MedShield Ascend Telehealth Consent

EJWK Medical P.C.
TELEHEALTH CONSENT FORM

Last Updated: April 2025

OUR HEALTHCARE PROVIDERS DO NOT ADDRESS MEDICAL EMERGENCIES. IF YOU BELIEVE YOU ARE HAVING A MEDICAL EMERGENCY, YOU SHOULD CALL YOUR LOCAL MEDICAL PROVIDER, DIAL 911 OR GO TO THE NEAREST EMERGENCY ROOM.TELEHEALTH IS CONTEMPLATED ONLY FOR SPECIFIC, NON-EMERGENCY MEDICAL CONDITIONS AND CONCERNS.

INTRODUCTION

Telehealth is a mode of delivering health care services via communication technologies to facilitate diagnosis, consultation, treatment, education, care management, and self-management of a patient’s health care where the health care provider and patient are not in the same physical location (the “Services”). Such communications include, but are not limited to, (a) electronic transmission of information including photo images, personal health information, or other data between a patient and health care provider, (b) interactions between a patient and health care provider via videoconferencing, telephonic, and asynchronous technology, and/or (c) transmission of data from medical or monitoring devices, including sound and images.

You are reviewing and acknowledging this Telehealth Consent Form because you are seeking the Services from one or more Medical Practices (as further described in the MedShield Ascend Management Company, LLC (“MedShield Ascend”) Terms of Use) utilizing telehealth technologies facilitated through the MedShield Ascend website, iOS mobile app, web mobile app, or any partner platform, mobile app, or web mobile technologies (collectively, the “MedShield Ascend Platform”). This Telehealth Consent Form supplements but does not modify or supersede any Terms of Use, Privacy Policy, or Notice of Privacy Practices of the Medical Practice.

By checking the box below, you indicate that you have reviewed this Telehealth Consent Form, you indicate that you have reviewed this Telehealth Consent Form or had it explained to you, that you understand the risks and limitations of using telehealth technologies, that you have been given the opportunity to ask questions by calling 833-MED-SHLD, and that such questions have been answered to your satisfaction, and that you consent to receiving the Services from licensed health care providers employed by or contracted with the Medical Practice (“Providers”) who are located at sites remote from you.

TREATMENT-SPECIFIC CONSENT

I understand that the Medical Practice offers telehealth visits, which are conducted through videoconferencing, telephonic, and asynchronous technology and my Provider will not be present in the room with me.

To protect the confidentiality of my health information, I agree to undertake my telehealth visit in a private location, and I understand that my Provider will similarly be in a private location. If any other individuals are present (i.e., for technological or translation assistance), I will be informed of the individual’s presence and such individual’s role, and I will be given the opportunity to consent to such individual’s presence.

I understand there are benefits to the use of telehealth technology, including but not limited to, increasing the efficiency for me to access medical care and treatment, and allowing medical care and treatment at convenient times without the necessity of an in-office appointment.I understand there are potential risks to the use of telehealth technology, including but not limited to, (a) the quality, accuracy or effectiveness of the Services may be limited and evaluation and treatment of certain conditions (e.g., sexually transmitted diseases, alcohol poisoning, drug overdoses) may require an in-person visit, (b) the inability of Providers to conduct certain tests or assess vital signs may in some case prevent the Provider from providing a diagnosis or treatment exclusively via telehealth and may require referral for an in-person visit, (c) given regulatory requirements in certain jurisdictions, your Providers’ diagnosis and/or treatment options, especially pertaining to certain prescriptions, may require an in-person evaluation, and (d) interruptions, delays, unauthorized access, and or other technical difficulties. I understand that either my Provider or I can discontinue the telehealth appointment if the technical connections are not adequate for my visit. I AGREE TO HOLD HARMLESS THE MEDICAL PRACTICE AND ITS MANAGEMENT COMPANY, MEDSHIELD ASCEND, TOGETHER WITH THEIR RESPECTIVE EMPLOYEES, CONTRACTORS, AGENTS, DIRECTORS, MEMBERS, MANAGERS, SHAREHOLDERS, OFFICERS, REPRESENTATIVES, ASSIGNS, PREDECESSORS, AND SUCCESSORS, FOR DELAYS IN EVALUATION OR FOR INFORMATION LOST DUE TO SUCH TECHNICAL FAILURES.

I understand that in some cases, my Provider might be a nurse practitioner or a physician assistant and not a physician.

