My-IUD.com Informed Consent
NEW PATIENT AGREEMENT & INFORMED CONSENT FOR TELEHEALTH
My-IUD LLC (My-IUD.com and My-IUDSupplply.com) clinical care is provided by one of the nation’s leading physician groups, Gyn-Care, Inc and its contractual affiliates. My-IUD.com connects you to a Gyn-Care, Inc physician or nurse practitioner who will provide medical or nursing services via telehealth (“Medical Services”). My-IUD LLC does not provide any medical services, does not practice medicine, and does not influence the practice of medicine or any licensed profession provided by My-IUD.com clinicians, each of whom are responsible for his or her services and compliance with the requirements applicable to his or her profession and license.
This New Patient Agreement (the “Agreement”), effective as of the date of the Patient’s acceptance (the “Effective Date”), is made by and between My-IUD LLC and Gyn-Care Inc., a Georgia S corporation and its contractual affiliates (“Practice”), and the patient (the “Patient,””You” or “I” when making affirmative statements in this Agreement).
Term, Termination, and Cancellation
This Agreement will commence on the Effective Date and will extend until the visit concludes.
You acknowledge that the signing of this Agreement is strictly voluntary. This Agreement does not restrict or limit your ability to receive professional services from other health care professionals.
Insurance or Other Medical Coverage
This Agreement and the Practice’s provision of Medical Services are not substitutes for health insurance or other health plan coverage (such as membership in an HMO). You acknowledge that the Practice has advised You to obtain or keep in full force your health insurance policy(ies) or plans in order to cover You and your family members for other healthcare services and/or costs. You acknowledge that this Agreement is not a contract that provides health insurance for you, and this Agreement is not intended to replace any insurance coverage provided to You by an Insurer. You acknowledge that neither Practice nor My-IUD LLC will bill your Insurer for any Medical Services and that Medical Services are not intended to be covered by your Insurer. It is Your responsibility to submit any invoices paid for Medical Services to any health insurance or health plan coverage provider. The Practice in no way provides any representations to You that any Medical Services performed by the Practice will be eligible for coverage under any insurance policy held by You.
If for any reason any provision of this Agreement shall be deemed, by a court of competent jurisdiction, to be legally invalid or unenforceable in any jurisdiction to which it applies, the validity of the remainder of the Agreement shall not be affected, and that provision shall be deemed modified to the minimum extent necessary to make that provision consistent with applicable law and in its modified form, and that provision shall then be enforceable.
Modifications, Termination, Interruption and Disruptions
You understand, agree and acknowledge that My-IUD.com may modify, suspend, disrupt or discontinue the My-IUD.com platform, any part of the platform or the use of the platform, whether to all clients or to You specifically, at any time with or without notice to You. You agree and acknowledge that My-IUD.com will not be liable for any of the aforementioned actions or for the failure to provide any future Medical Services to You, or for any losses or damages that are caused by any of the aforementioned actions.
The My-IUD.com platform depends on various factors such as software, hardware and tools, either our own or those owned and/or operated by our contractors and suppliers. While we make commercially reasonable efforts to ensure the platform’s reliability and accessibility, You understand and agree that no platform can be 100% reliable and accessible and so we cannot guarantee that access to the platform will be uninterrupted or that it will be accessible, consistent, timely or error-free at all times.
Moreover, if federal, state, or local law or regulation (“Applicable Law”) requires this Agreement to contain provisions that are not expressly set forth in this Agreement, then, to the extent necessary, such provisions shall be incorporated by reference into this Agreement and shall be deemed a part of this Agreement as though they had been expressly set forth in this Agreement.
This Agreement, and any rights You may have under it, may not be assigned or transferred by You. This Agreement, and any rights the Practice may have under it, may not be assigned or transferred to its heirs, successors, or assignees.
Relationship of Parties
You and the Practice intend and agree that the Practice, in performing the Medical Services under this Agreement, is an independent contractor, as defined by the guidelines promulgated by the United States Internal Revenue Service and/or the United States Department of Labor, and the Practice shall have exclusive control of its work and the manner in which it is performed.
You acknowledge that this Agreement is a legal document and creates certain rights and responsibilities. You also acknowledge that You have had a reasonable time to seek legal advice regarding the Agreement and have either chosen not to do so or have done so and are satisfied with the terms and conditions of the Agreement.
All written notices are deemed delivered and received when sent if sent to the e-mail address of the party.
This Agreement shall be governed and construed under the laws of the state or commonwealth in which You are located. This Agreement shall be construed without regard to any presumptions or rules requiring construction against the party causing the instrument to be drafted.
