Wheel Provider Group Telehealth Informed Consent

Last Updated: July 15, 2021

This is a legal and binding document between you and Wheel Medical, P.A., a Florida professional association, on behalf of itself and its affiliated professional entities (collectively, “Wheel Provider Group,” “We,” “Our”, or “Us”). Read it carefully before clicking “I accept”.

By clicking “I accept”, you hereby consent to receive health care services from licensed health care providers contracted with Wheel Provider Group (“Wheel-affiliated Providers”) who are located at sites remote from you to provide consultative services to you. The receipt of health care services from a Wheel-affiliated Provider (the “Services”) is a type of “telemedicine” or “telehealth” service.

Wheel Health, Inc. does not provide the Services; it performs administrative, payment, and other supportive activities for Wheel Provider Group and Wheel-affiliated Providers.

Description of Services

Wheel-affiliated Providers may include behavioral health or primary care practitioners, nurse practitioners, physician’s assistants, specialists, and/or subspecialists. The name, credentials, and specialty or subspeciality of your Wheel-affiliated Provider will be disclosed to you before, during, or after the Services are provided. In some cases, telemedicine visits may not be the most appropriate way for you to seek medical care and treatment. For example, certain medical conditions may require an in-person procedure, more urgent attention, or a health care provider other than your health care provider using the Services.

We may ask you a series of initial questions to help you determine whether a telemedicine visit is appropriate for you. Based on your responses to these questions, we may determine that a telemedicine visit may not be appropriate for the particular issue for which you are seeking a telemedicine visit or for other reasons related to your health status. In such a case: (i) you will receive an alert notifying you that you will be unable to use the Services for the particular issue you submitted; (ii) your request for a telemedicine visit will not be submitted to your Wheel-affiliated Provider; (iii) your Wheel-affiliated Provider will not receive any of the information that you submitted; and (iv) you will need to seek any needed care in another way.

Your Wheel-affiliated Provider may, following submission of a telemedicine visit request, determine that your diagnosis or treatment requires an in-person office visit or is otherwise not appropriately addressed through use of the Services. In such a case, your Wheel-affiliated Provider may notify you that you will be unable to use the Services for the particular issue you submitted and provide additional information regarding next steps. Your Wheel-affiliated Provider is solely responsible for providing you any such notification, whether through the Services or by some other means.

We will use store-and-forward technology, audio-only consultations, and/or audio-video consultations to provide the Services. To ensure privacy and confidentiality of the Services, we use industry standard security measures. The Services may, but not necessarily will, result in a new prescription, refilling an existing prescription, patient education, non-prescriptive recommendations, or a recommendation to seek follow-up care in-person or through a different provider.

Wheel Provider Group will have no responsibility or liability for your Wheel-affiliated Provider’s delay or failure to respond to a telemedicine visit request, to notify you that your telemedicine visit cannot be completed, or to provide you with next steps or follow-up information, or for any care, medical advice or treatment provided by your Provider.

Benefits and Risks

Your use of the Services may have the following possible benefits:

Making it easier and more efficient for you to seek medical care and treatment for the conditions treated by the applicable health care provider;
Allowing you to seek medical care and treatment by your Wheel-affiliated Provider at times that are convenient for you; and
Enabling you to communicate with your Wheel-affiliated Provider without the necessity of an in-office appointment.

As with any medical procedure, there are potential risks associated with the use of telemedicine or telehealth services, which may include, without limitation, the following:

The information transmitted to your Wheel-affiliated Provider may not be sufficient (e.g., poor resolution of images) to allow your Wheel-affiliated Provider to make an appropriate medical decision;
Your Wheel-affiliated Provider’s inability to conduct certain tests or assess vital signs in-person may in some cases prevent the provider from providing a diagnosis or treatment or from identifying the need for emergency medical care or treatment for you;
Your Wheel-affiliated Provider may not be able to provide medical treatment for your particular condition and you may be required to seek alternative health care or emergency care services;
Delays in medical evaluation/treatment or a failure to obtain needed treatment could occur due to unavailability of your Wheel-affiliated Provider, deficiencies or failures of the technology or electronic equipment used, a transmission delay or failure, issues with the internet or other communications means, or for other reasons;
The electronic systems, public networks, or security protocols or safeguards used in the Services could fail, causing a breach of privacy of your medical or other information;
Your Wheel-affiliated Provider’s diagnosis and treatment options, especially pertaining to certain prescriptions, may be limited;
Lack of access to your medical records or ability to perform an in-person examination, which could result in negative health outcomes (e.g., adverse drug interactions, allergic reactions).

