Thank you for choosing Ezra and Beluga Health, P.A. (“Beluga”)! You are viewing this form because you have elected to engage in asynchronous telemedicine visits with a Beluga healthcare practitioner via Ezra. Your practitioner is a board-certified physician licensed in your state.
By clicking “I Agree,” I acknowledge that I have read and understand the terms presented below. I understand the risks and benefits of asynchronous telemedicine, and by accepting these terms of use, I hereby give my informed consent to participate in asynchronous telemedicine under these terms.
What is Telemedicine?
Telemedicine is the delivery of healthcare services—such as examination, consultation, diagnosis, and treatment—through electronic communication technologies when you (the patient) are in a different location than your healthcare practitioner. Beluga allows you to receive treatment from a healthcare practitioner without having to travel to another location or schedule a separate appointment. It also helps you avoid long wait times that you might otherwise experience at an in-person visit.
What is Asynchronous Telemedicine?
Asynchronous telemedicine is one method of delivering telemedicine. It involves “store-and-forward” communication, where participants submit and collect information at different times. For example, you might send photos, videos, or other communications to a healthcare practitioner via email or text message, and your practitioner may review them later.
Asynchronous means “not occurring at the same time” and differs from synchronous telemedicine, which includes real-time interactions through live audio or video (e.g., phone calls or video-conferencing). Healthcare practitioners may use asynchronous telemedicine to aid in diagnoses and medical consultations when live communication or face-to-face contact is not possible or necessary.
Beluga’s platform (the “Platform”) enables the following asynchronous telemedicine services:
- Text-based practitioner-patient interactions via Short Message Service (“SMS”) and Multimedia Messaging Service (“MMS”) communications.
- Secure information collection through asynchronous store-and-forward patient questionnaires.
What are the Possible Risks of Using Asynchronous Telemedicine?
As with any medical treatment, potential risks exist. Beluga believes the likelihood of these risks materializing is very low. Potential risks include, but are not limited to, the following:
- Technical Issues: Delays in medical evaluation, consultation, or treatment may occur due to equipment or Internet failures, which may include poor data quality, Internet outages, or service interruptions. You may reschedule your visit should these interruptions occur.
- Security Breaches: Security protocols could fail, causing a breach of your personal medical information.
- Incomplete Medical History: Because Beluga does not have access to your complete medical records, if you do not fully disclose your medical history (including diagnoses, treatments, medications/supplements, and allergies), adverse treatment outcomes, drug interactions, allergic reactions, or other negative outcomes may occur.
- Not for Emergencies: Asynchronous telemedicine services are NOT emergency services, and your Personal Data (as defined in the Beluga Privacy Policy) will not be monitored 24/7. If you think you are experiencing a medical emergency, call 911 immediately.
The care you receive will be at the sole discretion of the healthcare practitioner who is treating you, with no guarantee of diagnosis, treatment, or prescription. The healthcare practitioner will determine whether the condition being diagnosed and/or treated is appropriate for care through an asynchronous telemedicine encounter via the Platform.
Your Rights and Acknowledgements
- Privacy: You have the same privacy rights via asynchronous telemedicine that you would have during an in-person visit. Identifiable images or information from the asynchronous telemedicine visit will not be disseminated without your written consent. For more information on how we protect your privacy, please read the Beluga Privacy Policy here.
- Electronic Communication: Asynchronous telemedicine may involve the electronic communication of your personal medical information to healthcare practitioners who may be located in other areas, including out of state.
- No Guaranteed Results: You understand that you may expect the anticipated benefits from the use of asynchronous telemedicine, but no results can be guaranteed or assured.
- Medical Record Access: All information submitted to Beluga via text message, and all information entered by your healthcare practitioner in the Beluga Platform, will be part of your medical record. You may request access to your records by emailing admin@belugahealth.com. This information will have the same restrictions on dissemination without your consent.
- Provider Identification: You understand that your healthcare practitioner’s initial text message to you will include their name and credentials, and this will be recorded in the Beluga Platform as part of your medical record.
- Withdrawal of Consent: You may withdraw your consent and delete your patient profile at any time by emailing admin@belugahealth.com.
- Information Sharing: Your healthcare information may be shared with other individuals in accordance with the Beluga Privacy Policy and applicable regulations or laws in the state or territory where you are located.
- Additional Circumstances for Information Sharing: You understand that your healthcare information may be shared in the following circumstances:
- When a valid court order is issued for medical records.
- Reporting suspected abuse, neglect, or domestic violence.
- Preventing or reducing a serious threat to anyone’s health or safety.
Call/Email/Text Messaging Consent
You expressly consent to allow Beluga or its healthcare practitioners to call, email, or text you (via SMS and/or MMS) regarding Personal Data (as defined in the Beluga Privacy Policy), appointments, or similar matters related to your telemedicine encounters, using the contact information you have provided. Calls or texts may be placed using an auto-dialer or a pre-recorded or artificial voice, even if your number is on a do-not-call list. Your phone carrier’s normal rates may apply.
This is consent, not a condition of purchase. You may revoke this consent at any time by emailing admin@belugahealth.com.
This Asynchronous Telemedicine Informed Consent is valid during your entire treatment with Beluga.