Captions in this Agreement are used for convenience only and shall not limit, broaden, or qualify the text.
This Agreement contains the entire agreement between the parties regarding the subject matter of this Agreement, and supersedes all prior oral and written understandings and agreements regarding the subject matter of this Agreement. If any provision of this Agreement is held by a court of competent jurisdiction to be illegal, invalid, unenforceable, or otherwise contrary to law, the remaining provisions of this Agreement will remain in full force and effect.
MEDICAL SERVICES PATIENT WARNING/DISCLAIMER
Patient understands and agrees that email and the internet should never be used to access medical care in the event of an emergency, or any situation that Patient could reasonably expect may develop into an emergency. Patient agrees that in such situations, when a Patient cannot speak to a physician or other appropriated license clinician that may provide Medical Services hereunder (a “Clinician”) immediately in person or by telephone, that Patient shall call 911 and/or seek treatment at the nearest emergency medical assistance provider and follow the directions of emergency medical personnel.
Background on Telemedicine:
Telemedicine involves the use of electronic communications technologies to enable the transfer of medical/health and other information between a health care provider and patient who are in different locations. Telemedicine technologies may include interactive two-way audio and video, interactive audio, asynchronous chat-based care, remote monitoring, management of patient medical records, medical images, e-mail, output data from medical devices, and sound and video files. Information conveyed using telemedicine may be used for the diagnosis, treatment, follow-up and/or education of patients.
Electronic systems incorporate network and software security protocols to protect your confidentiality and the confidentiality of Your data, including that which is considered protected health information (“PHI”) as further defined in the “Notice of Privacy Practices.” Our system also includes measures to safeguard the data, including all PHI, and to ensure its integrity against intentional or unintentional corruption.
Expected Benefits of receiving Medical Services via Telemedicine:
- Improved access to medical care by enabling you to consult with your Clinician remotely.
- More efficient medical evaluation and management.
- Obtaining the expertise of a distant specialist.
Possible Risks of Receiving Medical Services via Telemedicine:
As with any medical procedure, there are potential risks associated with the use of telemedicine. These risks include, but may not be limited to:
- In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision making by the Clinician.
- Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment.
- In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information, including PHI.
- In rare cases, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors.
- There may be other risks that are currently not known.
BY CLICKING “PLACE YOUR ORDER,” I ACKNOWLEDGE THAT I UNDERSTAND AND AGREE WITH THE FOLLOWING:
- I give my informed consent to receive medical services including telemedicine from Practice, and its primary care practitioners and specialists (“Clinicians”) for myself or for the patient for whom I am the parent or legal guardian. This medical care may include services related to my health (or the identified person) and may include any treatment offered through My-IUD.com . This consent includes contact and discussion with other health care professionals for care and treatment.
- My-IUD.com is a separate entity that is independent from the Practice, is not licensed to practice medicine, and has been contracted by the Practice to furnish administrative services for Practice and to assist with the provision of technologies and administrative services used to support telemedicine encounters.
- It is up to the Practice Clinician to determine whether my needs are appropriate for a telemedicine encounter.
- I will not be prescribed any controlled substance, as determined by any applicable federal or state agency, and there is no guarantee that I will receive a prescription for any medication.
- A variety of alternative methods of medical care may be available to me, and that I may choose one or more of these at any time.
- Telemedicine may involve electronic communication of my personal medical information, including PHI, to Practice Clinicians or other healthcare providers who may be located in other areas, including in other states as well as with My-IUD.com pursuant to applicable state and federal laws.
- It is my duty to inform my Clinician of relationships I may have with other healthcare providers providing treatment to me to ensure my Clinician has a full clinical picture when making treatment decisions.
- Some parts of the services involving physical tests may be conducted by individuals at my location, or at a testing facility, at the direction of my Clinician.
- I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment.
- I may suspend or terminate access to telemedicine services at any time for any reason or for no reason.
- I understand that if I am experiencing a medical emergency, that I will be directed to dial 9-1-1 immediately and that neither Practice, nor Clinicians nor My-IUD.com service specialists may be able to connect me directly to any local emergency services.
- I have the right to inspect all information obtained and recorded in the course of a telemedicine interaction, including my medical record, and may receive copies of this information for a reasonable fee.
- Video images and audio recordings of me may be captured and stored electronically. I understand that these recordings may be later viewed and used for purposes of evaluation and training, which may include Practice or My-IUD.com non-clinical personnel. I understand and consent to the use of these images and audio recordings for the telemedicine consultation and, potentially, evaluation, education and training.
