CONSENT TO TREAT:
You acknowledge and agree that you have requested to receive medical treatment and services from Brisk Technologies, Inc. hereinafter called “Brisk Health.” Further, you consent to the rendering of medical treatment and services as considered necessary and appropriate by your treating provider. You have the right to decline treatment and services at any time, but you may be responsible for paying for services already rendered. You also acknowledge that no assurances or guarantees have been made to you by Brisk Health or any of Brisk Health’s staff concerning the outcome and/or results of any medical treatment or services.
In-Person Visits: Brisk Health provides mobile, in-person visits at patient-specified locations for both adult and pediatric patients. Available services for in-person visits include scheduled, primary-care services as well as well as short-noticed, non-emergency, sick-care services to treat illnesses or minor injuries. For example, during an in-person visit your treating provider may administer vaccinations, perform wellness exams and/or annual physicals, assess and treat chronic conditions, assess and treat illness like the common cold, flu, stomach aches or ear infections, or assess and treat minor injuries. Please note, Brisk Health does not provide general obstetrics services or any emergency services.
Telehealth Services : Brisk Health also provides non-emergent, telehealth and remote patient monitoring (“RPM”) services, whereby patients may receive limited healthcare services with out in-person contact between the patient and provider. Telehealth services and RPM services are available only in limited circumstances, and only at the Brisk Health’s sole discretion. Telehealth services are not intended to replace the need for in-person medical treatment and evaluation. By signing this consent form, you are also agreeing to use of telehealth services. However, at anytime you may opt not to receive telehealth services.
Under certain limited circumstances, your treating provider or Brisk Health may determine, in his or her best judgment, that he or she is unable to provide medical treatment and services to you, based on information received or conduct occurring during the course of a visit. However, in no case will Brisk Health or any of its staff make such a determination based on any patient’s sex, sexual orientation, gender-identity, race, creed, color, religion, national origin or disability, or status in any other protected class.
BRISK HEALTH DOES NOT PROVIDE EMERGENCY MEDICAL CARE:
If you have an emergency, such as chest pain, severe shortness of breath, severe headache or bleeding, call 911or proceed directly to the nearest hospital emergency room.
PRESCRIPTION POLICY: You understand and acknowledge that no assurances or guarantees will made by Brisk Health or Brisk Health’s staff concerning the prescription of any medication(s). Your treating provider, based on his or her professional judgment, is solely responsible for determining the clinical appropriateness and necessity, or lack thereof, for any prescribed medication(s). At the time of prescribing any medication(s), your treating provider will advise you on known risks and potential benefits of the medication(s).You further understand that Scheduled II, III, or IV drugs, or any other drug that is reasonably determined by the prescribing provider and/or Brisk Health to pose a risk of abuse or diversion(collectively, these drugs are referred to herein as “Controlled Medications”), will only be prescribed to established and existing patients who use Brisk Health as their primary care provider, and even then only when the prescribing provider determines such medications to be medically appropriate after a complete in-person evaluation to assess the condition for which the medications are indicated. Brisk Health never requires or guarantees that any Controlled Medication will be prescribed or continued.
PEDIATRIC VACCINATION POLICY: Brisk Health strictly follows the vaccination schedules put out the American Academy of Pediatrics (AAP) and Centers for Disease Control(CDC). Brisk Health will not treat pediatric patients who are not adequately vaccinated incompliance with these standards. Prior to a child’s visit Brisk Health will require a copy of the child’s immunization record showing the child is adequately vaccinated.
For children who are not adequately vaccinated at the time of the patient’s first appointment with Brisk Health, Brisk Health will only treat the child if the guardian(s) commit to a formal vaccination plan with Brisk Health that will bring the child’s immunizations into compliance with the AAP schedules. Brisk Health is committed to helping families understand that vaccinations are both safe and effective. If Brisk Health arrives at a visit where the child’s immunizations are not in compliance with these standards and the child’s guardian will not commit to bringing the child’s immunizations into compliance with the AAP’s schedules, then Brisk Health will not treat the child and will terminate the physician-patient relationship. In addition, if Brisk Health arrives at a visit and the child’s guardian is not present for a first-time visit or a well child visit for vaccinations, we will charge a $159 cancelation fee.
For those families who are not willing to commit to vaccinating their children, Brisk Health requests that you seek medical care at another medical provider who shares more similar beliefs with your family.
