Consent to Telehealth
CONSENT TO TELEHEALTH
Consent to TELEHEALTH, mymedrefills.com
Last updated 4/12/2023
PURPOSE
The purpose of this form is to obtain your consent for our telemedicine service. The purpose of our telemedicine service is to provide you a one time emergency medication refill upon reviewing and approving your request by a medical doctor. Technically, this is a renewal service. A refill is when you can order a new supply of your medication that has been previously authorized by your prescribing doctor without a new prescription. A renewal is a new prescription for a medication that has run out of refills. For the purposes of our service and this document, however, we will be using the term “refill” for “renewal.”
We expect you to read entirely the Consent to Telehealth, Terms and Conditions, as well the Privacy Notice. We also expect you to understand our model of care from the information provided on our Website and what information you will be expected to provide. I understand this service is for the purpose of providing my a one time emergency refill on my medication(s) under the direction of a medical doctor.
I understand the difference between a refill and renewal and technically this is a renewal service. I understand, when I see the word “refill” it technically means “renewal”. I understand before using this service, I must read and understand this Consent to Telehealth, the Terms and Conditions, and Privacy Notice. I also acknowledge I must read the information that is provided on the Website for my full understanding of the service and what information is expected of me.
BACKGROUND
HealthSource Medical Associates, PLLC through mymedrefills.com, LLC provides services by US Board Certified Licensed Physicians. We are available in all 50 states.
We do not diagnose or treat any new medical conditions. We are here to help patients stay on track of their chronic and stable medications in situations where patients are not able to get refills of their medication(s) on time.
I understand that by using this service, I will only request for refills on my medications that I have been taking consistently and have been stable on for my chronic conditions.
NATURE OF TELEMEDICINE CONSULTATION
Telemedicine is the use of digital technology to provide medical services to patients who otherwise would not be able to obtain in person. Our service requires you to submit all relevant and personal information digitally including photos of their photo ID and medication bottles. Our providers will review the submitted request and contact you via text messaging. Depending on the state you live, a provider may need to call you, or send you a text message link for a video call.
We assume the responsibility of your care at the time our Provider reviews your request.
I understand that by using this service, I will need to be able to accept text messages. I understand I may also need to receive phone calls or have video capabilities on my phone depending on the state in which I live. I understand my care begins when the provider reviews my request.
RISKS AND BENEFITS
There are many benefits to using a Telehealth service like ours. It is convenient, quick, and easy. We believe our service is also very safe to use. We have built in our system the ability to only approve medications that are safe to refill. If your medication is not part of our predetermined list of medications that we feel would be safe to refill, you will not be able to select your medication from the list when it comes time to enter your medication information. Please make sure the medication(s) you are asking for a refill is not part of our refill exclusion list before you begin using our service. Our refill exclusions include all controlled substances, muscle relaxers, chronic pain medications, Promethazine, antipsychotics and ADHD medications, weight loss medications, injectable medications, hormone replacement therapy, immunomodulators or immunosuppressants including steroids, antibiotics, antivirals, antifungals, and any medications that require monitoring.
Certain situations may delay having your requests reviewed by the doctor. We review all requests from 6am to 6pm PST from Sunday to Thursday and 6 am to 1 pm PST on Fridays. We are closed on Saturdays. If you submit your request outside of these hours you will have to wait for your request to be processed by the provider the next available day. For example, if you submit a request at 7 pm PST Thursday night, it will be reviewed between 6am to 1 pm PST on Friday. If you submit a request at 3 pm PST on Friday, your request will be reviewed between 6am to 6pm PST the following Sunday.
All prescriptions are sent electronically to the pharmacy you have selected. It is possible for delays to occur up to a few hours for an electronic prescription to transfer and be processed, but this is very rare. Typically, the electronic transmission of a prescription is immediate and your prescriptions should be ready no later than 2 hours after the physician has sent it. Should a delay or any other issues occur, please email us at contact@mymedrefills.com or call us at 1-888-457-1844.
Situations may arise where our website or service may fail due to unforeseen circumstances. These unforeseen circumstances may include but are not limited to: acts of God, failures of internet connectivity, power outages, acts or omissions of any government. We will take all reasonable efforts to promptly notify you in such circumstances.
If you decide to create an online account to access your information, you will gain access to a secure patient portal. Using our website on a device that has been “hacked,” “jailbroken,” or modified, puts you at risk for have your Personally-Identifying Information and/or Protected Health Information (PHI) unintentionally disclosed to unauthorized personnel. It is your sole responsibility to make sure your device is in conformity to the most up to date security features. We will have no liability for any breach of your personal data or PHI that occurs due to the lack of proper security features on your device.
