Consent to Telehealth
Thank you for choosing Sava Rx, a service of EA Sava LLC! You are viewing this form because you have elected to receive care via telehealth: a secure online intake, with synchronous video or phone visits when your provider requires it or when state law requires it, reviewed by a licensed provider through SamaritanMD. Your practitioner is a licensed provider.
By clicking “I Agree,” I ACKNOWLEDGE I HAVE READ AND UNDERSTAND THE TERMS PRESENTED BELOW, AND UNDERSTAND THE RISKS AND BENEFITS OF TELEHEALTH SERVICES, AND BY ACCEPTING THESE TERMS OF USE I HEREBY GIVE MY INFORMED CONSENT TO PARTICIPATE IN TELEHEALTH SERVICES UNDER THESE TERMS.
What is Telemedicine?
Telemedicine is the delivery of healthcare services, including examination, consultation, diagnosis, and treatment, through electronic communication technologies when you (the patient) are located in a different location than your healthcare practitioner. With Sava Rx, you complete a secure online intake. A licensed provider through SamaritanMD reviews each intake and determines whether treatment is appropriate. A prescription is not guaranteed.
How Is Care Delivered Through Telehealth?
Sava Rx delivers care via telehealth. Care begins with a secure online intake, which is reviewed by a licensed provider through SamaritanMD. When your provider requires it, or when the law of your state requires it, your care will also include a synchronous (real-time) video or phone visit with your provider. Some information, such as questionnaires, photos, or messages, may be submitted and reviewed at different times.
Sava Rx’s platform (“Platform”), in particular, allows for the following telehealth services: 1) secure online intake questionnaires; 2) synchronous video or phone visits when your provider requires it or when state law requires it; and 3) text-based healthcare practitioner-patient interactions through short message service (“SMS”) and multimedia messaging service (“MMS”) communications.
What are the Possible Risks to Using Telehealth?
As with any medical treatment, there are potential risks associated with the use of telehealth. Sava Rx believes that the likelihood of these risks materializing is very low.
These risks may include, without limitation, the following:
• Delays in medical evaluation and consultation or treatment may occur due to deficiencies or failures of the equipment or the Internet, which may include poor data quality, Internet outages, or other service interruption issues. You may reschedule the visit with your healthcare practitioner should these interruptions occur.
• Security protocols could fail, causing a breach of privacy of personal medical information.
• Because Sava Rx does not have access to your complete medical records, if you do not disclose to your healthcare practitioner a full list of your medical history including diagnoses, treatments, medications/supplements, and allergies, adverse treatment, drug interactions or allergic reactions, or other negative outcomes may occur.
• Telehealth services are NOT emergency services and your Personal Data (as defined in the Sava Rx Privacy Policy) WILL NOT BE MONITORED 24/7. If you think you are experiencing a medical emergency, CALL 911 IMMEDIATELY.
THE CARE YOU RECEIVE WILL BE AT THE SOLE DISCRETION OF THE HEALTHCARE PRACTITIONER WHO IS TREATING YOU, WITH NO GUARANTEE OF DIAGNOSIS, TREATMENT, OR PRESCRIPTION. THE HEALTHCARE PRACTITIONER WILL DETERMINE WHETHER OR NOT THE CONDITION BEING DIAGNOSED AND/OR TREATED IS APPROPRIATE FOR THE CARE PROVIDED THROUGH A TELEHEALTH ENCOUNTER VIA THE PLATFORM.
Your Rights and Acknowledgements:
• You have the same privacy rights via telehealth that you would have during an in-person visit. Dissemination of any identifiable images or information from the telehealth visit to researchers or other entities will not occur without your written consent. For more information about how we protect your privacy, please read the Sava Rx Privacy Policy here
• Telehealth may involve electronic communication of your personal medical information to healthcare practitioners who may be located in other areas, including out of state.
• You understand that you may expect the anticipated benefits from the use of telehealth, but that no results can be guaranteed or assured.
• You understand that all information submitted to Sava Rx via text message and entered by your healthcare practitioner in the Sava Rx Platform will be part of your medical record and available to you by emailing support@savarx.com. This information will have the same restrictions on dissemination without your consent.
• You understand that your healthcare practitioner’s initial text message to you will include his/her name and credentials, and this will be recorded in the Sava Rx Platform as part of your medical record.
• You understand you may withdraw your consent and delete your patient profile at any time by emailing support@savarx.com.
• You understand that your healthcare information may be shared with other individuals in accordance with the Sava Rx Privacy Policy and regulations or laws in state or territory in which you are located.
• You further understand that your healthcare information may be shared in the following circumstances:
When a valid court order is issued for medical records.
Reporting suspected abuse, neglect, or domestic violence.
Preventing or reducing a serious threat to anyone's health or safety
Call/Email/Text Messaging Consent: You expressly consent to allow Sava Rx or its healthcare practitioners to call, email, or text you (via SMS and/or MMS) with or regarding Personal Data (as defined in the Sava Rx Privacy Policy), appointments, or similar matters related to your telemedicine encounters using the contact information you have provided. Any calls or texts to you may be placed using an auto-dialer or a pre-recorded or artificial voice, even if your number is on a do-not-call list. Your phone carrier’s normal rates may apply. This is consent, not a condition of purchase.
You may revoke this consent at any time by emailing us at support@savarx.com.
This Telehealth Informed Consent is valid during your entire treatment with Sava Rx (EA Sava LLC).