Informed Consent for Telehealth Services
Before you give your consent to request telehealth services, please be aware of how obtaining health services remotely from licensed health care professionals (the “Providers”) affiliated with one or more of the following Reset Kidney™ professional entities: Reset Kidney LLC and Epsilon Kidney Care, PC (collectively, “Reset Kidney™”) through an online telehealth platform (the “Platform”) developed and maintained by Reset Kidney Health LLC, differs from in-person care. The terms “Reset Kidney Health,” “Reset Kidney,” “Reset,” “we”, “us”, or “our” refers to the Reset Kidney™ professional entities and Reset Kidney Health LLC. The terms “you” and “yours” refer to the patient using the Platform to request telehealth services (the “Services”) from Providers affiliated with the Reset Kidney™ professional entities. Please read each item carefully.
You understand that you should never use the Platform in a medical emergency. You understand that in a medical emergency you should dial 911 or visit an emergency room. You understand that Reset Kidney™ provides, through its Providers, chronic kidney care management and related treatments through a web-based Platform and that it is not a full-service medical practice. Reset Kidney™ is focused on remotely delivering chronic kidney care management and related treatments to patients (the “Services”). You understand that the Reset Kidney™ Services are supported by licensed nephrologists and by coaches, dieticians, and other health care professionals under the supervision of licensed nephrologists in a team-based medical practice (the “Providers”).
In using the Services on the Platform, you understand that you will be provided with your treating Provider’s name and credentials. You understand that state medical licensure laws require that you be seen by a Provider who is licensed to practice in the state where you are located at the time of the Service. When scheduling appointments through the Platform, you will be asked where you will be located at the time of the appointment. You agree that you will accurately report your anticipated location and will update Reset Kidney™ if your location plans change prior to your appointment.
You understand that by using the Platform for Services, you will not have an in-person physical examination that might identify a potentially serious medical condition. You also understand and agree that the health information you provide through the Platform may be the only source of health information used by Providers during the course of your evaluation and treatment through the Platform, and that such Providers may not have access to any other health information held by your previous medical providers (e.g., allergies, drug reactions, etc.) You understand that you are not guaranteed treatment through the Platform and that a Provider will determine whether or not it is appropriate to treat you through the Platform.
You certify that the information you provide to the Platform for the Services is true, accurate, and complete. You understand that if you knowingly provide false, misleading, or incomplete information to a Provider, it may have a negative effect on your treatment and your health. We reserve the right to terminate your access to the Platform if you knowingly provide incorrect information. You understand that you should ask questions about anything you do not understand. You understand that a Provider is available to answer any questions you may have when receiving Services through the Platform.
You understand that Providers may bill certain insurance for Services you receive through the Platform, but that you will be responsible for payment for any Services that are not paid for by your insurance plan. You understand that you will assign and transfer to Reset Kidney™ sufficient monies and/or benefits to which you are or may be entitled from government agencies, insurance carriers, or others who may be financially responsible for your medical care to cover costs of the care and the treatment rendered. You understand that Reset Kidney™ may submit a bill to your insurance plan for the cost of Services rendered. You accept that you are financially responsible for all co-payments or deductibles as dictated by your insurance plan. You understand that it is your responsibility to arrange and pay for any follow-up care that the Provider recommends you receive.
You further understand that the electronic nature of the Service means that there is a greater risk to the privacy of your electronic health information relative to receiving in-person care. By agreeing to use the Platform, you are consenting to Reset Kidney™ sharing your personal information, including health information, with certain third parties as more fully described in our Privacy Policy. For information about Reset Kidney’s privacy and security practices, please read our Privacy Policy at https://www.resetkidneyhealth.com/privacy. You understand, agree, and expressly consent to Reset Kidney™ obtaining, using, storing, and disseminating to necessary third parties, information about you and your image, as necessary to provide Services through the Platform. You further understand that records of Services provided to you through the Platform may be lost through technical failures and could result in a breach of our confidentiality to you. You understand that if you are experiencing technical difficulties through the Platform, you may email support@resetkidneyealth.com. You understand that technical issues in the Platform may result in a delay in receiving Services. In the event of an issue with connecting to the Platform, the Provider may contact you by phone to continue the Services. You hereby release and hold harmless Reset Kidney™ from any loss of data or information due to technical failures associated with the Platform.
You agree that it is your choice whether or not to use the Services on the Platform. You understand that at any time, you can change your mind about receiving Services and may seek alternative in-person services. You understand that you have no obligation to use the Services provided by Reset Kidney™ through the Providers, and that you are voluntarily consenting to participate in the Reset Kidney™ Services. If you would like to have the records relating to the Services received through the Platform sent to your primary care provider, you understand that you will need to request such transfer of such records. You may obtain copies of your medical records for Services by emailing support@resetkidneyhealth.com. Reset Kidney™ will respond to messages as they are received but does not guarantee an immediate response.
You understand that under applicable state laws, Providers may be required to report suspicions of child abuse, neglect, statutory rape, domestic violence, and sexual assault. Reset Kidney™ does not become involved in those decisions. You hereby release and hold harmless Reset Kidney™ and Providers for Provider’s good faith compliance with state mandatory reporting laws.
Reset Kidney™ makes every effort to comply with applicable state laws and regulations with respect to its telehealth platform. You understand that this Informed Consent is intended to incorporate these additional state protections.
You hereby consent to the use of telehealth to examine, consult, diagnose, or treat you.
You further acknowledge and agree that:
You are at least eighteen (18) years of age;
You are located in the state you identified during registration at the time of your visit(s);
You have read and understood the information above, including the benefits, risks and limitations of using the Platform for Services
Our Providers may share your health records with other health care providers for purposes relating to the provision, coordination or management of your healthcare so that we can meet your healthcare needs.
Our Providers may determine that our clinical services are not appropriate for some or all of your treatment needs and may elect not to provide Services to you through the Platform.
This informed consent will become a part of your medical record.