’s website, here: https://www.mbp.state.md.us/forms/complaint.pdf.
Nebraska: If I am a Medicaid recipient, I retain the option to refuse the telehealth consultation at any time without affecting my right to future care or treatment and without risking the loss or withdrawal of any program benefits to which the patient would otherwise be entitled. All existing confidentiality protections shall apply to the telehealth consultation. I shall have access to all medical information resulting from the telehealth consultation as provided by law for access to my medical records. Dissemination of any patient identifiable images or information from the telehealth consultation to researchers or other entities shall not occur without my written consent. I understand that I have the right to request an in-person consult immediately after the telehealth consult and I will be informed if such consult is not available. (Neb. Rev. Stat. Ann. § 71-8505; 471 Neb. Admin. Code § 1-006.05). I have been informed that if I want to register a formal complaint about a provider, I should visit: https://dhhs.ne.gov/Pages/Complaints.aspx
New Hampshire: I understand that the telehealth Provider may forward my medical records to my primary care or treating provider. (N.H. Rev. Stat. § 329:1-d).
New Jersey: I understand I have the right to request a copy of my medical information and I understand my medical information may be forwarded directly to my primary care provider or health care provider of record, or upon my request, to other health care providers. (N.J. Rev. Stat. Ann. § 45:1-62).
Oklahoma: I have been informed that if I want to register a formal complaint about a Provider, I should visit the medical board’s website, here: http://www.okmedicalboard.org/complaint.
Board of Osteopathic Examiners can be found at: https://www.ok.gov/osboe/faqs.html
Rhode Island: If I use e-mail or text-based technology to communicate with my Provider, then I understand the types of transmissions that will be permitted and the circumstances when alternate forms of communication or office visits should be utilized. I have also discussed security measures, such as encryption of data, password protected screen savers and data files, or utilization of other reliable authentication techniques, as well as potential risks to privacy. I acknowledge that my failure to comply with this agreement may result in the telehealth provider terminating the e-mail relationship. (Rhode Island Medical Board Guidelines).
South Carolina: I understand my medical records may be distributed in accordance with applicable law and regulation to other treating health care practitioners. (S.C. Code Ann. § 40-47-37).
South Dakota: I have received disclosures regarding the delivery models and treatment methods or limitations. I have discussed with the telehealth Provider the diagnosis and its evidentiary basis, and the risks and benefits of various treatment options. (S.D. Codified Laws § 34-52-3).
Tennessee: I understand that I may request an in-person assessment before receiving a telehealth assessment if I am a Medicaid recipient.
Texas: I understand that my medical records may be sent to my primary care physician. (Tex. Occ. Code Ann. § 111.005). I have been informed of the following notice:
Utah: I understand (i) any additional fees charged for telehealth services, if any, and how payment is to be made for those additional fees, if the fees are charged separately from any fees for face-to-face services provided in combination with the telehealth services; (ii) to whom my health information may be disclosed and for what purpose, and have received information on any consent governing release of my patient-identifiable information to a third-party; (iii) my rights with respect to patient health information; (iv) appropriate uses and limitations of the site, including emergency health situations. I understand that the telehealth services meets industry security and privacy standards, and comply with all laws referenced in Subsection 26-60-102(8)(b)(ii). I was warned of: potential risks to privacy notwithstanding the security measures and that information may be lost due to technical failures, and agree to hold the provider harmless for such loss. I have been provided with the location of telehealth company’s website and contact information. I was able to select my provider of choice, to the extent possible. I was able to select my pharmacy of choice. I am able to a (i) access, supplement, and amend my patient-provided personal health information; (ii) contact my provider for subsequent care; (iii) obtain upon request an electronic or hard copy of my medical record documenting the telemedicine services, including the informed consent provided; and (iv) request a transfer to another provider of my medical record documenting the telemedicine services. (Utah Admin. Code r. 156-1-603).
Virginia: I acknowledge that I have received details on security measures taken with the use of telemedicine services, such as encrypting date of service, password protected screen savers, encrypting data files, or utilizing other reliable authentication techniques, as well as potential risks to privacy notwithstanding such measures; I agree to hold harmless Beam Healthcare S.C. for information lost due to technical failures; and I provide my express consent to forward patient-identifiable information to a third party. (Virginia Board of Medicine Guidance Document 85-12).
Vermont: I understand that I have the right to receive a consult with a distant-site provider and will receive one upon request immediately or within a reasonable time after the results of the initial consult. I have been informed that if I want to register a formal complaint about a Provider, I should visit the medical board’s website, here: http://www.healthvermont.gov/health-professionals-systems/board-medical-practice/file-complaint; Board of Osteopathic Examiners can be found at: https://www.sec.state.vt.us/professional-regulation/file-a-complaint-employer-mandatory-reporting.aspx
I have read this document carefully and understand the risks and benefits of the telehealth services and have had my questions regarding the services explained. By entering my name below, I hereby give my informed consent to participate in telehealth consultations under the terms described herein.