Telehealth Consent Form

I understand and agree with the following:

Telehealth/Telemedicine involves the use of electronic communications to enable health care providers at different locations to share individual patient medical information for the purpose of improving patient care. Providers may include primary care practitioners, specialists and/or subspecialists, nurse practitioners, registered nurses, medical assistants and other healthcare providers who are part of my clinical care team. In addition to myself and the members of my clinical care team, my family members, caregivers, or other legal representatives or guardians may join and participate on the telehealth/telemedicine service, and I agree to share my personal information with such family members, caregivers, legal representatives or guardians. The information may be used for diagnosis, therapy, follow-up and/or education.

Telehealth/Telemedicine requires transmission, via Internet or tele-communication device, of health information, which may include:
• Progress reports, assessments, or other intervention-related documents
• Bio-physiological data transmitted electronically
• Videos, pictures, text messages, audio and any digital form of data

The laws that protect the privacy and confidentiality of health and care information also apply to telehealth/telemedicine. Information obtained during telehealth/telemedicine that identifies me will not be given to anyone without my consent except for the purposes of treatment, education, billing and healthcare operations. By agreeing to use the telehealth/telemedicine services, I am consenting to Sistemas Medicos Nacionales S.A. de C.V. (“SIMNSA”) sharing of my protected health information with certain third parties as more fully described in SIMNSA’s Notice of Privacy Practices. I understand, agree, and expressly consent to SIMNSA obtaining, using, storing, and disseminating to necessary third parties, information about me, including my image, as necessary to provide the telehealth/telemedicine services.

As with any Internet-based communication, I understand that there is a risk of security breach. Electronic systems used 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.

Individuals other than my clinical care team or consulting providers may also be present and have access to my information for the telehealth/telemedicine session. This is so they can operate or repair the video or audio equipment used. These persons will adhere to applicable privacy and security policies.

Telehealth/telemedicine sessions may not always be possible. Disruptions of signals or problems with the Internet’s infrastructure may cause broadcast and reception problems (e.g., poor picture or sound quality, dropped connections, audio interference) that prevent effective interaction between consulting clinician(s), participant, patient or care team.

I hereby release and hold harmless SIMNSA and all members of my care team from any loss of data or information due to technical failures associated with the telehealth/telemedicine service.

I understand and agree that the health information I provide at the time of my telehealth/telemedicine service may be the only source of health information used by the medical professionals during the course of my evaluation and treatment at the time of my telehealth/telemedicine visit, and that such professionals may not have access to my full medical record or information held at SIMNSA.

I understand that I will be given information about test(s), treatments(s) and procedures(s), as applicable, including the benefits, risks, possible problems or complications, and alternate choices for my medical care through the telehealth/telemedicine visit.

I have the right to withhold or withdraw consent to the use of telehealth/telemedicine services at any time and revert back to traditional in-person clinic services. I understand that if I withdraw my consent for telehealth/telemedicine, it will not affect any future services or care benefits to which I am entitled.

All my questions have been answered to my satisfaction.

I hereby consent to the use of telehealth/telemedicine in the provision of care and the above terms and conditions.

y consenting to the above, I certify that I am the legal representative of the participant or that I am the patient and am 18 years of age or older, or otherwise legally authorized to consent. I have carefully read and understand the above statements as well as SIMNSA’s Notice of Privacy Practice provided to me during enrollment. I have had all my questions answered. I understand that this informed consent will become a part of my medical record.

Purchase Policy

I understand and agree with the following:

1.- The patient must pay the cost of telehealth service before being able to start communication with the doctor.
2.- The cost of the telehealth service will depend on the specialty of the consultation and the patient's medical plan.
3.- In case of disconnection or miscommunication during the service, the patient has the possibility to request help through the live chat or by calling the customer service center at the telephone number +52 664 231 4747.
4.- When canceling an appointment 2 hours or more in advance, the reimbursement will be made to the patient for 100% of the amount paid.
5.- There is no reimbursement when canceling an appointment in the last 2 hours prior to the appointment or expired appointments.
6.- If for technical reasons in which the company is responsible communication is not achieved, the refund will be made for 100% of the amount paid.
7.- Refunds will be delivered to the patient in a period of time no longer than 48 business hours.

Política de Compra

Entiendo y estoy de acuerdo con lo siguiente:

1.- El paciente deberá pagar el costo de la consulta antes de poder comenzar la comunicación con el médico.
2.- El costo de la consulta dependerá de la especialidad de la consulta y del plan médico del paciente.
3.- En caso de desconexión o pérdida de comunicación durante la consulta, el paciente tiene la posibilidad de pedir ayuda mediante el chat en vivo o llamando al centro de atención a clientes al número telefónico +52 664 231 4747.
4.- Al cancelar una cita con 2 horas o más de anticipación el reembolso se realizara al paciente por el 100% del monto pagado.
5.- No existe reembolso para citas canceladas con menos de 2 horas previo a la cita o citas expiradas.
6.- Si por motivos técnicos en los que la empresa sea responsable no se logra la comunicación, el reembolso se realizara por el 100% del monto pagado.
7.- Los reembolsos por cancelación serán entregados al paciente en un período de tiempo no mayor a 48 horas hábiles.