AASM SleepTM

Patient Consent Form

EFFECTIVE DATE: 5/4/2016 ("Effective Date")

AASM SleepTM, LLC’s ("AASM”) telemedicine platform (the “Telemedicine System”) enables health care professionals to provide telemedicine services to interested patients with sleep disorders and related conditions.

DO NOT USE THE TELEMEDICINE SYSTEM FOR A MEDICAL EMERGENCY OR URGENT CARE. In an emergency, call 911.

The Telemedicine System is licensed by AASM to health care entities composed of one or more health care professionals who desire to use the Telemedicine System to treat interested patients.

If you decide to use the Telemedicine System to communicate with a health care professional, it is important that you understand the benefits and risks associated with using the Telemedicine System, as well as the rights, responsibilities and expectations of the treating health care professional (“Health Professional”) and the health care entity that licenses the Telemedicine System (“Practice”).

There are benefits and risks associated with the use of the Telemedicine System. Benefits include the ability to send information to your Health Professional without having to make, and travel to, an in-person appointment. Risks include, but are not limited to, those items listed in Section 2 (“Risks Associated with Use of Telemedicine System”).

If you decide to use the Telemedicine System, you will be asked to provide information about yourself, medical history, and current health issues (“Collected Information”).

The Health Professional with whom you communicate via the Telemedicine System may request that you submit additional information about your condition through the Telemedicine System’s messaging service or by telephone, prescribe a course of treatment to you, request that you schedule an in-person office visit with your Health Professional at his or her office during business hours, request that you schedule an appointment with another physician, or direct you to seek urgent care.

If you have any clinical, non-technical questions about use of the Telemedicine System (such as whether use of the Telemedicine System, rather than schedule an in-person visit, or the risks associated with using the Telemedicine System), please contact the Health Professional at his or her office during regular business hours.

For technical questions, please contact AASM at 888-334-6820.

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In exchange for my use of the Telemedicine System to receive treatment, I acknowledge and agree to the following terms and conditions of this Consent (this "Consent"):

  1. Use of Telemedicine System. For Adult Users: By using the Telemedicine System, I represent to Practice that I am the age of majority or older in my state of residence (age 21 in Mississippi, age 19 in Alabama and Nebraska and age 18 in all other states) and the health condition for which I seek Health Professional’s assistance is my own. For Pediatric Users (the patient is under the age of majority in the patient’s state of residence): I authorize the use of the Telemedicine System to communicate with the patient who is my child or for whom I serve as a legal representative or guardian. I represent to Practice that (1) I am authorized by law to direct the medical care of the minor patient who is receiving care via the Telemedicine System, (2) I will explain the terms of patient consent form to the Pediatric User in a clear manner and obtain the patient’s assent/permission to proceed with the telemedicine encounter when appropriate; and (3) I will remain physically present with the Pediatric User during the entire duration of the telemedicine encounter via the Telemedicine System.

    I understand that I am under no obligation to use the Telemedicine System to obtain medical care from the Health Professional. I choose to use the Telemedicine System rather than seek an in-person examination with a health professional. I understand and agree that:
    • I will not use the Telemedicine System for medical emergency or urgent care services.
    • I have the right to be informed of any party who will be present during the consultation and I have the right to exclude anyone from being present. I also understand that I have the right to object to the videotaping of the telehealth consultation.
    • The Health Professional will decide, in his or her sole discretion, whether it is appropriate to treat my condition using the Telemedicine System. I understand that I have the right to request an in-person consultation before or after the telehealth consultation and I will be informed if such consultation is not available.
    • The Health Professional may require an in-person examination prior to diagnosing or prescribing a treatment plan.
    • The Health Professional will use his or her professional judgment when determining whether to prescribe medication.
    • The Health Professional may not prescribe any controlled substances for conditions diagnosed through the Telemedicine System unless the Health Professional has performed an in-person physical examination of the condition for which he or she is prescribing the controlled substance.
    • The anticipated response time for electronic communications submitted through the Telemedicine System varies and I accept any risk associated with the response time, including a delay in obtaining medical care.
    • No warranty or guarantee has been made to me concerning any particular result related to my condition or diagnosis.
  2. Risks Associated with Use of Telemedicine System. I understand that use of the Telemedicine System has risks associated with it, such as (1) information that I transmit through the Telemedicine System may be insufficient to allow for appropriate medical decision-making by the Health Professional (e.g., poor resolution of transmitted images); (2) failures of equipment (e.g., servers, devices) or infrastructure (e.g., communications lines, power supply) may cause delays in evaluation and treatment, or loss of information; and (3) unauthorized access to my medical information. I understand and consent to the risks associated with my use of the Telemedicine System.

  3. Accuracy of Information Submitted to Health Professional. I acknowledge and agree that I am solely responsible for ensuring that the information submitted by me through the Telemedicine System is accurate, complete and current. I understand that the Health Professional will rely on this information to diagnose and prepare a treatment plan for my condition and my failure to provide accurate, complete and current information may lead to a delay in my treatment or a misdiagnosis.

  4. Privacy and Security.
    • I acknowledge that, although Practice and AASM strive to prevent unauthorized access to information about me through encryption of information transmitted by the Telemedicine System and other security measures, Practice, Health Professional and AASM cannot guarantee that my use of the Telemedicine System and the information will be private or secure, and I consent to this risk.
    • I understand that, when I submit information about myself through the Telemedicine System, I consent to and grant Practice the right to use and disclose the information that I submit about me in accordance with Practice’s Notice of Privacy Practices.
    • I acknowledge and agree to the terms of the Telemedicine System’s Privacy Policy.
  5. Release and Waiver. I acknowledge and agree to all of the terms of the Telemedicine System’s Privacy Policy and Terms and Conditions of Use, including, without limitation, any provisions that limit, disclaim, or release the Practice, Health Professional and/or AASM from liability in connection with the Telemedicine System’s use.

  6. Expenses. I understand and agree that I am responsible for:
    • The cost of all professional fees associated with my use of the Telemedicine System, which may change from time to time.
    • The cost of any medications or supplies prescribed by the Health Professional.
  7. Other Legal Terms. I understand and agree to the following general legal terms:
    • This Consent cannot be amended except in writing by mutual agreement of Practice and me.
    • If any provision of this Consent is or becomes unenforceable or invalid, the remaining provisions will continue with the same effect and effect.
  8. Right to Revoke. I understand that I can revoke this Consent by sending written notice using certified mail to Practice (my “Revocation”). I agree that my Revocation must contain my name and my address. I also understand that my Revocation means that I am not permitted to use the Telemedicine System. My Revocation will be effective upon Practice’s receipt of my written notice,except that my Revocation will not have any effect on any action taken by the Health Professionalin reliance on this Consent before it received my written notice of Revocation.

BY CHECKING THE BOX THAT STATES “AGREE”, I ACKNOWLEDGE THAT I HAVE READ, UNDERSTAND AND CONSENT TO ALL OF THE TERMS OF THIS CONSENT.

IF THE PATIENT IS A PEDIATRIC USER FOR WHOM I AM THE PEDIATRIC USER’S PARENT OR LEGAL GUARDIAN, BY CHECKING THE BOX THAT STATES “AGREE”, I ACKNOWLEDGE THAT I HAVE READ, UNDERSTAND AND CONSENT TO ALL OF THE TERMS OF THIS CONSENT ON THE PEDIATRIC USER’S BEHALF, AND, TO THE EXTENT APPROPRIATE, HAVE EXPLAINED THE TERMS OF THIS INFORMED TO CONSENT TO THE PEDIATRIC USER AND HAVE SECURED THE PEDIATRIC USER’S ASSENT.

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