SUBSEQUENT CARE & COORDINATION WITH YOUR PRIMARY CARE PROVIDER: If Brisk Health is not your primary care provider, it is your sole responsibility to follow through with your primary care provider on any medical conditions or potential abnormalities detected or not detected by the visit, and to obtain a medical examination by your primary care provider related to the findings, or lack of findings, of this visit.
RELATIONSHIP WITH BRISK HEALTH, INC.: You understand and agree that by downloading, registering and/or using the Brisk Health Application alone does not create a patient relationship with the Brisk Health. A patient relationship with Brisk health is only established when you have actually been treated by one of Brisk Health’s providers. In addition, you acknowledge and agree that you have selected to receive services from Brisk Health, Inc. and that no third-party, has referred, suggested or recommended the Brisk Health, Inc. to you.
EQUITABLE ACCESS & NON-DISCRIMINATORY CARE POLICY: It is Brisk Health’s policy to make all commercially reasonable efforts to provide accommodations that will allow seniors and people with disabilities to request and receive equitable access and non-discriminatory medical care. As such, to the extent practicable and/or required by law, Brisk Health’s operations align with the standards set by Section 504 of the 1973 Rehabilitation Act, the Americans with Disabilities Act, as amended (ADA), and other applicable state laws and regulations that prohibit discrimination on the basis of disability. However, Brisk Health does not have any medical office open to the public or any other public facility where Brisk Health provides medical services. You understand and agree that Brisk Health’s mobile care delivery model means that Brisk Health has no control over any physical accommodations at the specific locations where you may request and/or receive medical services.
PAYMENT FOR SERVICES: Brisk Health generally charges on a fee-for-service basis for the services it provides, or by some other fee-schedule negotiated between Brisk Health and its contracted health plans (the “Service Fee”). Any Service Fees, or portion thereof that is your financial responsibility must be made by credit card through the Brisk Health Application. When necessary to accommodate patients with disabilities, Brisk Health may accommodate payment telephonically. Brisk Health does not accept cash payments from patients or accept any in person payments. If timely payment is not made, Brisk Health may engage third parties to collect any outstanding payments. If you are a member of an insurance plan that contracts with Brisk Health as an in-network provider, and your insurance coverage has previously been verified, Brisk Health will bill the insurance plan for the portion of the Service Fee for which it is responsible. Brisk Health is a participating medical practice in the Medicare Program and accepts assignment for Medicare claims. If you are a Medicare beneficiary, Brisk Health accepts the Medicare approved amount as full payment for covered services. You will be responsible for any applicable copayments or deductibles, and your credit card will be charged accordingly. Please be aware that some – and perhaps all – of the services you receive may not be covered or not considered reasonable or necessary by your health insurance plan. The balance of your claim is your financial responsibility, whether or not your health insurance plan pays your claim. It is your responsibility, as the insured, to determine if Brisk Health is a network provider and how your benefits apply.
RETENTION OF RECORDS: Brisk Health shall retain health care records for at least six (6)years after their receipt or production, unless a longer period is required by law (e.g., for records of minors). Brisk Health may destroy health records once it is no longer required to retain them.
COORDINATION WITH HEALTH RECORDS AND HEALTH DATA: In an effort to gain amore complete picture of your health and help avoid unnecessary testing and duplicated efforts, Brisk Health supports coordinating access to your health records and health data that may be created by various third-party sources before, after and/or in between your visit(s). This may include access to (1) your patient health records from other providers and/or (2) your electronic health data created by your use of different wellness, fitness or medical devices. In an effort to streamline this coordination via wireless transmission, you can connect your account in the Brisk Health Application with other third-party platforms and/or products that will share your information with the Brisk Health Application. Brisk Health will be able to see any of your records and data that are shared with the Brisk Health Application. Your information will only be shared with Brisk Health in this manner as long as your account remains connected. Your decision to connect your accounts is completely voluntary and you may disconnect from third-party platforms or products at any time. Because Brisk health is not affiliated with any applicable third parties, it makes no promise that third-party platforms or products will be fault free. Further, Brisk Health is not responsible for the accuracy of your health records or health data that are created by any third parties.