- I understand and consent that healthcare information, including PHI, may be shared with My-IUD.com or other individuals for scheduling, billing, and other necessary purposes subject to all applicable privacy and security laws.
- The laws that protect privacy and the confidentiality of medical information, particularly PHI, also apply to telemedicine, and that no information obtained in the use of telemedicine that identifies me will be disclosed to researchers or other entities without my express written consent.
- I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured.
- There is a risk of technical failures during the telemedicine encounter beyond the control of Gyn-Care Inc and. My-IUD.com I agree to hold harmless Gyn-care, Inc, Practice and My-IUD.com for delays in evaluation or for information lost due to such technical failures.
- In the event of any problem with the website or related services, I agree that my sole remedy is to cease using the website or terminate access to the service. Under no circumstances will Gyn-Care, Inc, Practice and My-IUD.com be liable in any way for the use of the telemedicine services, including but not limited to, any errors or omissions in content or infringement by any content on the website of any intellectual property rights or other rights of third parties, or for any losses or damages of any kind arising directly or indirectly out of the use of, inability to use, or the results of use of the website, and any website linked to the website, or the materials or information contained on any or all such websites. I agree that I will not hold Gyn-Care, inc Practice nor My-IUD.com liable for any punitive, exemplary, consequential, incidental, indirect or special damages (including, without limitation, any personal injury, lost profits, business interruption, loss of programs or other data on my computer or otherwise) arising from or in connection with your use of the website whether under a theory of breach of contract, negligence, strict liability, or otherwise, even if we or they have been advised of the possibility of such damages; provided however that I do not waive any right to bring valid malpractice claims against any Clinicians that have provided Medical Services to me.
- Gyn-Care, Inc. and My-IUD.com make no representation that materials on this website are appropriate or available for use in any other location. I understand that may not access these services from a location outside of the United States,.
- I have been offered a copy of this consent form.
All Clinicians that provide Medical Services on the My-IUD.com platform hold professional licenses issued by the professional licensing boards in the states where they practice, hold doctoral degrees in medicine, have undergone post-doctoral training, and/or have other applicable education, experience and certification. You can report a complaint relating to services provided by any Clinician by contacting the professional licensing board in the state where the services were received. In a professional relationship, sexual intimacy is never appropriate and should be reported to the board that licenses, registers, or certifies the licensee.
You can find the contact information for each of the state professional licensing boards governing medicine on the Federation of State Medical Boards website at: http://www.fsmb.org/state-medical-boards/contacts
Any patient medical records created as a result of your use of the site will be securely maintained by the Practice on behalf of your treating Clinician for a period that is no less than the minimum number of years such records are required to be maintained under state and federal law, and which is typically at least six years.
Please report any violations of this New Patient Agreement and Informed Consent to firstname.lastname@example.org.
PATIENT BILL OF RIGHTS
Many states have adopted a patient bill of rights applicable to patients of Clinicians and/or hospitals and other health care facilities. Some of those states require that physicians provide a copy of the bill of rights to their patients. The portion of the bill of rights that is relevant to any Medical Services provided to You here on behalf of Practice. Please note that it includes patient responsibilities as well.
- A patient has the right to be treated with courtesy and respect, with appreciation of his or her individual dignity, and with protection of his or her need for privacy.
- A patient has the right to a prompt and reasonable response to questions and requests within the context of the Service.
- A patient has the right to know who is providing medical services and who is responsible for his or her care.
- A patient has the right to know what patient support services are available, including whether an interpreter is available if he or she does not speak English.
- A patient has the right to know what rules and regulations apply to his or her conduct.
- A patient has the right to be given information by the health care provider concerning diagnosis, planned course of treatment, alternatives, risks, and prognosis.
- A patient has the right to refuse any treatment provided via the Service unless otherwise required by law.
- A patient has the right to receive a copy of a reasonably clear and understandable, itemized bill and/or receipt and, upon request, to have the charges explained.
- A patient has the right to impartial access to medical treatment or accommodations, regardless of race, national origin, religion, handicap, or source of payment, subject to the technical limitations of the Service.
- A patient has the right to express grievances regarding any violation of his or her rights, as stated in state law, through the grievance procedure of the health care provider which served him or her and to the appropriate state licensing agency.
- A patient is responsible for providing to the Provider, to the best of his or her knowledge, accurate and complete information about present complaints, past illnesses, hospitalizations, medications, and other matters relating to his or her health.
- A patient is responsible for reporting unexpected changes in his or her condition to the Provider.
- A patient is responsible for reporting to the Provider whether he or she comprehends a contemplated course of action and what is expected of him or her.
- A patient is responsible for following the treatment plan recommended by the Provider.
