Informed Consent for Pery Services
Before you provide your informed consent to request telehealth or other non-medical services for yourself or your minor child, please be aware of how obtaining health services remotely from licensed health care professionals (the “Providers”) employed by or affiliated with Periapt Corp., doing business as “Pery” (“Periapt” or “Pery”), or non-medical services through other non-licensed personal of Periapt, through an online telehealth platform (the “Platform”) developed and maintained by Periapt, differs from in-person care and in-person services as set forth in this document (hereinafter referred to as the “Informed Consent”).
The terms “Periapt” “we”, “us”, or “our” refers to Periapt, its employees, contractors and the affiliated Providers. The terms “you” and “yours” refer to the customer, patient and/or parent or guardian using the Platform to request telehealth services from Providers affiliated with Periapt or non-medical services offered by Periapt. Please read each item carefully.
You understand that you should never use the Platform in a medical emergency. You understand that in a medical emergency you should dial 911 or visit an emergency room. Our Services (defined below) are not designed for acute treatment of severe behavioral health issues. In the event you are experiencing severe emotional distress, please contact the National Suicide Prevention Hotline: Crisis Text Line at 1-800-273-8255, text 988, or text “Home” to 741-741, to obtain immediate assistance.
You understand that Periapt provides, through its Providers, education, consultation, and treatment recommendations for children with attention deficit hyperactivity disorder (“ADHD”) through a web-based Platform and that neither Periapt nor the Providers operate a full-service medical practice. Periapt is focused on remotely delivering education, consultation, and treatment recommendations for children with ADHD to both children and their parents/guardians (the “Services”). You understand that Periapt’s Providers and the Services are supported by customer support, technical support, and other individuals who do not provide clinical care, but may provide individuals with additional educational information or other support services related to the use of the Platform. These non-medical services are offered by non-licensed individuals and do not constitute medical advice and are not intended to diagnose, treat, mitigate or cure any health or mental health condition.
In using the Services on the Platform, you understand that you will be provided with your treating Provider’s name and credentials. You understand that state professional licensure laws require that you be seen by a Provider who is licensed to practice in the state where you are located at the time of the Service. When scheduling appointments through the Platform, you will be asked where you will be located at the time of the appointment. You agree that you will accurately report your anticipated location and will update Periapt if your location plans change prior to your appointment. You further understand that you may use the Platform to obtain certain non-medical services provided by non-licensed individuals; these non-medical services will be clearly identified as non-medical.
You understand that by using the Platform to receive Services, you will not have an in-person physical examination that might identify a potentially serious medical condition. You also understand and agree that the health information you provide through the Platform may be the only source of health information used by Providers during the course of your evaluation and treatment through the Platform, and that such Providers may not have access to any other health information held by your previous medical providers (e.g., allergies, previous medical history, previous mental health information, drug reactions, etc.) You understand that you are not guaranteed treatment through the Platform and that a Provider will determine whether it is appropriate to treat you through the Platform. You understand that at any point during the treatment relationship, your Provider may determine that your condition is not appropriate for the Platform and may recommend that you seek additional or alternative treatment through another care provider, including in-person care. You understand that a variety of alternative methods of care may be available to you, and that you may decide to stop using the Services and choose one or more of these alternative models of care at any time. You further understand that by seeking non-medical services through the Platform, you will not be evaluated by a licensed professional and that no medical advice or treatment will be provided to you unless you seek Telehealth Services. Periapt’s non-licensed personnel are not trained nor qualified to identify a medical or mental health condition and Periapt expressly disclaims any obligation by its non-licensed personnel to provide any medical care or other licensed service or to refer you to any licensed person for the provision of such medical or other licensed service.