ASSIGNMENT OF BENEFITS; AUTHORIZED REPRESENTATIVE: In exchange for and in connection with any and all of the service(s) provided to you by Brisk Health, by signing below you hereby irrevocably and expressly request that payment of authorized insurance benefits be made on your behalf to Brisk Health for services furnished to you. In addition, by signing below, you hereby designate Brisk Health as your duly authorized representative in connection with all matters arising from or relating to the services provided, and you agree to cooperate with and take all steps necessary to effectuate, perfect, confirm or validate the assignment of benefits and/or authorization of a Brisk Health is your authorized representative, as addressed herein.
INDEMNIFICATION: You acknowledge that you shall be liable for, and shall indemnify, defend and hold harmless Brisk Health from any and all liability, loss, claim, lawsuit, injury, cost, damage or expense whatsoever (including reasonable attorneys’ fees and court costs) arising out of, incident to or in any manner occasioned by (1) the performance or nonperformance of any duty or responsibility by patient, (2) any tortious acts committed by you or any other person at your residence or other location of the visit, and (3) any damages resulting from any defects at your residence or location, but only to the extent, and only in such amount, that such liability, loss, claim, lawsuit, injury, cost, damage or expense is not covered and paid by third party insurance. The foregoing indemnification provision shall in all instances be deemed to be subordinate to any third-party insurance coverage that may cover all or any portion of any indemnification claim, including without limitation the patient’s homeowner’s insurance policy, as applicable.
DISCLOSURE OF PROVIDER INFORMATION & PATIENT GRIEVANCES: All Brisk Health clinicians are licensed, certified or otherwise permitted to provide medical services in the state of where medical services are provided. Your treating provider’s information, including name, highest level of academic degree, specialty, license status, and license number, and board certification (where applicable) are available through the Brisk Health Application. Should you have any questions, comments, feedback or grievances concerning your treating clinician, Brisk Health’s clinical team or other staff, and/or the treatment you received, you may always reach out directly at firstname.lastname@example.org. Additionally, patients always have the right to report concerns or grievances to the appropriate state medical Board, or other applicable regulatory body. Brisk Health provides you with information regarding how to contract such regulatory bodies in your “new patient” documents. You may, at any time, request that Brisk Health provide you with that information again.
• How Brisk Health will use and disclose your protected health information.
• Your privacy rights with regard to your protected health information.
• Brisk Health’s obligations concerning the use and disclosure of your protected health information.
You acknowledge that you have received a copy of Brisk Health’s HIPAA Notice of Privacy Practices and have been provided an opportunity to review it, and consent to receipt of an electronic copy. You further acknowledge that Brisk Health’s Notice of Privacy Practices is available from Brisk Health upon request, and is available at https://www.briskhealth.com
You consent to the use of unsecured email, mobile phone text message, or other electronic methods of communication (“E-messages”) between yourself and Brisk Health, your treating provider, and any other agents or representatives of Brisk Health, for purposes of discussing personal material relevant to your treatment or health records. You understand that E-Messages are typically not confidential means of communication and that there is a reasonable chance that a third-party (including people in your home or other environments who can access your phone, computer, or other devices; your employer, if using your work email; and/or third parties on the Internet such as server administrators and others who monitor Internet traffic) may be able to intercept and see these messages. You have been informed of the risks—including but not limited to the risk with respect to the confidentiality of your treatment—of transmitting your protected health information by an unsecured means. You acknowledge that E-messages are not to be used in the case of an emergency, and that you should call 911 or proceed directly to the nearest emergency room.
You acknowledge that you have read, understand and agree to the information below, which applies if you have requested telehealth services, and that your name and identity have been correctly identified in communications with Brisk Health:
I hereby consent to receiving treatment through telehealth from Brisk Health as part of my health evaluation and treatment. I further give Brisk Health and its providers permission to consult with relevant specialists as needed during the course of my treatment, and I further consent to Brisk Health and its providers forwarding my medical information to my primary care provider/provider of record. I am providing the foregoing consents based on my understanding of the following:
1. During my treatment through telehealth, my provider and I will be indifferent physical locations and my medical and/or health information will be communicated to health care providers at those other physical locations. I may benefit from the use of telehealth, including from the increased availability and access to care, but results cannot be guaranteed or assured. Furthermore, the use of telehealth may present certain risks, such as delays in medical evaluation and treatment due to technological issues, the need to reschedule if the transmitted information is of insufficient quality, or failure of potential failure security protocols which could cause disclosure of personal information. In addition, I understand a lack of access to my complete medical record could result in adverse drug interactions or other unintended results, and I understand it is my responsibility to share complete and accurate information with my provider.
