Last Modified: April 15, 2022

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 AND SHOULD NOT PROCEED WITH CLINICAL SERVICES USING THE BLOOM HEALTH CARE LLC.

IF YOU ARE CONTEMPLATING SUICIDE, CONTACT 911 OR THE NATIONAL SUICIDE PREVENTION LINE AT 1-88-273-TALK (8255).

1. Introduction

You are reviewing and acknowledging this Telehealth Informed Consent because you are seeking Health Care Services utilizing telehealth technologies  facilitated through the Bloom Health website,  or other telehealth technologies collectively the “Bloom Health Care LLC.” This Telehealth Informed Consent does not modify or supersede any Terms of Use, Privacy Policy, or Notice of Privacy Practices of Bloom Health or the Providers, rather it supplements these terms and documents.

By creating an account, starting a consult, clicking “I consent to telehealth,” checking a related box to signify your acceptance or using any other acceptance protocol presented through the Bloom Health Care LLC you indicate that you have reviewed the risks as described herein of receiving services utilizing telehealth technologies and consent to receiving the services. A record of this Telehealth Informed Consent is maintained in the files and records of the applicable Provider delivering your services, and your on-going participation in services by the Bloom Health using telehealth technologies serves as an on-going acknowledgement of your acceptance of this Telehealth Informed Consent and updates at such time the representations you provide herein.

1. What is Telehealth?

Telehealth involves the delivery of health and wellness services using electronic communications, information technology, or other means between a licensed, certified, or registered healthcare professional at one location and a patient in another location about a clinical matter. Telehealth may be used for diagnosis, treatment, follow-up and/or patient education. These telehealth services may involve various modalities, including asynchronous interactions, real-time video and audio encounters and interactive audio with store and forward. This “Telehealth Informed Consent” informs the patient or guardian (“patient,” “you,” or “your”) concerning the treatment methods, risks, and limitations of utilizing telehealth to meet your health and wellness needs.

III. What are the Possible Benefits of Telehealth?

It can be easier and more efficient for you to access health and wellness services. You can obtain health and wellness services at times that are convenient for you without the necessity of an in-office appointment.

1. What are the Possible Risks of Telehealth?

Information transmitted to your health professional may not be sufficient to allow for appropriate health or wellness services to meet your particular need. Some clinical needs may not be appropriate for a telehealth visit and your Provider will make that determination. The technology necessary to interact with your health professional may fail and delay your services. As all data exchanged is in a digital format, a data breach enables increased access to your health data. In rare events, a lack of access to complete medical records, and/or the quality of transmitted data could result in adverse drug interactions, allergic reactions, and/or other clinical judgment errors. You may stop or decline any on-going Health Care Services provided by Bloom Health using telehealth technologies at any time, although you acknowledge that applicable fees may apply if a medical consultation has occurred prior to request to cancel services and Bloom Health has no obligation for your on-going care or selection of separate health care services in such circumstances.

LABORATORY PRODUCTS AND SERVICES To facilitate certain Health Care Services provided to you, Providers may require that you complete diagnostic test(s). These diagnostic tests are provided by third-party laboratories, and neither Bloom Health, nor your Provider(s) can guarantee the accuracy or reliability of these tests. These laboratory tests can provide false negative, false positive, or inconclusive results that could impact your Provider(s) ability to correctly diagnose or treat your medical conditions. A failure or defect of these tests could also impact your Provider(s) ability to correctly diagnose or treat your medical conditions.

1. Patient Acknowledgments

By accepting this Telehealth Informed Consent, you acknowledge you understand and consent to the following:

1. I have reviewed this Telehealth Informed Consent carefully, and understand there are risks, limitations, and benefits of utilizing telehealth.

2. I understand that the electronic nature of the telehealth services means that there is a greater risk to the privacy of my health information.

3.My Provider is a nurse practitioner and not a physician.

4. Persons may be present during the telehealth visit other than my Provider in order to operate the telehealth technologies and/or for language translation assistance, if requested. If another person is present during the telehealth visit, I will be informed of the individual’s presence and his/her role.

5. I understand that information I provide as part of any telehealth offering is viewed as accurate, true, and complete. I understand that I can log into my patient account on the BloomHRT.com website at any time to access, amend, or review my health information and send messages to my provider.

