Last updated: [•], 2022
Note from Moment Management, Inc. (“Moment”): Moment is not a medical provider. Our goal is to use the Moment website currently located at https://www.momenthealth.co (together with any current or future affiliated mobile application, successor site(s), or any services or materials available therein, collectively the “Site”, “Website”, or “Platform”) to make it as easy to gain direct access to healthcare providers provided by third-party affiliated professional entities for communication, consultations, assessments, pharmacy and laboratory services by using our platform. Providing healthcare through technology is called “telehealth.” Below we outline the potential benefits and risks of telehealth and ask you to consent to its use as part of your Moment experience. We believe the benefits outweigh the risks, however we want you to review this Patient Consent in order to make an informed decision about your care.
In using the Moment Platform, you will be consulting with a licensed healthcare provider (“Provider”) solely via the use of “telehealth.” Telehealth involves the delivery of healthcare services using electronic communications, information technology or other means between a healthcare provider and a patient who are not in the same physical location. Telehealth may be used for diagnosis, treatment, follow-up and/or patient education, and may include, but is not limited to:
- Electronic transmission of medical records, photo images, personal health information, or other data between a patient and a healthcare provider
- Interactions between a patient and healthcare provider via audio, video, and/or data communications
- Use of output data from medical devices, sound, and video files
Provider(s) using Moment will be interacting with you via the use of the Moment Platform. As a result, a substantial portion (if not all) of the medical care and treatment you receive from such Providers on the Moment Platform will be provided via telehealth, and you may not be able to meet with your Provider in the same physical location.
The electronics system used in the Moment Platform will incorporate network and software security protocols to protect the privacy and security of health information and imaging data, and will include measures to safeguard the data to ensure its integrity against intentional or unintentional corruption.
Anticipated benefits: The use of telehealth by Providers through the Moment Platform may have the following benefits:
- Making it easier and more efficient for you to access the medical care for the conditions treated by Providers
- Reducing wait times for diagnosis, treatment, and appropriate prescriptions
- Allowing you to obtain medical care and treatment by Providers at times that are convenient for you
- Avoiding unnecessary travel and allowing you to obtain medical care from the comfort and privacy of your home
- Enabling ongoing care and follow-up communication with your Providers on your terms without travel or missed work
Possible risks: While the use of telehealth may provide numerous benefits, there are also potential risks. These risks include, but may not be limited to, the following:
- The information transmitted to your Provider may not be sufficient to allow for appropriate medical decision-making by the Provider
- The inability of your Provider to conduct certain tests or assess vital signs in-person may in some cases prevent the Provider from providing a diagnosis or treatment or from identifying the need for emergency care
- Your Provider may not be able to provide medical treatment for a particular condition, and you may be required to seek alternative health care or emergency care services
- Delays in medical evaluation or treatment could occur due to unavailability of Providers or the possibility of deficiencies or failures of the technology or electronic equipment used
- In rare instances, security protocols or safeguards could fail, causing a breach of privacy
- Given regulatory requirements in certain jurisdictions, your Providers treatment options, especially pertaining to certain prescriptions, may be limited
- In rare cases, a lack of access to all of your medical records may result in adverse drug interactions or allergic reactions or other judgment errors
BY CONSENTING TO THE FORM, I UNDERSTAND AND AGREE TO THE FOLLOWING:
- All medical care and treatment I receive from Providers using the Moment Platform will be provided using telehealth and my Providers will not be able to provide any medical care and treatment to me via the Platform without the use of telehealth.
- In some cases, I understand that my treating Provider may be a nurse practitioner or physician assistant, and not a physician. By deciding to seek care via the Moment Platform, I consent to treatment by a non-physician Provider if applicable.
- The delivery of healthcare services via telehealth is an evolving field and the use of telehealth in my health care and treatment from Providers may include uses of technology not specifically described in this Patient Consent.
- While the use of telehealth may provide potential benefits to me, as with any medical care service (in-person or using telehealth technology) no such benefits or specific results can be guaranteed. My condition may not be cured or improved, and in some cases, may get worse.
- There are certain risks to me in the use of telehealth, including but not limited to the risks described in the Patient Consent.
- I have the right to withhold or withdraw my consent to the use of telehealth at any time by terminating my use of the Moment platform.
- The use of telehealth involves electronic communication of my personal information to Providers who may be located in other areas, including outside of the state in which I reside.
- My medical information may be shared with additional Providers to facilitate my care and treatment.
- It is my duty to provide each Provider providing services on the Moment Platform all information relevant to my healthcare, including all information regarding care that I may have received or may be receiving from other healthcare providers outside of the Moment Platform.
- My Provider, after assessing my medical condition, may determine in their sole discretion that it is medically appropriate to diagnose and/or treat my condition via telehealth. By continuing to use the Moment Platform, I concur with my Provider’s medical assessment, and agree to receive a diagnosis and/or treatment via telehealth technology.
- My Provider may determine in his or her sole discretion that my condition is not suitable for treatment using the Moment Platform and that I may need to seek medical care and treatment from a specialist or other healthcare provider outside of the Moment Platform.
- My care at Moment is limited to the diagnosis and treatment of the Services offered and related disorders and not for the diagnosis or treatment of any other medical conditions. I understand that the Website is not a substitute for the in-person treatment or advice of my local primary care physician or any other qualified healthcare professional. I understand that I should never delay seeking advice from my local primary care physician or any other health professionals if advised to do so by my Moment healthcare Provider, or if I have any concerns.
- I understand that if I have an emergency health issue of any nature, I should call my local emergency medical number or take such other action as I deem necessary.
- I am fully responsible for payment for all services provided by Providers or through use of the Moment Platform.
BY CONTINUING, I HEREBY:
- Represent that I have read this Patient Consent carefully, and that I understand the benefits and risks of the use of telehealth in the medical care provided to me by Providers using the Moment Platform; and
- Give my informed consent to the use of telehealth by Providers using the Moment platform under the terms described in this Patient Consent.