2. My treating provider’s information, including name, highest level of academic degree, specialty, license status, license number, board certification (where applicable), are available through the Brisk Health Application, and if my treating provider is a physician assistant or nurse practitioner the name of the delegating/supervising physician is also available. In the event of an adverse reaction to treatment or the inability to communicate as a result of a technological failure, I understand that I may contact my treating provider for further assistance or to schedule follow-up care by calling (888) 59- BRISK, emailing email@example.com or by visitinghttps://www.briskhealth.com
3. Brisk Health may use telehealth to conduct examinations, diagnose and treat medical conditions, interact with me in connection with prescriptions and refills, and otherwise communicate with me about my health. I understand and agree that my provider has the sole responsibility and discretion to determine whether telehealth is appropriate for the diagnosis or treatment of my specific condition(s).
4. I have the right to withdraw my consent to the Brisk Health’s use of telehealth at any time without affecting my right to future care or treatment or risking the loss or withdrawal of any program benefits to which I would otherwise be entitled. Receiving treatment through telehealth does not mean that I cannot receive in-person health care services now or in the future.
5. The information and data disclosed by me during the course of my treatment through telehealth may be integrated into my medical record and will generally be protected and confidential. Brisk Health uses secure technology that complies with federal privacy laws to provide telehealth services, incorporating reasonable and appropriate network and software security protocols to protect patient information and ensure its integrity. Without limiting the foregoing, Brisk Health uses industry leading security standards to maintain the highest level of security for our patients, including multi-factor authentication andAES256 encryption to protect data. However, I understand and accept that, as is the case with all electronic data, there is a risk that data security protocols could fail or be breached, which may result in the unintended disclosure of my information.
6. Brisk Health will not provide my personally-identifiable information to any third parties without my express consent. Not withstanding the foregoing, I understand that my healthcare information may be shared with other individuals and entities for Brisk Health’s scheduling, billing, and other treatment, payment, and health care operations purposes, or other uses or disclosures permitted or required by law, and I consent to such use and disclosure solely to the extent such use or disclosure complies with applicable federal and state privacy laws.
7. Brisk Health and its providers are not responsible for any information lost as a result of any technical failures encountered during the course of my telehealth treatment.
8. An in person evaluation is required prior to prescribing any schedule II,III, or IV drugs and at least every 90 days for ongoing prescriptions. However, your doctor – at their discretion – may choose to renew or adjust prescriptions for controlled medications via telehealth as long as you have had an in person visit in the prior 90 days.
9. I understand that if I am experiencing a medical emergency I will be directed to call 911, and that Brisk Health is not able to connect me directly to local emergency services.10. I have discussed the foregoing information with my provider and all of my questions have been answered to my satisfaction.
CONSENT TO MARKETING COMMUNICATIONS: You consent to the receipt of communications about other healthcare products or services offered for purchase or subscription by Brisk Health. These communications may be received in several formats including electronic, SMS, and postal mail.
CONSENT TO DISCLOSURE OF INFORMATION FOR MARKETING: Brisk Health may share certain protected health information with partners and affiliates that provide, arrange or offer other healthcare-related services. These partners and affiliates may also receive your information to offer other products and services which are not healthcare-related but may be beneficial to you. By clicking the button below and proceeding with your selected services, you are agreeing to have your information shared for internal marketing purposes by Brisk Health and its Medical Practices, as well external marketing purposes with companies and affiliates with whom our Company works. These communications may be received in either electronic format or postal mail. Please note that you may revoke this consent at any time.
You acknowledge that you (1) have read, understand and accept the terms of the Brisk Health’s Patient Agreement; (2) have received a copy of Brisk Health’s Notice of Privacy Practices and further acknowledge that Brisk Health’s Notice of Privacy Practices is available from Brisk Health upon request; (3) consent to the use of E messages between yourself and Brisk Health, and/or other agents or representatives of Brisk Health, for purposes of discussing personal material relevant to your treatment or health records; and (4) have read and understand the information contained in the Consent to Use of Telehealth above, and are providing the consents expressly set forth therein. If patient is unable to consent, you acknowledge that you agree to the terms and conditions of this agreement as the legally authorized representative of patient.