UPSCRIPT HEALTH

Parent of Minor/Guardianship Patient Informed Consent to Telehealth Services and UpScriptSickleCell Health Policies

This form describes UpScriptSickleCell Telehealth treatment and payment policies for minor and/or incapacitated patients and includes:

• Your consent on behalf of the patient to receive medical treatment from Upscript;
• Your agreement on behalf of the patient to receive services using telehealth technology;
• Your agreement to pay in full any charges that are your responsibility; and
• Your agreement to upload a copy of your driver’s license or state identification card

By signing and clicking “I agree to Terms of Use” on the UpScriptSickleCell website, I

1. Understand and agree that I am signing this consent electronically;
2. 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 accept financial responsibility;
3. Certify I have reviewed, understand and accept the risks and benefits of telehealth services;
4. Agree to the remaining terms of this Consent; including terms of the UpScriptSickleCell Privacy Notice described below.
   • By using UpScriptSickleCell I agree for my child to receive telehealth services. Telehealth involves the delivery of health care services, including assessment, treatment, and diagnosis using interactive audio, video, and data communications. During my visit, my UpScriptSickleCell provider and I will be able to see and speak with each other from remote locations.
   • I agree to follow telehealth policies applicable to minor patients:
     • I will remain with the patient and available to the provider during the entire visit. If I am not present and/or available, I understand that the visit may not be completed;
     • I understand that UpScriptSickleCell does not provide telehealth services to patients under the age of 5 and certify that the patient is 5 years old or older; and
     • I will provide a valid email address for post-visit communications.
   • I understand and agree that:
     • I will not be in the same location or room as my medical provider.
     • My UpScriptSickleCell provider is licensed in the state in which my minor child is receiving services. I will report my location accurately during registration.
     • I further understand that the UpScriptSickleCell health provider 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 the UpScriptSickleCell provider relies on information provided by me before and during the telehealth virtual visit and that I must provide information about my minor child’s medical history, conditions, and current or previous medical care that is complete and accurate to the best of my ability.
     • I understand that the level of care provided by the UpScriptSickleCell provider is to be a similar level of care that is available through an in-person medical visit. If my provider believes my minor child would be better served by in person care or another form of care, I will be referred to my primary care physician, hospital, or other appropriate health care provider.
     • 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 treatments proposed by my health care provider(s).
     • UpScriptSickleCell will provide care consistent with the prevailing standards of medical practice but makes no assurances as to the result of treatment.

UpScriptSickleCell Notice of Privacy Practices (Privacy Notices)

UpScriptSickleCell will protect the privacy of my health information and will not disclose it except as permitted by law. UpScriptSickleCell Privacy Notice, is available for review and download here: https://www.upscriptsicklecell.com/privacy-policy/

I consent to, understand, and agree to UpScriptSickleCell Agreement of Self Payment Services which can be found here: https://www.upscriptsicklecell.com/self-payment-of-services/

Click here to download a copy of this document in PDF format.