Informed Consent to Treatment via TeleHealth

Last Updated: March 01, 2022

Telehealth involves the use of electronic communications to enable healthcare providers at different locations to share individual patient medical information for the purpose of improving patient care. Telehealth services offered via Skin by Anthos affiliates, including Shirley Chi MD, and Phillip Lee MD, and Monica Bang NP, may also include chart review, remote prescribing, health information sharing, and non-clinical services, such as patient education. The information you provide may be used for diagnosis, therapy, follow-up and/or patient education, and may include any combination of the following: (1) health records and test results; (2) images and asynchronous communications; (3) output data from medical devices and sound and video files.

The electronic communication systems we use will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

The Skin by Anthos providers (our “Providers”) are an addition to, and not a replacement for, your local primary care provider. Responsibility for your overall medical care should remain with your local primary care provider, if you have one, and we strongly encourage you to locate one if you do not.

Expected Benefits:

Improved access to care by enabling you to remain in your home while your Provider consults.

More efficient care evaluation and management.

Obtaining expertise of a specialist as appropriate.

You may contact your Provider for follow-up questions by directly sending a message to your Provider via our member portal. Your Provider will be familiar with and have access to available medical resources in order to make an appropriate referral where medically indicated. Your Provider will typically respond within thirty-six hours.

Service Limitations:

The primary difference between telehealth and direct in-person service delivery is the inability to have direct, physical contact with the patient. Accordingly, some clinical needs may not be appropriate for a telehealth visit and your Provider will make that determination.

OUR PROVIDERS DO NOT ADDRESS MEDICAL EMERGENCIES. IF YOU BELIEVE YOU ARE EXPERIENCING A MEDICAL EMERGENCY, YOU SHOULD DIAL 9-1-1 AND/OR GO TO THE NEAREST EMERGENCY ROOM. PLEASE DO NOT ATTEMPT TO CONTACT SKIN BY ANTHOS, INC., GROUP, OR YOUR PROVIDER. AFTER RECEIVING EMERGENCY HEALTHCARE TREATMENT, YOU SHOULD VISIT YOUR LOCAL PRIMARY CARE PROVIDER.

Possible Risks:

Delays in evaluation and treatment could occur due to deficiencies or failures of the equipment and technologies, or Provider availability.

In rare events, your Provider may determine that the transmitted information is of inadequate quality, thus necessitating a rescheduled telehealth consult or a meeting with your local primary care doctor.

In very rare events, security protocols could fail, causing a breach of privacy of personal medical information.

In rare events, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors.

By checking the box associated with “Informed Consent”, you acknowledge that you understand and agree with the following:

I hereby consent to receiving Skin by Anthos providers, Shirley Chi MD, Phillip Lee MD, and Monica Bang NP, services via telehealth technologies. I understand that Skin by Anthos providers, Shirley Chi MD and Phillip Lee MD and Monica Bang NP, offer telehealth-based medical services, but that these services do not replace the relationship between me and my primary care doctor. I also understand it is up to the Skin by Anthos Provider to determine whether or not my specific clinical needs are appropriate for a telehealth encounter.

I understand a licensed Provider from Skin by Anthos will be assigned to me prior to the consult, however, I can request a different licensed Provider at any time. I can review the credentials of my assigned Provider.

I understand that federal and state law requires health care providers to protect the privacy and the security of health information. I understand all medical reports resulting from the telehealth visit are part of my medical record.

I understand that Skin by Anthos will take steps to make sure that my health information is not seen by anyone who should not see it. I understand that telehealth may involve electronic communication of my personal medical information to other health practitioners who may be located in other areas, including out of state.

I understand there is a risk of technical failures during the telehealth encounter beyond the control of Skin by Anthos. I AGREE TO HOLD HARMLESS SKIN BY ANTHOS AND ITS EMPLOYEES, CONTRACTORS, AGENTS, DIRECTORS, MEMBERS, MANAGERS, SHAREHOLDERS, OFFICERS, REPRESENTATIVES, ASSIGNS, PARENTS, PREDECESSORS, AND SUCCESSORS FOR DELAYS IN EVALUATION OR FOR INFORMATION LOST DUE TO SUCH TECHNICAL FAILURES.

I understand that I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time, without affecting my right to future care or treatment. I understand that I may suspend or terminate use of the telehealth services at any time for any reason or for no reason.

I understand that if I am experiencing a medical emergency, that I will be directed to dial 9-1-1 immediately and that my Provider is not able to connect me directly to any local emergency services.

I understand that alternatives to telehealth consultation, such as in-person services are available to me.

I understand that I may expect the anticipated benefits from the use of telehealth in my care, but that no results can be guaranteed or assured.

I understand that my healthcare information may be shared with other individuals for operational, quality assurance, scheduling and billing purposes. I understand that I will not be prescribed any narcotics for any reason, nor is there any guarantee that I will be given a prescription at all. I understand that the decision of whether a prescription is appropriate will be made in the professional judgement of my Provider.

I understand that my Provider reserves the right to deny care for potential misuse of the Services or for any other reason if, in the professional judgment of my Provider, the provision of the Services is not medically or ethically appropriate.

I understand that if I participate in a consultation, that I have the right to request a copy of my medical records which will be provided to me at reasonable cost of preparation, shipping and delivery.

Additional State-Specific Consents: The following consents apply to users accessing the Skin by Anthos website for the purposes of participating in a telehealth consultation as required by the states listed below:

Texas: I understand that my medical records may be sent to my primary care provider. (Tex. Occ. Code Ann. ยง 111.005). I have been informed of the following notice: NOTICE CONCERNING COMPLAINTS – Complaints about physicians, as well as other licensees and registrants of the Texas Medical Board, including physician assistants, acupuncturists, and surgical assistants may be reported for investigation at the following address: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018, Assistance in filing a complaint is available by calling the following telephone number: 1-800-201-9353, For more information, please visit our website at www.tmb.state.tx.us.

Patient Consent: I have read this document carefully, and understand the risks and benefits of the telehealth consultation and have had my questions regarding the procedure explained and I hereby give my informed consent to participate in a telehealth consultation under the terms described herein.

Get Your Prescription Strength Formula

Once you make your purchase, your order will be completed in 3 easy steps.

1. You will be contacted by our team within one business day and be directed to complete a questionnaire through our secure patient portal.
2. One of our board-certified dermatology providers will respond to you and request some photos to be uploaded to the secure site.
3. Once approved, your personalized prescription formula will be delivered to your doorstep!

The fine print: if you do not complete the requested questionnaire or photo upload within 30 days, or if your medical provider determines that you are not an appropriate candidate for a prescription strength formula, your order will be canceled and payment will be credited back to your account.

If this is a refill of a prescription product, you will not need to complete the patient forms again. We will confirm that you are an existing patient and your product will be shipped directly.

Only for residents of California, Texas and Hawaii

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