Telehealth Consent

Last updated: January 8, 2021

BY CLICKING “I AGREE,” CHECKING A RELATED BOX TO SIGNIFY YOUR ACCEPTANCE, USING ANY OTHER ACCEPTANCE PROTOCOL PRESENTED THROUGH THE SERVICE OR OTHERWISE AFFIRMATIVELY ACCEPTING THIS CONSENT, YOU ACKNOWLEDGE THAT YOU HAVE READ, ACCEPTED, AND AGREED TO BE BOUND BY THIS CONSENT. IF YOU DO NOT AGREE TO THIS CONSENT, DO NOT CREATE AN ACCOUNT OR USE THE SERVICE. YOU HEREBY GRANT AGENCY AUTHORITY TO ANY PARTY WHO CLICKS ON THE “I AGREE” BUTTON OR OTHERWISE INDICATES ACCEPTANCE TO THIS CONSENT ON YOUR BEHALF.

IF YOU HAVE A MEDICAL EMERGENCY, SEEK IN-PERSON EMERGENCY CARE IMMEDIATELY OR DIAL 911.

Purpose

The purpose of this consent form (“Consent”) is to provide you with information about telehealth and to obtain your informed consent to the use of telehealth in the delivery of healthcare services to you by audiologists, physicians, physician assistants and nurse practitioners (“Providers”) using the online platforms or mobile applications owned and operated by Orka Labs Inc. (the “Service”). In this Consent, the terms “you” and “yours” refer to the person using the Service, or in the case of a use of the Service by or on behalf of an individual minor between the ages of thirteen (13) and eighteen (18) or higher age of majority under applicable state law, “you” and “yours” refer to and include (i) the parent or legal guardian who provides consent to the use of the Service by such minor or uses the Service on behalf of such minor, and (ii) the minor for whom consent is being provided or on whose behalf the Service is being utilized.

By accepting this Consent, you agree and consent to the following:

1. I voluntarily consent to receive services from a Provider through telehealth (remote care) technology.
2. I understand that the Provider and I will communicate by teleconference or other electronic means and that the Provider will provide services remotely. I understand that there are no guarantees regarding outcomes and results of these telehealth services.
3. It has been explained to me how telehealth technology will be used. I understand that the interactions I will have with the Provider through telehealth technology may be different than the interactions I would have during an in-person office visit because I will not be in the same location as the Provider and will not have direct, physical contact with the Provider.
4. I understand that there are risks inherent to telehealth technology, including, but not limited to, interruptions, potential unauthorized access to information shared over a phone or internet connection (including, potentially, unauthorized access to my health information), technical difficulties, issues with the quality of transmitted data which may affect the quality of services received through telehealth, the inability to change the environment and/or test conditions, and limitations of hearing examinations provided through telehealth technology. I understand that I may discontinue telehealth services at any time if I am uncomfortable receiving services via telehealth or if any necessary internet and/or phone connection is inadequate.
5. I understand and acknowledge that I or the Provider may find it necessary and/or useful for others to be present while I receive services through telehealth in order to operate the telehealth technology or otherwise facilitate the receipt of services through telehealth. I understand that any such individuals utilized by the Provider are bound to maintain the confidentiality of all information discussed. I understand that my personal information, including my health information, will be discussed in the presence of anyone present with me while I receive services through telehealth, and I consent to such disclosure. I also understand that, if others are present, I may ask them to leave and/or discontinue telehealth services if I am not comfortable with their presence.
6. I understand that the Provider will not initiate follow-up consultations unless expressly agreed upon during my telehealth visit and that it is my responsibility to initiate any necessary follow-up telehealth visits.
7. I understand that the services being provided through telehealth may be recorded by the Provider for treatment purposes and consent to such recording. The Provider will keep any such recording confidential in accordance with applicable law.
8. I authorize the Provider to release any of my relevant health information as allowed or required by law. I further authorize the Provider to release any information to my insurance company or any other party that may be responsible for payment for my treatment.
9. I understand that I have the right to withdraw this consent at any time.
10. I understand that I will receive the Provider’s contact information and that I may communicate with the Provider by phone and/or through website or mobile application.
11. I have read (or have had read to me) these terms carefully and consent to receive services through telehealth pursuant to these terms.