I understand only certain medications will be approved for a refill through this service. I understand there could be a delay in having my requests reviewed depending on the day and time I submit my request. I understand there could be a delay in my prescriptions being ready at pharmacy. I understand I will be expected to email contact@mymedrefills.com or call 1-888-457-1844 should there be a delay or issue that occurs. I understand I will be notified of any unforeseen circumstances causing a failure of this service. I understand I will do my utmost to make sure I am not using a device that has been “hacked,” “jailbroken,” or modified that puts me at risk for having my Personal Health Information being unintentionally disclosed.
MEDICAL INFORMATION
We rely on you to provide true, accurate, current and complete information in order for us to provide you with the safest outcome. Inappropriate use of our service may jeopardize your health, putting you at great risks, including death, if the information provided is false or inaccurate. The photos of the medication bottles will also need to have both your name and the name of your medication(s) printed on the bottle. We will need both pieces of information to approve any medication refills.
We will also have access to all of your prescription history provided by the services of third party e-prescribing vendor using the Surescripts network database. This information will be taken into account when reviewing the medication refill requests.
I understand the information I provide needs to be true, accurate, current and complete. I understand if I provide any false or inaccurate information I can be putting myself at risk including death. I understand my medication bottles need to have both the name of the medication and my name printed. I understand the provider will have access to and take into account my prescription history through the services of a third party vendor.
CONSENT TO TELEHEALTH
Consent to TELEHEALTH, mymedrefills.com
Last updated 4/12/2023
PURPOSE
The purpose of this form is to obtain your consent for our telemedicine service. The purpose of our telemedicine service is to provide you a one time emergency medication refill upon reviewing and approving your request by a medical doctor. Technically, this is a renewal service. A refill is when you can order a new supply of your medication that has been previously authorized by your prescribing doctor without a new prescription. A renewal is a new prescription for a medication that has run out of refills. For the purposes of our service and this document, however, we will be using the term “refill” for “renewal.”
We expect you to read entirely the Consent to Telehealth, Terms and Conditions, as well the Privacy Notice. We also expect you to understand our model of care from the information provided on our Website and what information you will be expected to provide. I understand this service is for the purpose of providing my a one time emergency refill on my medication(s) under the direction of a medical doctor.
I understand the difference between a refill and renewal and technically this is a renewal service. I understand, when I see the word “refill” it technically means “renewal”. I understand before using this service, I must read and understand this Consent to Telehealth, the Terms and Conditions, and Privacy Notice. I also acknowledge I must read the information that is provided on the Website for my full understanding of the service and what information is expected of me.
BACKGROUND
HealthSource Medical Associates, PLLC through mymedrefills.com, LLC provides services by US Board Certified Licensed Physicians. We are available in all 50 states.
We do not diagnose or treat any new medical conditions. We are here to help patients stay on track of their chronic and stable medications in situations where patients are not able to get refills of their medication(s) on time.
I understand that by using this service, I will only request for refills on my medications that I have been taking consistently and have been stable on for my chronic conditions.
NATURE OF TELEMEDICINE CONSULTATION
Telemedicine is the use of digital technology to provide medical services to patients who otherwise would not be able to obtain in person. Our service requires you to submit all relevant and personal information digitally including photos of their photo ID and medication bottles. Our providers will review the submitted request and contact you via text messaging. Depending on the state you live, a provider may need to call you, or send you a text message link for a video call.
We assume the responsibility of your care at the time our Provider reviews your request.
I understand that by using this service, I will need to be able to accept text messages. I understand I may also need to receive phone calls or have video capabilities on my phone depending on the state in which I live. I understand my care begins when the provider reviews my request.
RISKS AND BENEFITS
There are many benefits to using a Telehealth service like ours. It is convenient, quick, and easy. We believe our service is also very safe to use. We have built in our system the ability to only approve medications that are safe to refill. If your medication is not part of our predetermined list of medications that we feel would be safe to refill, you will not be able to select your medication from the list when it comes time to enter your medication information. Please make sure the medication(s) you are asking for a refill is not part of our refill exclusion list before you begin using our service. Our refill exclusions include all controlled substances, muscle relaxers, chronic pain medications, Promethazine, antipsychotics and ADHD medications, weight loss medications, injectable medications, hormone replacement therapy, immunomodulators or immunosuppressants including steroids, antibiotics, antivirals, antifungals, and any medications that require monitoring.
