Telemedicine Consent

Telehealth involves the use of live audio-video or other forms of synchronous and asynchronous electronic communications to deliver health care services to patients while the health care provider (Provider) is located at a physical location different from the patient receiving the health care services (Telehealth Services).

By agreeing to receive Telehealth Services from Hey Jane Clinicians, PLLC and Nightingale Medical, PC (Medical Practice) via all websites provided by Possible Health, Inc. (“Possible Health”, “we”, “us” or “our”), including the Site hosted on the domain [https://heyjane.co/] (collectively, “Sites”), and all services provided by us in connection with such Sites or otherwise (Hey Jane Platform).

I acknowledge that:

1. There are potential risks to using electronic communications for the purpose of a health care visit, including, but not limited to, service interruptions, unauthorized access, technical difficulties, call termination or other equipment failures. I acknowledge and accept those risks, understanding there are alternatives to receiving Telehealth Services.
2. I will receive protected health information via email or SMS text messaging. I understand that messages shared through these communication channels may not be secure in every instance.
3. Either I or the Provider can discontinue Telehealth Services if either of us determines that Telehealth Services are not right for my health care.
4. It is my responsibility to provide accurate, complete, and current information about me and my health condition(s) to the Provider while receiving Telehealth Services.
5. The Practice has made reasonable and appropriate efforts to eliminate any confidentiality risks associated with Telehealth Services. I am also responsible for mitigating any risks to my privacy or confidentiality stemming from the location or circumstances of my participation in Telehealth Services (e.g., joining the telehealth encounter from a quiet space, ensuring others do not overhear my conversation or see my computer or mobile device screen). All existing confidentiality protections under federal and state law apply to my information disclosed during Telehealth Services
6. I understand and acknowledge that Telehealth Services are not intended to be, and do not act as, emergency services. If I am experiencing an emergency, I should not rely on Telehealth Services and instead should call 911 or go to an emergency department.
7. I understand what it means to receive Telehealth Services and am legally authorized to acknowledge, agree, and consent to the use of Telehealth Services.
8. I am responsible for all charges (a) that I may incur from my mobile or internet service provider, as applicable, when receiving Telehealth Services.

By continuing, I, the patient, hereby:

• Represent that I have read and understand this Consent to use Telehealth Services and the anticipated benefits and risks of the use of telehealth provided to me through the Hey Jane Application. I hereby consent to receive Telehealth Services from providers engaged through the Hey Jane Application.