Telehealth Informed Consent
I understand that Telehealth is a mode of delivering health care services via communication technologies (e.g., internet or cellphone) to facilitate diagnosis, consultation, treatment, education, care management, and self management of a patient’s health care.
By acknowledging my consent below, I understand and agree to the following:
1. I understand that Mixx Health and Wellness LLC offer Telehealth consultations, which are conducted through videoconferencing, telephonic, and asynchronous technology and my Telehealth provider will not be present in the room with me.
2. I understand there are potential risks to the use of Telehealth technology, including but not limited to, interruptions, delays, unauthorized access, and or other technical difficulties. I understand that either my Telehealth provider or I can discontinue the Telehealth appointment if the technical connections are not adequate for my visit.
3. I understand that I could seek an in-office visit rather than obtain care from a Telehealth provider, and I am choosing to participate in a Telehealth consultation with Mixx Health and Wellness LLC.
4. To protect the confidentiality of my health information, I agree to undertake my Telehealth consultation in a private location, and I understand that my Telehealth provider will similarly be in a private location.
5. I understand that due to the nature of this treatment and the multi-month quantity of medication you will receive on the first month of service, there is a minimum commitment of 3 months of service associated with my use of Mixx Health and Wellness LLC services.
6. I understand that my initial payment to Mixx Health and Wellness LLC is non-refundable due to services rendered and expenses incurred immediately upon my enrollment including account setup, clinical coordination and prepaid labwork orders. However, if Mixx Health and Wellness LLC staff or affiliated services determine that it is not medically appropriate to prescribe the medication requested, a refund is provided.
7. I understand that I, and only I, am responsible for payment of any amounts due and owing resulting from my Telehealth subscription.
8. I understand that any subscription cancellation request must be submitted at least 15 days prior to your next billing date. Requests sent less than 15 days prior to your next billing date will be subject to an additional final monthly charge prior to being canceled.
9. I understand that failure to pay any amounts due and owing resulting from use of Mixx Health and Wellness LLC services may be turned over to a collection agency which may adversely affect my credit.
10. I understand that my enrollment in this service does not guarantee that I will be issued a prescription for the desired product(s). I further agree and understand that my initial charge for enrolling will be refunded in full in the event that the provider is unable to prescribe the requested prescription and associated product(s) for medical reasons.
11. I understand that my program does not provide support via telephone. In the event that a two way video consultation is requested for a program in which does not require two way video, an additional charge may be required to talk to your provider directly and will be billed separately outside of your normal monthly subscription fee. You may communicate with your provider via the “Chat” functionality of the Mixx Health and Wellness LLC portal. Email support is also always available and is included in your program.
12. In an emergency situation, I understand that the responsibility of my Telehealth provider may be to direct me to emergency medical services, such as an emergency room.
By acknowledging below, I certify:
that I have read this form and/or had it explained to me
that I understand the risks and benefits of a Telehealth appointment
that I have been given the opportunity to ask questions and that such questions have been answered to my satisfaction.
that I understand there is personal information required of me by the provider(s) and labs such as photo identification and social security number and that this portal is a secure, HIPAA-compliant portal where my information is maintained safely and securely.
that I understand the aforementioned personal information is no different than would be provided to an in person doctor’s office for the same services.