Consent to Treatment: Telehealth

My Catholic Doctor, PLLC
Chuck R. Colas, DO, PC.

1. I am selecting a telehealth provider through this portal. Such person is an independent contractor of My Catholic Doctor, PLLC except if I am located in California wherein the provider is an independent contractor of Chuck R. Colas, DO, PC. Information about the various providers, including their license numbers, is on this portal.
2. I understand that telehealth treatment has potential benefits including, but not limited to, easier access to care.
3. I understand that telehealth has been found to be effective in treating a wide range of disorders, and there are potential benefits including, but not limited to easier access to care. I understand, however, there is no guarantee that all treatment of all patients will be effective.
4. I understand that it is my obligation to notify my provider of my location at the beginning of each treatment session. If for some reason, I change locations during the session, it is my obligation to notify my provider of the change in location. I also affirm that I have verified my identity through the sign in process of this site.
5. I understand that it is my obligation to notify my provider of any other persons in the location, either on or off camera and who can hear or see the session. I understand that I am responsible to ensure privacy at my location. I will notify my provider at the outset of each session and am aware that confidential information may be discussed.
6. I understand that it is my obligation to ensure that any virtual assistant artificial intelligence devices, including but not limited to Alexa or Echo, will be disabled or will not be in the location where information can be heard.
7. I agree that I will not record either through audio or video any of the session, unless I notify my provider and this is agreed upon.
8. I understand there are potential risks to using telehealth technology, including but not limited to, interruptions, unauthorized access, and technical difficulties. I understand some of these technological challenges include issues with software, hardware, and internet connection which may result in interruption. The quality of transmitted data may affect the quality of services. Further I understand that in some circumstances physical presence may be require in order to properly treat me. I recognize that I have the option to use in person medical services such as physician offices, clinics, urgicare centers and hospital. The inability to have direct, physical contact with the patient is a primary difference between telehealth and direct in person service delivery. I understand that I am urged to have an in person health care appointment at least once a year, of sooner if advised or circumstances warrant. During my telehealth appointment, my provider will determine whether telehealth services are appropriate and in accordance with the standard of care. I am of the view that they are in view of the services I am seeking.
9. I understand that my provider is not responsible for any technological problems of which my provider has no control over. I further understand that my provider does not guarantee that technology will be available or work as expected.
10. I understand that I am responsible for information security on my device, including but not limited to, computer, tablet, or phone, and in my own location.
11. I understand that my provider or I (or, if applicable, my guardian or conservator), can discontinue the telehealth consult/visit if it is determined by either me or my provider that the videoconferencing connections or protections are not adequate for the situation. I may also change to a different telehealth provider.
12. I have the right to pose questions directed to my provider concerning services via telehealth.
13. My Catholic Doctor Foundation, Inc. is the technology service we will use to conduct telehealth videoconferencing appointments. This is the mode we normally use.

By agreeing to this document, I acknowledge:

1. My Catholic Doctor PLLC/ Chuck R. Colas, DO, PC is NOT an emergency service. In the event of an emergency, I will use a phone to call 9-1-1 and/or other appropriate emergency contact. I can communicate with my provider through this same portal as I am currently using.
2. I recognize my provider may need to notify emergency personnel in the event he/she feels there is a safety concern, including but not limited to, a risk to self/others or my provider is concerned that immediate medical attention is needed.
3. Though my provider and I may be in virtual contact through telehealth services, neither My Catholic Doctor PLLC/ Chuck R. Colas, DO, PC nor my individual provider provides any emergency or urgent healthcare services or advice. If emergency services are needed, I understand I should call 9-1-1.
4. My Catholic Doctor Foundation, Inc..facilitates videoconferencing and this technology platform is not, itself, a source of healthcare, medical advice, or care.
5. It is my obligation to contact my insurer before engaging in telehealth to determine if there are applicable co-pays or fees which I am responsible for. Insurance or other managed care providers may not cover telehealth sessions. I understand that if my insurance, HMO, third-party payor, or other payor does not cover the telehealth sessions, I will be solely responsible for the entire fee of the session. I understand that I am required to provide correct insurance information to my provider, and certify that I have done so.
6. To maintain confidentiality, I will not share my telehealth appointment link or information with anyone not authorized to attend the session. I understand that all existing privacy, security and confidentialty laws, rules and regulations apply to telehealth. Except as provided by HIPAA and other applicable law, my patient identifiable information will be available to me and will not be provided to third parties including researchers without my consent.
7. If I convey my consent to my provider, which is requested. said provider will forward my record to my primary care doctor. I will supply the name of address of my primary care doctor. I do consent to my provider seeking my medical records from other providers and certify that I have in person medical resources available for any needed follow up care which cannot be achieved through this provider. However, I can also obtain follow up by making a follow up appointment with a provider on this site.
8. I understand that either I or my provider can discontinue the telehealth services if those services do not appear to benefit me therapeutically or for other reasons which will be explained to me. I understand there may be no other treatment alternative available.
9. I also understand that in various states there are temporary laws and rules which may expire in due course and affect my ability to obtain telehealth care. An example is Connecticut which has a temporary statute which expires on June 30, 2023. I have read and understand the information provided above regarding telehealth and I hereby give informed consent to the use of telehealth for and on behalf of myself and my dependents as applicable.