6. I understand that in certain instances, and in compliance with applicable law, my Provider may determine that it is appropriate to provide my Health Care Services asynchronously via store-and-forward technology. In such instances, my Provider and I will communicate electronically through the Bloom Health Care LLC and not via telephone or video. I agree that if my provider makes that determination, I would like to receive Health Care Services in this manner.

7. I understand that there is no guarantee that I will be given a prescription and that the decision of whether a prescription is appropriate will be made in the professional judgment of my Provider. I understand that while the use of telehealth may provide benefits to me, no such benefits or specific results can be guaranteed, and my condition may not improve.

8. I understand there is a risk of technical failures during the telehealth encounter beyond the control of Bloom Health and my Provider(s). I AGREE TO HOLD HARMLESS BLOOM HEALTH AND ITS EMPLOYEES, CONTRACTORS, AGENTS, DIRECTORS, MEMBERS, MANAGERS, SHAREHOLDERS, OFFICERS, REPRESENTATIVES, ASSIGNS,, PREDECESSORS, AND SUCCESSORS, INCLUDING BLOOM HEALTH 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.

9. I understand that certain diagnostic testing services, including laboratory products and services offered through the Bloom Health Care LLC to support the Health Care Services of Providers, may contain defects, including ones which may limit functionality or produce erroneous results, any or all of which could limit or otherwise impact the quality, accuracy and/or effectiveness of the medical care or other services that I receive from my Provider(s).

10. I understand the Bloom Health Care LLC makes available a specific set of services and I may need to seek other resources for my other health needs. There is no guarantee that I will be treated by a Provider. My Provider reserves the right to deny care for any reason if, in the professional judgment of my Provider, the provision of the services, including when provided via telehealth is not medically or ethically appropriate. I understand that the Providers, and not Bloom Health are responsible for the quality and appropriateness of the care they render to me and make all decisions regarding clinical care in their independent discretion without the influence of Bloom Health. I agree to only seek relief against the Provider for any liabilities pertaining to medical or clinical issues arising as a direct result of medical or clinical services accessed through Bloom.

11. I understand that by using the Bloom Health website and services, I am not always speaking or messaging with my Provider in real-time, and there may be a delay before my messages or information is reviewed. I understand that I must check the Bloom Health patient portal for messages because this is the way that my Provider will communicate important information to me. I understand that if I do not check the Bloom Health patient portal regularly, then my services may be delayed.

12. I understand that I have the opportunity to discuss the use of telehealth, including the Health Care Services, with my Provider(s), including the benefits and risks of such use and the alternatives to the use of telehealth. I have the right to withdraw my consent to the use of telehealth in the course of my care, without prejudice to any future care or treatment and without risking the loss or withdrawal of any health benefits to which I am entitled, but I understand that the Providers who provide Health Care Services via the Bloom Health Care LLC do not offer in-person treatment.

13. I understand that I have access to my medical record pertaining to the Health Care Services of Providers utilizing the Bloom Health Care LLC in accordance with applicable laws and regulations and that my primary care provider, or other treating provider, may obtain copies of my health and wellness information with my consent.

14. I understand that while Bloom Health Care LLC may make available access to pharmacy or diagnostic lab services that are coordinated with the Health Care Services, I am able to request any pharmacy or lab of my preference. This prescription is provided for your personal use for the condition diagnosed by your healthcare provider. We do not guarantee the efficacy of the medication. Please be aware of possible side effects and interactions with other medications you may be taking. Always consult with your healthcare provider if you have any concerns or questions about your medications. Our practice is not liable for any direct or indirect complications from the use of this medication once dispensed. Your health information and prescription details are treated with confidentiality and privacy.

It is your right to obtain your prescription at the pharmacy of your choice if you prefer not to fill it at Bloom.  A fee of $59 to transfer your prescription will be paid before the prescription can be transferred.  This fee covers time spent and cost of software, to manually data input your personal information and prescription information into external software (iprescribe) to electronically transmit your prescription to an outside pharmacy. Any prior authorizations required by your insurance company will need to be obtained from your primary care provider, we do not have medical staff to assist you with this. By transferring your prescription, you terminate your membership with Bloom and the patient provider relationship is terminated.  You will lose access to your online account and will have to rejoin with a new membership fee applied should you want to restart.

15. I agree that Bloom Health is a third-party beneficiary of the Telehealth Patient Consent and has the right to enforce it against you.