THERE'S POWER IN HEALTH!

OUR PROVIDERS DO NOT ADDRESS MEDICAL EMERGENCIES. DO NOT PROCEED WITH CLINICAL SERVICES USING THE IMPERIUM HEALTH PLATFORM IF YOU BELIEVE YOU ARE HAVING A MEDICAL EMERGENCY. IF YOU BELIEVE YOU ARE EXPERIENCING A MEDICAL EMERGENCY, YOU SHOULD DIAL 9-1-1 AND/OR GO TO THE NEAREST EMERGENCY ROOM. 

IF YOU ARE CONTEMPLATING SUICIDE, CONTACT 911 OR THE NATIONAL SUICIDE PREVENTION LINE BY ONE OF THE FOLLOWING METHODS: 

DIAL 1-800-273-TALK 

DIAL OR TEXT 988 

Go to 988Lifeline.org to chat LIVE

You are reviewing and acknowledging this Telehealth Informed Consent because you are seeking Healthcare Services utilizing telehealth technologies by the Colchis Medical Group facilitated through the Imperium Health, Inc. website, iOS mobile app, web mobile app or other telehealth technologies collectively the “Imperium Health Platform.” This Telehealth Informed Consent does not modify or supersede any Terms of Use, Privacy Policy, or Notice of Privacy Practices of Imperium 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 Imperium Health Platform, 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 Colchis Medical Group 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.

Colchis Medical Group refers to a network of medical professional organizations affiliated with Imperium Health, Inc. and its employed and contracted health providers (the “Providers”).

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 (synchronous) video and audio encounters, and interactive audio with store and forward. This “Telehealth Informed Consent” informs the patient (“patient,” “you,” or “your”) concerning the treatment methods, risks, and limitations of utilizing telehealth to meet your health and wellness needs.

Benefits of telehealth include being 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, including follow-up care related to your treatment. If you need follow-up care, please contact us through the Imperium Health Platform.

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. If a technical failure prevents you from communicating with your Providers, you should call the following number: 

Phone: 1-800-(909) 787-2342 Mon - Sun 4:00 am PST - 5:00 pm PST

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 Healthcare Services provided by Colchis Medical Group 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 Colchis Medical Group has no obligation for your on-going care or selection of separate healthcare services in such circumstances.

I understand that certain diagnostic testing services, including laboratory products and services offered through the Imperium Health Platform to support the Healthcare 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).

THIRD-PARTY LABORATORY PRODUCTS AND SERVICES To facilitate certain Healthcare Services Providers may require that you complete diagnostic test(s). These diagnostic tests are provided by third-party laboratories, and neither Imperium Health, Colchis Medical Group, 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.

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

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

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

In some cases, my Provider may be a nurse practitioner or physician assistant and not a physician.

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 or her role.

I understand that information I provide as part of any telehealth offering is viewed as accurate, true, and complete. 

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

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.

I understand there is a risk of technical failures during the telehealth encounter beyond the control of Colchis Medical Group and my Provider(s). I AGREE TO HOLD HARMLESS COLCHIS MEDICAL GROUP AND ITS EMPLOYEES, CONTRACTORS, AGENTS, DIRECTORS, MEMBERS, MANAGERS, SHAREHOLDERS, OFFICERS, REPRESENTATIVES, ASSIGNS, PREDECESSORS, AND SUCCESSORS, INCLUDING IMPERIUM 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.

I understand that certain diagnostic testing services, including laboratory products and services offered through the Imperium Health Platform to support the Healthcare 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).

I understand the Imperium Health Platform 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 approved for treatment 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 Imperium Health or the Colchis Medical Group, 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 Imperium 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 Imperium Health Health

I understand that by using the Imperium Health Platform 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 Imperium Health Platform 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 Imperium Health Platform regularly, then my services may be delayed.

I understand that I have the opportunity to discuss the use of telehealth, including the Healthcare 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 Healthcare Services via the Imperium Health Platform do not offer in-person treatment.

I understand that I have access to my medical record pertaining to the Healthcare Services of Providers utilizing the Imperium Health Platform 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.

I understand that while the Imperium Health Platform may make available access to pharmacy or diagnostic lab services that are coordinated with the Healthcare Services, I am able to request any pharmacy or lab of my preference.

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