- A patient is responsible for his or her actions if he or she refuses treatment or does not follow the Provider’s instructions.
STATE SPECIFIC NOTIFICATIONS
FOR CALIFORNIA RESIDENTS
- You or your legal representative retain the option to withhold or withdraw consent to receive health care services via the Medical Services at any time without affecting your right to future care or treatment nor risking the loss or withdrawal of any benefits to which You or Your legal representative would otherwise be entitled.
- All existing confidentiality protections apply.
- All existing laws regarding patient access to medical information and copies of medical records apply.
- Dissemination of any of Your identifiable images or information from the telemedicine interaction to researchers or other entities shall not occur without Your consent.
- All provisions herein, including Your informed consent to receive services via the Service are for the benefit of the treating provider as well as for your benefit.
- Medical doctors are licensed and regulated by the Medical Board of California. To check up on a license or to file a complaint go to www.mbc.ca.gov, email email@example.com, or call (800) 632-2322.
- Physician assistants are licensed and regulated by the Physician Assistant Board of California, www.pab.ca.gov or (916) 561-8780.
FOR CONNECTICUT, OHIO, UTAH, AND TEXAS RESIDENTS
- If You would like the record of this visit to be forwarded to another provider, please include the name and contact information in a message to Your SteadyMD Provider.
FOR FLORIDA RESIDENTS
- Each provider is a physician licensed by the Florida Board of Medicine or the Florida Board of Osteopathic Medicine. Provider’s hours are variable and will be posted on My-IUD.com.
FOR GEORGIA RESIDENTS
- The patient has the right to file a grievance with the Georgia Composite Medical Board concerning the physician, staff, office, and treatment received. The patient should either call the Board with such a complaint or send a written complaint to the Board. The patient should be able to provide the physician or practice name, the address, and the specific nature of the complaint. The Georgia Composite Medical Board current phone number is (404) 656-3913 and the address is 2 Peachtree Street NW, 6th Floor, Atlanta, GA 30303-3465
FOR INDIANA RESIDENTS
- Unless Your provider specifically discloses otherwise, with the exception of charges for services delivered to patients, providers do not have any financial interest in any information, products, or services offered through the Service.
- I expressly consent to providers forwarding my patient identifiable information to the third-party payor responsible for the Service or its designee. I agree that I will hold harmless said payor(s), SteadyMD, the Practice and its Clinicians for any loss of information due to a technical failure.
- You may access, supplement and amend your personal health information that you have provided to the Practice and its Clinicians and you may provide feedback regarding the site and the quality of information and services, and you may register complaints, including information regarding filing a complaint with the Consumer Protection Division Office of the Attorney General. Notice Concerning Complaints
- You may either file a complaint online or download the appropriate complaint form. If downloading, you must complete, sign, print, and mail it, along with copies of all relevant supporting documentation to: § Consumer Protection Division Office of the Indiana Attorney General 302 W. Washington St., 5th Floor Indianapolis, IN 46204 § You can also request a complaint form by calling (800) 382-5516 or (317) 232-6330.
FOR KANSAS RESIDENTS
- Notice to Patients
- Required Signage for K.A.R. 100-22-6 Prepared by the State Board of Healing Arts April 5, 2007
- It is unlawful for any person who is not licensed under the Kansas Healing Arts Act to open or maintain an office for the practice of the healing arts in Kansas. Services are provided by a person who is licensed to practice the healing arts in Kansas
- Questions and concerns regarding this professional practice may be directed to:
- KANSAS STATE BOARD OF HEALING ARTS 800 SW Jackson, Lower Level – Suite A, Topeka, Kansas 66612 — PHONE: (785) 296-7413 TOLL FREE: 1(888) 886-7205 FAX: (785) 368-7102 WEBSITE: www.ksbha.org
FOR LOUISIANA RESIDENTS
- In addition to any informed consent and right to privacy and confidentiality pursuant to state and federal law or regulations, You shall be informed of the relationship between the Provider, you and the respective role of any other health care provider with respect to the management of Your care and treatment; and You may decline to receive Services and may withdraw from such care at any time.
FOR MARYLAND RESIDENTS
- My-IUD.com verifies the identity of the individual transmitting the communication: after the initial verification, My-IUD.com will verify Your identification through the assignment and use of a unique username and password combination and a pin number should you choose to use it. When You sign into the Service, your username and password (and pin number, as applicable) identify You.
- Access to data via the Service is restricted through the use of unique usernames and passwords. The username and password assigned to You are personal to You and You must not share them with any other individual.
