Consent to Local Doctor Services and Use of E-mail, Text Messaging, Video, Online in Chat Rooms and/or Telephone
In Arizona: First Opinion Arizona, P.C.
In California: First Opinion Professional Services California, PC
In District of Columbia: First Opinion District of Columbia, P.C.
In Florida: First Opinion Florida, P.A.
In Georgia: First Opinion Georgia, P.C.
In Illinois: First Opinion Illinois, S.C.
In Maryland: First Opinion Maryland, P.C.
In Massachusetts: First Opinion Massachusetts, P.C.
In Michigan: First Opinion Michigan, P.C.
In New York: Primary Assessment Medical Services, P.C.
In North Carolina: First Opinion North Carolina, P.C.
In Ohio: First Opinion Ohio, Inc.
In Pennsylvania: First Opinion Pennsylvania, P.C.
In Utah: First Opinion Utah, P.C.
In Virginia: First Opinion Virginia, P.C.
In Washington: First Opinion Washington PC
In Wisconsin: First Opinion Wisconsin, S.C.
This Request and Authorization to Share Protected Health Information (PHI) Via E-mail, Text Messaging, Video, Online in Chat Rooms and/or Telephone (“Technologies”) applies to users who have registered to use the Local Doctor Services provided by the professional corporation in your state named above (“PC”, “We,” “Our,” or “Us”) and electronically supported by First Opinion, Inc. a Delaware Corporation (“First Opinion”). By your electronic signature below, you acknowledge, understand and agree to the following:
- You have been fully informed of the identity and credentials of the physician(s) who is/are providing Local Doctor Services to you.
- You consent to receiving Our notice of privacy practices (“NPP”) and any material changes thereto electronically, and acknowledge receipt of the NPP, which is also available at http://firstopinionapp.com/pc-privacy-policies/.
- We will only provide services to you using Technologies if the physician with whom you are communicating determines the standard of medical care can be met, and in some cases you may be instructed to seek in person medical care from a health care provider located near you for evaluation and treatment.
- While there are benefits to using the Local Doctor Services, including convenient and improved access to care, you understand that limitations inherent in the use of Technologies may affect Local Doctor Services’ provision of medical services to you. As examples, in some cases, an in-person physical examination, test, or other procedure not available through Local Doctor Services might provide additional information relevant to your health and treatment; failures of equipment or Technologies or scheduling issues may cause delays in evaluation or treatment; and/or Local Doctor Services’ lack of access to all of your medical records could result in adverse drug interactions, allergic reactions, or other errors. You understand these risks, and that the quality, and in some cases quantity, of the information you provide to Us (including the quality of photographs and other data you upload) may affect the quality of the care/advice Local Doctor Services provides.
- By registering for Local Doctor Services, you are asking Us to provide a service that involves communicating with you by email, text message, video, online in chat rooms, and/or telephone for purposes of evaluation and treatment. You understand that such communications may involve your providing medical history, symptoms, current medications, photos, and other information (which could involve mental health, substance abuse, pregnancy, infectious disease/STD, and other sensitive health information) to Us. The e-mails, text messages, video, and online chat room communications will not be encrypted. Therefore, there may be some level of risk that third parties will be able to access the information. You have been notified of the security risks to potentially sensitive information, but nonetheless still wish to use unencrypted communications.
- Depending on the settings in your smartphone or portable electronic device, Our name, the name(s) of physicians associated with Us, or First Opinion’s identity may be visible on your phone at rest by way of a push-notification, banner or otherwise, and may remain in memory indefinitely, such that third parties may be able to see or read the names and other information. You have been notified of the risks, but nonetheless still wish to receive push-notifications and communications that may be read by third parties from Us and/or First Opinion.
- We are not responsible for unauthorized access of protected health information while in transmission to you via email, text message, video, online chat room, and/or telephone and are not responsible for safeguarding information once delivered to you. While we have safeguards in place to protect our digital medical record, we are not responsible for loss of protected health information or other data due to technical failures and other circumstances that are beyond our control.
- Our digital medical record permits Our physicians to prescribe medications electronically. As part of receiving Local Doctor Services you consent to Our use of e-prescribing if necessary. In doing so you are agreeing that the PC can request and use your prescription medication history from other healthcare providers and/or third party pharmacy benefit payors for treatment purposes. If you do not agree, you should tell the physician you are communicating with not to prescribe medications for you.
- You understand that your e-mails, text messages, video, online chat room communications, and/or telephone requests to Us may not be read or answered within any consistent timeframe and if you have an urgent or serious condition requiring immediate or urgent medical attention, you have been advised to call 9-1-1 or go to your nearest emergency or urgent care center, as appropriate, and/or to contact your personal physician or Primary Care Physician.
- You may cancel consent to receiving services and information (including the NPP) using Technologies, including this request for communication by email, text message, video, online chat room, and/or telephone, at any time by cancelling your user account or notifying Us or First Opinion in writing. You also understand that when you give or withdraw your request, it is effective from that date forward, and not retroactively. However, if you cancel your consent to communicating using Technologies the PC will not have the capability to communicate with you. Otherwise, your cancellation will not affect care or benefits that are available to you.
I request and authorize the PC to communicate with me via e-mail, text message, video, online chat room and/or telephone, about issues concerning my care, treatment, and services, and to use e-prescribing if necessary.