Certain situations may delay having your requests reviewed by the doctor. We review all requests from 6am to 6pm PST from Sunday to Thursday and 6 am to 1 pm PST on Fridays. We are closed on Saturdays. If you submit your request outside of these hours you will have to wait for your request to be processed by the provider the next available day. For example, if you submit a request at 7 pm PST Thursday night, it will be reviewed between 6am to 1 pm PST on Friday. If you submit a request at 3 pm PST on Friday, your request will be reviewed between 6am to 6pm PST the following Sunday.
All prescriptions are sent electronically to the pharmacy you have selected. It is possible for delays to occur up to a few hours for an electronic prescription to transfer and be processed, but this is very rare. Typically, the electronic transmission of a prescription is immediate and your prescriptions should be ready no later than 2 hours after the physician has sent it. Should a delay or any other issues occur, please email us at contact@mymedrefills.com or call us at 1-888-457-1844.
Situations may arise where our website or service may fail due to unforeseen circumstances. These unforeseen circumstances may include but are not limited to: acts of God, failures of internet connectivity, power outages, acts or omissions of any government. We will take all reasonable efforts to promptly notify you in such circumstances.
If you decide to create an online account to access your information, you will gain access to a secure patient portal. Using our website on a device that has been “hacked,” “jailbroken,” or modified, puts you at risk for have your Personally-Identifying Information and/or Protected Health Information (PHI) unintentionally disclosed to unauthorized personnel. It is your sole responsibility to make sure your device is in conformity to the most up to date security features. We will have no liability for any breach of your personal data or PHI that occurs due to the lack of proper security features on your device.
I understand only certain medications will be approved for a refill through this service. I understand there could be a delay in having my requests reviewed depending on the day and time I submit my request. I understand there could be a delay in my prescriptions being ready at pharmacy. I understand I will be expected to email contact@mymedrefills.com or call 1-888-457-1844 should there be a delay or issue that occurs. I understand I will be notified of any unforeseen circumstances causing a failure of this service. I understand I will do my utmost to make sure I am not using a device that has been “hacked,” “jailbroken,” or modified that puts me at risk for having my Personal Health Information being unintentionally disclosed.
MEDICAL INFORMATION
We rely on you to provide true, accurate, current and complete information in order for us to provide you with the safest outcome. Inappropriate use of our service may jeopardize your health, putting you at great risks, including death, if the information provided is false or inaccurate. The photos of the medication bottles will also need to have both your name and the name of your medication(s) printed on the bottle. We will need both pieces of information to approve any medication refills.
We will also have access to all of your prescription history provided by the services of third party e-prescribing vendor using the Surescripts network database. This information will be taken into account when reviewing the medication refill requests.
I understand the information I provide needs to be true, accurate, current and complete. I understand if I provide any false or inaccurate information I can be putting myself at risk including death. I understand my medication bottles need to have both the name of the medication and my name printed. I understand the provider will have access to and take into account my prescription history through the services of a third party vendor.
CONSENT TO TELEHEALTH
Consent to TELEHEALTH, mymedrefills.com
Last updated 4/12/2023
PURPOSE
The purpose of this form is to obtain your consent for our telemedicine service. The purpose of our telemedicine service is to provide you a one time emergency medication refill upon reviewing and approving your request by a medical doctor. Technically, this is a renewal service. A refill is when you can order a new supply of your medication that has been previously authorized by your prescribing doctor without a new prescription. A renewal is a new prescription for a medication that has run out of refills. For the purposes of our service and this document, however, we will be using the term “refill” for “renewal.”
We expect you to read entirely the Consent to Telehealth, Terms and Conditions, as well the Privacy Notice. We also expect you to understand our model of care from the information provided on our Website and what information you will be expected to provide. I understand this service is for the purpose of providing my a one time emergency refill on my medication(s) under the direction of a medical doctor.
I understand the difference between a refill and renewal and technically this is a renewal service. I understand, when I see the word “refill” it technically means “renewal”. I understand before using this service, I must read and understand this Consent to Telehealth, the Terms and Conditions, and Privacy Notice. I also acknowledge I must read the information that is provided on the Website for my full understanding of the service and what information is expected of me.
BACKGROUND
HealthSource Medical Associates, PLLC through mymedrefills.com, LLC provides services by US Board Certified Licensed Physicians. We are available in all 50 states.
We do not diagnose or treat any new medical conditions. We are here to help patients stay on track of their chronic and stable medications in situations where patients are not able to get refills of their medication(s) on time.