I understand that I could seek an in-office visit rather than obtain care from a Provider via telehealth, and I am choosing to participate in a telehealth visit with a Provider. I further understand that my Provider may not have access to a complete copy of my medical records and will not have the ability to perform an in-person examination, which could result in negative health outcomes from the recommended treatment (e.g., adverse drug interactions or allergic reactions). I further understand that while using telehealth technologies may benefit me, no such benefits or specific results are guaranteed and my condition may not improve.

I agree that any information I provide as part of any telehealth visit is accurate, true, and complete.

I understand that my Provider may determine that a telehealth visit is not appropriate for me due to my particular health concern or for other reasons related to my health status. In such a case: (i) I be notified that I will be unable to use the Services for the particular issue requested; and (ii) I will need to seek any needed care in another way.

I understand that participating in a telehealth visit is not a guarantee that I will be given a prescription, and that the decision as to whether a prescription is appropriate for my condition will be made in the professional judgment of my Provider.

I understand that while the MedShield Ascend Platform may make available access to certain pharmacy or diagnostic lab services, I may request to use any pharmacy or lab of my preference.

I understand that I am responsible for payment of any amounts due and owing resulting from my telehealth visit.

I understand that Providers do not address medical emergencies via the MedShield Ascend Platform. I understand that it may be my Provider’s responsibility to direct me to emergency medical services, such as an emergency room.

I agree that MedShield Ascend is a third party beneficiary of the Telehealth Consent Form and has the right to enforce it against me.

I understand that I have the right to withdraw my consent at any time.I understand that my withdrawal of consent may prevent me from obtaining some or all of the services on the MedShield Ascend platform.

CONSENT TO TEXT OR EMAIL USAGE FOR APPOINTMENT AND OTHER HEALTHCARE REMINDERS AND GENERAL INFORMATION

I further authorize the Medical Practice and MedShield Ascend to contact me by phone or SMS/ text message at the telephone number I have provided, or to send emails at the email address I have provided, with appointment reminders and general health information. I understand that this request is to receive emails and/or text messages will apply to all future appointment reminders/feedback/health information unless I request a change in writing. I also acknowledge this means of communication is not considered secure for the transmission of private information.

ADDITIONAL STATE-SPECIFIC DISCLOSURES

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

Alaska: I understand that my primary care provider may obtain a copy of my records of my telehealth encounter.

California Patients: The Open Payments database is a federal tool used to search payments made by drug and device companies to physician and teaching hospitals. It can be found at https://openpaymentsdata.cms.gov.

For informational purposes only, a link to the federal Centers for Medicare & Medicaid Services (CMS) Open Payments web page is provided above. The federal Physician Payments Sunshine Act requires that detailed information about payment and other payments of value worth over ten dollars ($10) from manufacturers of drugs, medical devices, and biologics to physicians and teaching hospitals be made available to the public.

Treatment Records: I understand that If I live in one of the following states, my primary care provider or other treating physician may obtain a copy of my telehealth treatment records with my consent, and the Medical Practice or MedShield Ascend on its behalf, may securely send a copy of my telehealth treatment records to my primary care provider or other treating physician. If I need help sending my telehealth treatment records to my primary care provider I can contact support@campusmedshield.com.If I would like MedShield Ascend to do so, I can contact support@campusmedshield.com and provide information necessary for MedShield Ascend to securely send my records.

Connecticut: I understand that my primary care provider may obtain a copy of my records of my telehealth encounter.

Kansas: I understand that if I have a primary care provider or other treating physician, the person providing telemedicine services must send a report to such primary care or other treating physician of the treatment and services rendered to me during the telemedicine encounter within three days of me providing consent to the person providing telemedicine services to send such report.

New Hampshire: I understand that my primary care provider or treating provider may obtain a copy of my records of my telehealth encounter.

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.

Ohio: I understand that my primary care provider may obtain a copy of my records of my telehealth encounter.

South Carolina: I understand that my medical records may be distributed only with my consent and in accordance with applicable laws and regulations to other treating health care practitioners.

Texas: I understand that with my consent my medical records may be sent to my primary care physician within 72 hours after receiving Services.

Formal Complaints:

California: 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 physician assistant board’s website here.

Georgia: 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.

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.

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.

New York: I have been informed that to get information regarding your rights and how to report professional misconduct, I should visit 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.

Oregon: 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.

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:

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 en www.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.

Wyoming: 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.