AUTHORIZATION AND CONSENT TO PARTICIPATE IN REMOTE HEALTH SERVICES

The purpose of this form is to obtain your consent to participate in a Remote Health evaluation (the “evaluation”).
1. Purpose and Benefits. The purpose and benefit of the evaluation is to provide more timely and available access to erectile dysfunction services and treatment.

2. Nature of Evaluation. During the evaluation:
A nurse or physician will be available to answer any questions and assist with the encounter and any routine or emergent needs which may arise.
Non-medical technical personnel may be able to monitor the evaluation in order to assist with any potential or actual electronic transmission and/or communication issues, and to ensure quality compliance.

3. Medical Information and Records. All existing laws regarding your access to medical information and copies of your medical records apply to this evaluation. Additionally, dissemination of any patient-identifiable images or information from this interaction to researchers or other entities shall not occur without your consent, unless authorized under existing confidentiality laws. Records and prescriptions requiring original signatures may take longer to process, allowing for transport from the doctor’s site to the issuing pharmacy. All records and prescriptions are transported via secure courier.

4. Modality. Remote evaluation based on online questionnaire if/when permitted by state law.

5. Confidentiality. Reasonable and appropriate efforts have been made to eliminate any confidentiality risks associated with the evaluation. All existing confidentiality protections under federal and Pennsylvania and Florida State laws apply to information disclosed during this evaluation.

6. Fees. Fees are disclosed to you during you online check out

7. Risks and Consequences. The evaluation will be similar to a routine physician office visit, except interactive technology will allow you to communicate with a health professional at a distance and remotely. As with any medical procedure, there are potential risks associated with the use of Remote Health. These risks include, but are not limited to:

1. In rare cases, the health professional may determine that the transmitted information is of inadequate quality, thus necessitating an in person examination.
2. Delays in medical evaluation and treatment could occur due to deficiencies or failures of equipment.
3. In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information.
4. In rare cases, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors.

8. Acknowledgments. By authorizing and consenting to Remote Health, you are acknowledging “Informed Consent, and you understand and agree with the following:

1. The evaluation may involve electronic communication of your personal medical information to other medical practitioners who may be located in other areas, including out of state.
2. You may expect the anticipated benefits from the evaluation, but that no results can be guaranteed or assured.

9. Rights. You may withhold or withdraw consent to the consultation at any time without affecting your right of future care or treatment, or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled.

I have been advised of all the potential risks, consequences and benefits of the evaluation. I have had an opportunity to ask questions about this information and all of my questions have been answered. I understand the written information provided above.

Last updated: April 4, 2024