I understand that by using this service, I will only request for refills on my medications that I have been taking consistently and have been stable on for my chronic conditions.
NATURE OF TELEMEDICINE CONSULTATION
Telemedicine is the use of digital technology to provide medical services to patients who otherwise would not be able to obtain in person. Our service requires you to submit all relevant and personal information digitally including photos of their photo ID and medication bottles. Our providers will review the submitted request and contact you via text messaging. Depending on the state you live, a provider may need to call you, or send you a text message link for a video call.
We assume the responsibility of your care at the time our Provider reviews your request.
I understand that by using this service, I will need to be able to accept text messages. I understand I may also need to receive phone calls or have video capabilities on my phone depending on the state in which I live. I understand my care begins when the provider reviews my request.
RISKS AND BENEFITS
There are many benefits to using a Telehealth service like ours. It is convenient, quick, and easy. We believe our service is also very safe to use. We have built in our system the ability to only approve medications that are safe to refill. If your medication is not part of our predetermined list of medications that we feel would be safe to refill, you will not be able to select your medication from the list when it comes time to enter your medication information. Please make sure the medication(s) you are asking for a refill is not part of our refill exclusion list before you begin using our service. Our refill exclusions include all controlled substances, muscle relaxers, chronic pain medications, Promethazine, antipsychotics and ADHD medications, weight loss medications, injectable medications, hormone replacement therapy, immunomodulators or immunosuppressants including steroids, antibiotics, antivirals, antifungals, and any medications that require monitoring.
Certain situations may delay having your requests reviewed by the doctor. We review all requests from 6am to 6pm PST from Sunday to Thursday and 6 am to 1 pm PST on Fridays. We are closed on Saturdays. If you submit your request outside of these hours you will have to wait for your request to be processed by the provider the next available day. For example, if you submit a request at 7 pm PST Thursday night, it will be reviewed between 6am to 1 pm PST on Friday. If you submit a request at 3 pm PST on Friday, your request will be reviewed between 6am to 6pm PST the following Sunday.
All prescriptions are sent electronically to the pharmacy you have selected. It is possible for delays to occur up to a few hours for an electronic prescription to transfer and be processed, but this is very rare. Typically, the electronic transmission of a prescription is immediate and your prescriptions should be ready no later than 2 hours after the physician has sent it. Should a delay or any other issues occur, please email us at contact@mymedrefills.com or call us at 1-888-457-1844.
Situations may arise where our website or service may fail due to unforeseen circumstances. These unforeseen circumstances may include but are not limited to: acts of God, failures of internet connectivity, power outages, acts or omissions of any government. We will take all reasonable efforts to promptly notify you in such circumstances.
If you decide to create an online account to access your information, you will gain access to a secure patient portal. Using our website on a device that has been “hacked,” “jailbroken,” or modified, puts you at risk for have your Personally-Identifying Information and/or Protected Health Information (PHI) unintentionally disclosed to unauthorized personnel. It is your sole responsibility to make sure your device is in conformity to the most up to date security features. We will have no liability for any breach of your personal data or PHI that occurs due to the lack of proper security features on your device.
I understand only certain medications will be approved for a refill through this service. I understand there could be a delay in having my requests reviewed depending on the day and time I submit my request. I understand there could be a delay in my prescriptions being ready at pharmacy. I understand I will be expected to email contact@mymedrefills.com or call 1-88-457-1844 should there be a delay or issue that occurs. I understand I will be notified of any unforeseen circumstances causing a failure of this service. I understand I will do my utmost to make sure I am not using a device that has been “hacked,” “jailbroken,” or modified that puts me at risk for having my Personal Health Information being unintentionally disclosed.
MEDICAL INFORMATION
We rely on you to provide true, accurate, current and complete information in order for us to provide you with the safest outcome. Inappropriate use of our service may jeopardize your health, putting you at great risks, including death, if the information provided is false or inaccurate. The photos of the medication bottles will also need to have both your name and the name of your medication(s) printed on the bottle. We will need both pieces of information to approve any medication refills.
We will also have access to all of your prescription history provided by the services of third party e-prescribing vendor using the Surescripts network database. This information will be taken into account when reviewing the medication refill requests.
I understand the information I provide needs to be true, accurate, current and complete. I understand if I provide any false or inaccurate information I can be putting myself at risk including death. I understand my medication bottles need to have both the name of the medication and my name printed. I understand the provider will have access to and take into account my prescription history through the services of a third party vendor.