By clicking “I accept”, you also represent and warrant the following:

Your Wheel-affiliated Provider has discussed the use of telemedicine services with you, including the benefits and risks of such use and the alternatives to the use of the Services, and you have provided consent to your Wheel-affiliated Provider for the use of the Services.
You understand that you have the right to access your medical information created during use of the Services or to have the medical information forwarded to a third-party or alternative provider. Wheel will not forward any personally identifiable information to third-parties or other providers without your written consent.
You understand Wheel may use third-party vendors to provide the Services.
You understand that the use of the Services involves electronic communication of your personal medical information to your Wheel-affiliated Providers who may be located in other areas, including outside of the state in which you reside, and that the electronic systems, public networks, or security protocols or safeguards used in the Services could fail, causing a breach of privacy of your medical or other information. You agree to hold Wheel harmless for any information lost due to technical failures.
You understand that, despite the privacy risks associated with the Services, all federal and state laws, rules, and regulations regarding privacy and confidentiality will apply to the Services, including HIPAA.
You understand that it is your duty to provide your Wheel-affiliated Provider truthful, accurate, and complete information, including all relevant information regarding care that you may have received or may be receiving from other health care providers or outside of the Services. You also understand that if you are uncomfortable with receiving the Services or the method in which the Services are provided, you should inform your Wheel-affiliated Provider.
You understand that your Wheel-affiliated Provider may determine that your condition is not suitable for diagnosis or treatment using the Services, or may fail to respond promptly or ever to your request for a telemedicine service, and that you may need to seek medical care and treatment from your Wheel-affiliated Provider, a specialist, or other health care provider outside of the Services.
You understand that in the event of an emergency or an adverse reaction to treatment, you should dial 911 to receive appropriate follow-up care. In the event of technology failure or your Wheel-affiliated Provider determining you need see another provider or make an in-person appointment, he or she will provide you with next steps or follow-up information.
You understand the risks and benefits of the Services and its use in the medical care and treatment provided to you by your Wheel-affiliated Provider. You also understand that you may refuse or withdraw from care at any time, and that your refusal or withdrawal will not affect your ability to receive care in the future.
You understand that failure to comply with the terms of this document may result in the termination of your ability to use the Services.
No potential benefits from the use of the Services, care provided via the Services, or specific results can be guaranteed. Your condition may not be cured or improved, and in some cases, may get worse.

Additional State-Specific Consents:

The following consents apply to patients accessing the Services for the purposes of participating in a telehealth consultation within the states listed below, as required by state law:

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.
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.
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.
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.
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.
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; or, the Oklahoma Board of Osteopathic Examiners’ website, here.
Rhode Island: 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.
Texas: I have been informed of the following notice:

NOTICE CONCERNING COMPLAINTS - Complaints about physicians, as well as other licensees and registrants of the Texas Medical Board, including physician assistants, acupuncturists, and surgical assistants may be reported for investigation at the following address: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018, Assistance in filing a complaint is available by calling the following telephone number: 1-800-201-9353, For more information, please visit our website at www.tmb.state.tx.us.

AVISO SOBRE LAS QUEJAS - Las quejas sobre médicos, asi como sobre otros profesionales acreditados e inscritos del Consejo Médico de Tejas, incluyendo asistentes de médicos, practicantes de acupuntura y asistentes de cirugia, se pueden presentar en la siguiente dirección para ser investigadas: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018, Si necesita ayuda para presentar una queja, llame al: 1-800-201-9353, Para obtener más información, visite nuestro sitio web enwww.tmb.state.tx.us.

Vermont: 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; Or, the Vermont Board of Osteopathic Examiners’ website, here.

Acknowledgement

By clicking “I accept”, you (a) further certify that you are the patient, or that you are duly authorized by the patient as the patient’s representative or legal guardian, (b) acknowledge and accept the risks identified above and the terms associated with the receipt of clinical services via the Services, and (c) give your informed consent to receive clinical services under the terms described herein.