- Provider is hereby providing You with access to Provider’s notice of privacy practices. During the appointment, the provider will communicate with You and respond to Your questions.
- A primary difference between telehealth and direct in-person service delivery is the inability to have direct physical contact with You.
- The quality of transmitted data may affect the quality of Services provided by Gyn-Care, Inc. the Practice or its Clinicians
- Changes in the environment and test conditions could be impossible to make during delivery of Services.
- Services may not be provided by correspondence only. Services must be delivered by either audio or audio-visual devices.
FOR MINNESOTA RESIDENTS
- Disclosures of Your health records without Your written consent shall be made in accordance with state and federal law regarding privacy and confidentiality. Examples of such disclosures include, but are not limited to, for specific public health activities, for health oversight activities, for judicial and administrative proceedings, for specific law enforcement purposes.
- You have the right to access and obtain copies of Your health records and other information about You that is maintained by the Practice. For more specific information regarding Your rights to access to health records, please refer to the Minnesota Department of Health Notices Related to Health Records at health.state.mn.us/facilities/notices/index.html
FOR OKLAHOMA RESIDENTS
- You always retain the option to withhold or withdraw consent from obtaining health care services via the Service. If You decide that You no longer wish to obtain health care services via the Service, it will not affect Your right to future care or treatment, nor will You risk the loss or withdrawal of any program benefits to which You would otherwise be entitled.
- Patient access to all medical information transmitted during a telemedicine interaction is guaranteed by Provider and copies of this information are available at stated costs, which shall not exceed the direct cost of providing the copies.
- All existing confidentiality protections apply.
- Dissemination of any of any of Your identifiable images or information from the telemedicine interaction to researches or other entities shall not occur without Your consent.
FOR OREGON RESIDENTS
- You have choices with respect to receiving care and treatment from Practice. In this regard, You have a choice when You are referred to a facility or other health care provider by Practice for a diagnostic test or health care treatment, and may elect to receive the diagnostic test or other health care treatment from a facility or health care provider other than the one recommended by Practice.
- If You choose to have the diagnostic test, health care treatment or service at a facility different from the one recommended by Practice, You are responsible for determining the extent or limitation of coverage for the diagnostic test, health care treatment or service at your chosen facility.
FOR TEXAS RESIDENTS
- An additional in-person medical evaluation may be necessary to meet Your needs if the provider is unable to gather all the clinical information via the Service to safely treat You.
- Unless Your provider specifically discloses otherwise, with the exception of charges for Services delivered to patients, providers do not have any financial interest in any information, products, or services offered through the Service.
- The response time for emails, electronic messages and other communications can be found on My-IUD.com
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 the website at www.tmb.state.tx.us
FOR VIRGINIA RESIDENTS
- Practice will maintain your records while You are an active patient or will transfer your records to another practitioner or health care provider should You wish to seek care elsewhere. Practice shall maintain Your records for a minimum of six (6) years following Your last encounter with a Provider with the following exceptions:
- Records of a minor child, including immunizations, must be maintained until the child reaches the age of 18 or becomes emancipated, with a minimum time for record retention of six years from the last patient encounter regardless of the age of the child;
- Records that have previously been transferred to another practitioner or health care provider or provided to the patient or his personal representative; or
- Records that are required by contractual obligation or federal law to be maintained for a longer period of time.
- Patient records will only be destroyed in a manner that protects patient confidentiality.
- For more information from the Virginia Department of Health Professions, go to www.dhp.virginia.gov/Medicine.
- Practice will obtain identification information on each patient.
- My-IUD.com and the Practice offer a variety of types of activities using telemedicine services. These include but are not limited to: diagnosis and management of both acute and chronic medical conditions, prescriptions, ordering of laboratory testing, radiographic studies, and other diagnostic testing, patient education, and appointment scheduling.
- The patient agrees that it is the role of the physician to determine whether or not the condition being diagnosed and/or treated is appropriate for a telemedicine encounter.
- My-IUD.com uses the latest security measures with the use of telemedicine services to ensure patient’s protected health information is secure. My-IUD.com utilizes a secure server for storage of information. All computers are password protected and EMR is password protected.
- Notwithstanding such measures there is still potential risk to privacy.
- Patients will hold My-IUD.com, the Practice and its Clinicians harmless for information lost due to technical failure.
- My-IUD.com, the Practice and its Clinicians will obtain expressed patient consent to forward patient-identifiable information to a third party.
FOR WISCONSIN RESIDENTS
- You have the right to request and receive information within a reasonable period of time after your request the fees charged for a health care service, diagnostic test, or procedure provided by the Practice.
Last Updated: March 1st 2023