Any care that you receive from the Providers is based on the information you provide to us. You understand that you need to be responsible for ongoing requests for information from your Provider[s], when indicated. You certify that the information you provide through the Platform for the Services is true, accurate, and complete. You understand that if you knowingly provide false, misleading, or incomplete information to a Provider, it may have a negative effect on your treatment and your health. We reserve the right to terminate your access to the Platform if you knowingly provide incorrect information. You understand that you should ask questions about anything you do not understand. You understand that a Provider is available to answer any questions you may have when receiving Services through the Platform.
Payment and Insurance
The Periapt Services offered through the Platform are currently self-pay only; Periapt does not currently participate with any third party insurance. You accept that you are financially responsible for payment for all Services received by you through the Platform. You further understand that it is your responsibility to arrange and pay for any follow-up care that the Provider recommends you receive. You understand that you may be eligible to receive similar services from another health care provider under your insurance benefits and that by choosing to use the Services, you are agreeing to pay out of pocket for the Services.
Nature of Electronic Services
You understand that the electronic nature of the Services means that there is a greater risk to the privacy of your personal information and electronic health information relative to receiving in-person care and in-person services. You further understand that records of Services provided to you through the Platform may be lost through technical failures and could result in a breach of our confidentiality to you. You understand that information transmitted may not be sufficient (e.g. poor bandwidth) to allow for appropriate medical or health-care decision making by the Provider. You understand that if you are experiencing technical difficulties through the Platform, you may email [email protected]. You understand that technical issues in the Platform may result in a delay in receiving Services. In the event of an issue with connecting to the Platform, the Provider may contact you by phone to continue the Services. You hereby release and hold harmless Periapt from any loss of data or information due to technical failures associated with the Platform.
Consent to Share Information
You understand that under applicable state laws, Providers or other Periapt personnel may be required to report suspicions of child abuse, neglect, statutory rape, domestic violence, and sexual assault. In addition, if your Provider believes that you may be a danger to yourself or others, then your Provider may need to share information with your emergency contact or send care to you by calling 911, other emergency services or initiating a welfare check. You hereby release and hold harmless Periapt and our Providers and other personnel for the good faith compliance with state mandatory reporting laws and good faith reports concerning your care.
Voluntary Nature of Services
You agree that it is your choice whether or not to use the Services on the Platform. You understand that at any time, you can change your mind about receiving Services and may seek alternative in-person services. You understand that you have no obligation to use the Services provided by Periapt through the Providers, and that you are voluntarily consenting to participate in the Periapt Services. If you would like to have the records relating to the Services received through the Platform sent to your primary care provider, you understand that you will need to request transfer of such records. You may obtain copies of your medical records for Services by emailing [email protected]. Periapt will respond to messages as they are received but does not guarantee an immediate response. You understand that there may be some records of your care that may not be available to you if your Provider has a good faith belief that your access to such information may endanger your safety or the safety of another person. Any such determination will be provided to you in writing.
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Periapt makes every effort to comply with applicable state laws and regulations with respect to its Platform. You understand that this Informed Consent is intended to incorporate these additional state protections. After reading the following Informed Consent, you hereby consent to the use of telehealth to examine, consult, diagnose, or treat you. You further agree that to the extent that you use Periapt’s non-medical services, the limitations on such services as described herein and our Terms and Conditions will apply to such non-medical services.
You further acknowledge and agree that:
You are at least eighteen (18) years of age;
You are located in the state you identified during registration at the time of your visit(s);
You have read and understood the information above, including the benefits, risks and limitations of using the Platform for Services;
Our Providers may share your health records with other health care providers and with Periapt for purposes relating to the provision, coordination or management of your healthcare so that we can meet your healthcare needs;
Our Providers may determine that our clinical services are not appropriate for some or all of your treatment needs and may elect not to provide Services to you through the Platform; and
This Informed Consent will become a part of your medical record.
Consent for Services Provided to Minor: By electronically signing this Informed Consent, you hereby swear and declare that you are the parent or legal guardian of the minor you provided the details for earlier and that there are no court orders preventing you from granting this Informed Consent to provide Services to the minor.