This form describes Smart Doctor’s Telehealth treatment and payment policies and includes:
- Your consent to receive medical treatment from Smart Doctors (and your other rights and
- Your agreement to receive services using telehealth technology; and
- Your agreement to pay in full any charges that are your responsibility.
Doctors Telehealth portal, I understand and agree that I am signing this
Consent electronically and that (i) I have reviewed, understand and accept
the risks and benefits of telehealth services as described below and wish to
receive such services, and (ii) I agree to the remaining terms of this
Consent, including the terms of the Smart DoctorsPrivacy Notice described
If I am signing on behalf of a minor, incapacitated or otherwise legally
dependent patient, I certify that I am a person with legal authority to act on
behalf of the patient, including the authority to consent to medical services,
and I accept financial responsibility for services rendered.
- By using the Smart Doctors Telehealth portal, I agree to receive
telehealth services. Telehealth involves the delivery of health care
services, including assessment, treatment, diagnosis, and
education, using interactive audio, video, and data
communications. During my visit, my Smart Doctors provider and I
will be able to see and speak with each other from remote
I understand and agree that:
- I will not be in the same location or room as my medical
My Smart Doctors provider is licensed in the state in which
I am receiving services. I will report my location accurately
Potential benefits of telehealth (which are not guaranteed
or assured) include: (i) access to medical care if I am
unable to travel to my Smart Doctorsprovider’s office; (ii)
more efficient medical evaluation and management; and
(iii) during the COVID-19 pandemic, reduced exposure to
patients, medical staff and other individuals at a physical
Potential risks of telehealth include: (i) limited or no
availability of diagnostic laboratory, x-ray, EKG, and other
testing, and some prescriptions, to assist my medical
provider in diagnosis and treatment; (ii) my provider’s
inability to conduct a hands-on physical examination of me
and my condition; and (iii) delays in evaluation and
treatment due to technical difficulties or interruptions,
distortion of diagnostic images or specimens resulting from
electronic transmission issues, unauthorized access to my
information, or loss of information due to technical failures.
I will not hold Smart Doctors responsible for lost
information due to technological failures.
I further understand that my Smart Doctors Provider’s
advice, recommendations, and/or decisions may be based
on factors not within his/her control, including incomplete
or inaccurate data provided by me. I understand that my
Smart Doctors provider relies on information provided by
me before and during our telehealth encounter and that I
must provide information about my medical history,
condition(s), and current or previous medical care that is
complete and accurate to the best of my ability.
- I may discuss these risks and benefits with my Smart
Doctors provider and will be given an opportunity to ask
questions about telehealth services. I have the right to
withdraw this consent to telehealth services or end the
telehealth session at any time without affecting my right to
future treatment by Patient First.
I understand that the level of care provided by my Smart
Doctors provider is to be the same level of care that is
available to me through an in-person medical visit.
However, if my provider believes I would be better served
by face-to-face services or another form of care, I will be
referred to the nearest Smart Doctors medical center,
hospital emergency department or other appropriate
health care provider.
I have the right to receive face-to-face medical services at
any time by traveling to a Smart Doctors medical center
that is convenient to me.
In case of an emergency, I will dial 911 or go directly to the
nearest hospital emergency room.
I consent to, understand and agree that:
- I have the right to discuss the risks and benefits of all
procedures and courses of treatment proposed by my
health care provider(s), together with any available
- Smart Doctors will provide care consistent with the
prevailing standards of medical practice but makes no
assurances or guarantees as to the results of treatment.
- Before prescribing any controlled substance to me, Smart
Doctors may review information from the Prescription Drug
Monitoring Program in my state of residence regarding my
prior receipt of controlled substances.
- My Smart Doctors provider will not prescribe opioids,
Schedule 2 controlled substances (including stimulant
medications used to treat attention deficit disorders), or
new prescriptions for benzodiazepines to me during a
- I have the right to review and receive copies of my medical
records, including all information obtained during a
telehealth interaction, subject to Patient First’s standard
policies regarding request and receipt of medical records
and applicable law
- The laws of the state in which I am located will apply to my
receipt of telehealth services.
Smart Doctors Notice of Privacy Practices (“Privacy Notice”)
Smart Doctors will protect the privacy of my health information and will not
use or disclose it except as permitted by law. Patient First’s privacy policies
are more fully described in the Privacy Notice.
By signing this Consent, I acknowledge receipt of the Privacy Notice and
consent to Patient First’s use and disclosure of my health information in
accordance with its terms. I understand that all existing confidentiality
protections that apply to in-person treatment apply to telehealth services.
New Jersey patients only: By signing this consent electronically, I authorize
Smart Doctors to disclose information related to HIV/AIDS for treatment,
payment, health care operations, and other purposes consistent with the
Privacy Notice. I may revoke consent by sending written notice as required
by the Privacy Notice. Revocation will be effective upon receipt, except to
the extent that Smart Doctors has already taken action in reliance on my
I acknowledge, understand and agree that:
- It is my responsibility to determine whether Smart Doctor’s
services are covered by my insurer. I will pay the cost of any
service that is not covered by my health plan for any reason or are
covered but applied to a deductible.
I will pay at time of service any required co-payments,
co-insurance and deductibles, as well as charges for services not
covered by insurance, outstanding balances and delinquent
- I assign to Smart Doctors all health care benefits to which I am
entitled under any insurance policy or benefit plan and authorize
payment of benefits directly to Smart Doctors.
If I have health care benefits, Smart Doctors will submit a claim to
my insurer and allow 60 days for a response. If my insurer does
not respond within 60 days, Smart Doctors will assume that the
visit is not covered and will, to the extent permitted by law, bill me
for the visit charges.
By providing my credit card information and receiving telehealth
services, I (i) authorize Smart Doctors to charge my credit card for
any and all unpaid amounts that Smart Doctors or my insurer
determines are my responsibility, and (ii) agree to pay all amounts
charged pursuant to this consent and authorization in accordance
with the issuing bank cardholder agreement. I agree that Smart
Doctors may charge my credit card for such amounts at the end of
my telehealth visit or at a later date.
I will be billed for all unpaid balances deemed by Smart Doctors or
my insurer to be my responsibility and agree to pay such amounts
in full. Smart Doctors will charge late fees of 1.5% per month on
unpaid balances starting 30 days after the first statement, as well
as a $30 fee for returned checks. Delinquent accounts may be
turned over to a collection agency at which time I am responsible
for a $40 collections charge and all associated legal fees in
addition to the amount owed.
Smart Doctors reserves the right to deny non-emergency services
if my account is delinquent.