CONSENT

Patient Acknowledgement.

By continuing to book an appointment, you acknowledge you understand and consent to the following Telehealth Informed Consent:

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. In some cases, my Provider may be a nurse practitioner or physician assistant and not a physician. I understand and agree that my Provider is licensed in the state that I reside in and that my provider may not be able to prescribe certain medications for me, and cannot assist me in an emergency situation. My licensed healthcare provider will utilize telemedicine only for the services that are appropriate for my medical condition, and like all medical care, no specific results can be guaranteed or assured.

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 may have opportunities to correct any incorrect information.

6. 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.

7. I understand there is a risk of technical failures during the telehealth encounter beyond the control of Divergent Healthcare and my Provider(s). I AGREE TO HOLD HARMLESS PHILOMENA PHYSICIAN ASSISTANT SERVICES/DIVERGENT HEALTHCARE AND ITS EMPLOYEES, CONTRACTORS, AGENTS, DIRECTORS, MEMBERS, MANAGERS, SHAREHOLDERS, OFFICERS, REPRESENTATIVES, ASSIGNS, PREDECESSORS, AND SUCCESSORS, INCLUDING NURX 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.

8. I understand that certain diagnostic testing services, including laboratory products and services offered through PHILOMENA PHYSICIAN ASSISTANT SERVICES/DIVERGENT HEALTHCARE 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). Upon being recommended for such diagnostic lab tests I am under no obligation to complete such tests, or to complete them with PHILOMENA PHYSICIAN ASSISTANT SERVICES/DIVERGENT HEALTHCARE and its affiliates, and I understand that I may have the tests done by another lab of my choosing.

9. I understand PHILOMENA PHYSICIAN ASSISTANT SERVICES/DIVERGENT HEALTHCARE 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 PHILOMENA PHYSICIAN ASSISTANT SERVICES/DIVERGENT HEALTHCARE, 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 PHILOMENA PHYSICIAN ASSISTANT SERVICES/DIVERGENT HEALTHCARE 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 PHILOMENA PHYSICIAN ASSISTANT SERVICES/DIVERGENT HEALTHCARE.

10. I accept that by using the PHILOMENA PHYSICIAN ASSISTANT SERVICES/DIVERGENT HEALTHCARE 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 PHILOMENA PHYSICIAN ASSISTANT SERVICES/DIVERGENT HEALTHCARE 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 PHILOMENA PHYSICIAN ASSISTANT SERVICES/DIVERGENT HEALTHCARE Platform regularly, then my services may be delayed.

11. 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 PHILOMENA PHYSICIAN ASSISTANT SERVICES/DIVERGENT HEALTHCARE Platform do not offer in-person treatment.

12. I understand that I have access to my medical record pertaining to the Health Care Services of Providers utilizing the PHILOMENA PHYSICIAN ASSISTANT SERVICES/DIVERGENT HEALTHCARE Platform in accordance with applicable laws and regulations and that my primary care provider, or another treating provider, may obtain copies of my health and wellness information with my consent.

13. I understand that while the PHILOMENA PHYSICIAN ASSISTANT SERVICES/DIVERGENT HEALTHCARE Platform 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.

14. I agree that PHILOMENA PHYSICIAN ASSISTANT SERVICES/DIVERGENT HEALTHCARE is a third-party beneficiary of the Telehealth Patient Consent and has the right to enforce it against you.

15. In giving the consent hereunder, I, as patient, am relying on the judgment of the clinical professional evaluating me and administering the treatments. I have had the meaningful chance to ask questions and have received satisfactory answers to my questions. The risks and potential benefits of the treatment I am consenting to have been explained to me. Alternatives to the treatments I am consenting to have also been discussed with me.

Patient Code of Conduct 

Divergent Healthcare is committed to providing high-quality care to our patients and communities in a safe and respectful environment that supports health and healing.
To ensure our clinics, care locations, and staff are safe and inclusive, we ask that patients and visitors follow the example of Divergent Healthcare Health providers and associates by adhering to our Patient and Visitor Code of Conduct. By continuing to book with us, you agree to the following: 

1. Everyone will be treated with kindness, dignity, and respect. Offensive comments about race, religion, gender, sexual orientation, or personal traits are not acceptable, and neither is the refusal to see a clinician or associate based on these traits.
2. All patients and visitors will use respectful, appropriate language and behavior. Physical or verbal threats or assaults, suggestive or explicit words, phrases, gestures, or actions will not be tolerated.
3. All patients and visitors will respect patient privacy and avoid disrupting other patients' care or experiences.
4. All patients and visitors must obtain the consent of everyone involved for any photographing or video/audio recording within all clinic and patient care locations. No staff member shall be recorded/photographed unless given explicit written consent by that staff member.
5. Communication with any member of the staff/medical team will be done through the patient portal or business telephone number only.

 
If these guidelines are not followed:

1. Patients may be asked to leave and make other plans for their non-emergent immediate care, and for severe violations, future non-emergency care at Divergent Healthcare Health may require review. Review cases will be sent to the CEO via email within 72 hours of the event. The e-mail will contain the following items: employee(s) involved, patient(s)/client(s) involved, location, date of event, approximate time of event, explanation of event including which of the items above the employee feels was violated.

 
In cases of perceived non-compliance, patients will also have an opportunity to explain their perspective, which will be considered prior to any decisions regarding future care at Divergent Healthcare Health. Director of operations will reach out to the patient within 72 hours to obtain the patient/client viewpoint including the following items: employee(s) involved, patient(s)/client(s) involved, location, date of event, approximate time of event, explanation of event. After both statements have been documented, the CEO will have 7 calendar days to finalize the decision, during which period the patient/client will refrain from receiving services with Divergent Healthcare.

 
2. Patients who make threats of or engage in: physical/verbal/sexual abuse will be immediately dismissed from the practice without undergoing any review process. In this circumstance, patients may be dismissed by any member of the healthcare team if they feel their safety is in jeopardy.
Every day, our providers, nurses, and associates are committed to providing the highest levels of care to our patients. Please show them the respect they deserve and that you expect as a patient or visitor.
Thank you for choosing Divergent Healthcare and joining us in our commitment to ensuring a safe, caring and inclusive environment for us all.