Consent to Receive Telehealth

This form describes Jacksonville Speech & Hearing Center, Inc (JSHC)’sTelehealth treatment and payment policies and includes:

• Your consent to receive healthcare treatment from JSHC (and your other rights and responsibilities);
• Your agreement to receive services using telehealth technology; and
• Your agreement to pay in full any charges that are your responsibility.

By signing my name and clicking “I agreeto Terms of Use”, I understand and agree that I am signing this Consent electronically and that (i) I have reviewed, understand and accept the risks and benefits of telehealth services as described below and wish to receive such services, and (ii) I agreeto the remaining terms of this Consent, including the terms of the JSHCPrivacy Notice

If I am signing on behalf of a minor, incapacitated or otherwise legally dependent patient, I certify that I am a person with legal authority to act onbehalf of the patient, including the authority to consent to healthcareservices, and I accept financial responsibility for services

By using the telehealth portal JSHC has selected, I agree to receive telehealth services. Telehealth involves the delivery of health care services, including assessment, treatment, diagnosis, and education, using interactive audio, video, and data communications. During my visit, my JSHCprovider and I will be able to see and speak with each other from remote locations. I understand and agree that: I will not be in the same location or room as my healthcareprovider. My JSHCprovider is licensed in the state in which I am receiving services. I will report my location accurately during registration. Potential benefitsof telehealth (which are not guaranteed or assured) include: (i) access to healthcare if I am unable to travel to my JSHCprovider’s office; (ii) more efficient healthcareevaluation and management; and (iii) during the COVID pandemic, reduced exposureto patients, clinic staff and other individuals at a physical location. Potential risks of telehealth include: (i) limited or no availability of diagnostic toolto assist my healthcareprovider in diagnosis and treatment; (ii) my provider’s inability to conduct a handson physical examination of me and my condition; and (iii) delays in evaluation and treatment due to technical difficulties or interruptions, distortion of diagnostic images or specimens resulting from electronic transmission issues, unauthorized access to my information, or loss of information due to technical failures. I will not hold JSHCresponsible for lost information due to technological failures. I further understand that my JSHCProvider’s advice, recommendations, and or decisions may be based on factors not within his/her control, including incomplete or inaccurate data provided by me. I understand that my JSHCprovider relies on information provided by me before and during our telehealth encounter and that I must provide information about my healthcarehistory, condition(s), and current or previous healthcarecare that is complete and accurate to the best of my ability. I may discuss these risks and benefits with my JSHCprovider and will be given an opportunity to ask questions about telehealth services. I have the right to withdraw this consent to telehealth services or end the telehealth session at any time without affecting my right to present or future treatment by JSHC I understand that the level of care provided by my JSHCprovider is to be the same level of care that is available to me through an inperson healthcarevisit. However, if my provider believes I would be better served by facetoface services or another form of care, I will be referred to the JSHCclinicor other appropriate health care provider. I have the right to receive facetoface healthcareservices at any time by traveling to theJSHCclinic In case of an emergency, I will dial 911 or go directly to the nearest hospital emergency room. I consent to, understand and agree that: I have the right to discuss the risks and benefits of all procedures and courses of treatment proposed by my health care provider(s), together with any available alternatives. JSHwill provide care consistent with the prevailing standards of healthcarepractice but makes no assurances or guarantees as to the results of treatment. I have the right to review and receive copies of my healthcarerecords, including all information obtained during a telehealth interaction, subject to JSHCstandard policies regarding request and receipt of healthcarerecords and applicable law. The laws of the state in which I am located will apply to my receipt of telehealth services.

JSHC Notice of Privacy Practices (“Privacy Notice”)

JSHC will protect the privacy of my health information and will not use or disclose it except as permitted by law. JSHC privacy policies are more fully described in the Privacy Notice, which is available for review here and in office. By signing this Consent, I acknowledge receipt of the Privacy Notice and consent to JSHC use and disclosure of my health information in accordance with its terms. I understand that all existing confidentiality protections that apply to in-person treatment apply to telehealth services.

Payment Policy

I acknowledge, understand and agree that:

1. It is my responsibility to determine whether JSHC services are covered by my insurer. I will pay the cost of any service that is not covered by my health plan for any reason or are covered but applied to a deductible.

2. I will pay at time of service any required co-payments, co-insurance and deductibles, as well as charges for services not covered by insurance, outstanding balances and delinquent accounts.

3. I assign to JSHC all health care benefits to which I am entitled under any insurance policy or benefit plan and authorize payment of benefits directly to JSHC.

4. If I have health care benefits, JSHC will submit a claim to my insurer and allow 60 days for a response. If my insurer does not respond within 60 days, JSHC will assume that the visit is not covered and will, to the extent permitted by law, bill me for the visit charges.

5. By providing my credit card information and receiving telehealth services, I (i) authorize JSHC to charge my credit card for any and all unpaid amounts that JSHC or my insurer determines are my responsibility, and (ii) agree to pay all amounts charged pursuant to this consent and authorization in accordance with the issuing bank cardholder agreement. I agree that JSHC may charge my credit card for such amounts at the end of my telehealth visit or at a later date.

6. JSHC reserves the right to deny non-emergency services if my account is delinquent.