Master Consent Agreement
Effective September 20, 2024
Thank you for your interest in pediatric endocrinology services from EndoMD Health LLC (“EndoMD Health,” “We,” “Us,” or “Our”). This Master Consent Agreement includes the following agreements and consents that will govern the relationship among you, your child, and EndoMD Health:
1- Clinical Services and Practice Policies Agreement
2- Telehealth Informed Consent
3- Consent to Treat a Minor
4- Authorization for Use or Disclosure of Information
5- Financial Agreement
6- Authorization for Communication
“You” means the parent or legal guardian identified below, individually, on behalf of yourself and your child or minor identified below (the “Child”). You consent to be bound to all the terms of the Master Consent Agreement, and acknowledge that You understand them.
1- Clinical Services and Practice Policies
General Information
EndoMD Health provides pediatric telehealth services for children through its engaged clinicians and sub-clinical specialists (the “Clinical Care Team”) and non-clinical support. This Clinical Services and Practices Policies Agreement describes EndoMD Health’s services and clinical programs. It is important for You to read this document and discuss any questions You might have with an EndoMD Health representative.
Our Services and Technology
When Your Child becomes a patient of EndoMD Health, You will be given access to the online platform of EndoMD Health (the “EndoMD Health Platform”) and Our Clinical Care Team. The EndoMD Health Platform 1.) provides personalized content and interactive resources for You, 2. Provides billing information, 3.) serves as Your hub of information, including Your Child’s medical records, and 4.) connects You and/or Your Child to the Clinical Care Team.
Telehealth care is a flexible and convenient way to get healthcare, but it may not be right for treating certain problems or illnesses that need an in-person doctor or urgent care visit. The Clinical Care Team may therefore determine telehealth is not appropriate for Your Child’s treatment and may direct You to Your Child’s primary care physician. EndoMD Health does not provide emergency care or handle medical emergencies.
The Clinical Care Team will be with You and Your Child every step of the way and work collaboratively to support standard, effective care, via telehealth using asynchronous messaging services and store-and-forward technology (the “Telehealth Services”). Telehealth Services do not involve videotaping.
EMERGENCIES
Please note that Endo MD Health is not equipped or designed to handle medical emergencies. If You or Your Child has a medical emergency, or You think either of You or Your Child MIGHT have a medical emergency, please call 911, or go immediately to the nearest emergency room. If You or Your Child experience a mental health crisis or need to speak to someone, please call Suicide Prevent Lifeline at 800-273-TALK (8255) at any time.
SUPPLEMENTAL PRIVACY PRACTICES INFORMATION
Our privacy practices are described in detail in our Notice of Privacy Practices and in our Privacy Policy. Please read those documents, as well as this one, and contact us with any questions you may have.
Because We treat children (see Children’s Online Privacy Protection Act, below) and do so via telemedicine, and because We permit text and email communications (see Text and Email Communications, below), We provide below some supplemental information here to help you better understand how We handle confidential information you entrust to us.
In accordance with applicable law, EndoMD Health uses standard physical, electronic, and business security methods to help prevent access to Your Child’s health information by people who should not see it. Nevertheless, We cannot promise that data sent over the Internet, text, or through a data storage facility will be secure. Thus, EndoMD Health cannot guarantee the security of any information You or Your Child provides to us.
Text and Email Communications
The Clinical Care Team will primarily communicate with You and Your Child, including for clinical, clinical triage, and treatment purposes, via video calls, text messages, and emails. Video calls, text messages, and emails are not always secure because they travel over unencrypted networks that we do not control.
By providing us Your cell phone number and email address, You agree to permit us to communicate with You by text message and email. You may ask to stop such communication by contacting Your Clinical Care Team.
By signing this document, You acknowledge that You may have to pay data costs to receive text messages that We send to Your mobile phone and that You are solely responsible for any such costs, and that such messages may not always be secure.
Children’s Online Privacy Protection Act
As part of the Telehealth Services, EndoMD Health will collect the personal information of Your Child. Your consent is required for the collection, use, and disclosure of Your Child’s information. EndoMD Health will not collect Your Child’s personal information unless You consent. However, if You do not give Your consent, Your Child may not use the Telehealth Services.
The types of personal information We collect directly from Your Child includes:
any information Your Child provides to us during a telehealth appointment, including health related information, or while logged into the account You created for the EndoMD Health Platform if You provide Your Child with Your credentials (We do not currently allow children under age 18 to register directly with us);
information about Your Child’s use of the Telehealth Services and EndoMD Health Platform, including information sent by the mobile device or computer used by You or Your Child (e.g., IP address, unique device identifiers, website usage information, etc.) and information sent by the mobile device(s), and location information.
We use and disclose that personal information:
to provide Our services;
for business analytics purposes;
to obtain reimbursement for Our services;
for Our own marketing purposes;
to provide customer support to You;
for account and network security purposes;
to maintain legal and regulatory compliance; and
to enforce compliance with Our agreements and policies.
You consent to the collection, use, and disclosure of You or Your Child’s information, as described in this Clinical Services and Practice Policies Agreement, Our Privacy Policy, and Our Notice of Privacy Practices. You may revoke this consent at any time. However, once Your consent is revoked, Your Child may not use Our Telehealth Services or the EndoMD Health Platform again unless a new Clinical Services and Practice Policies Agreement is signed by You.
Parental & Guardianship Attestation
To authorize health services for Your Child, You must be his or her parent or legal guardian. If You are separated or divorced (or become separated or divorced) from the other parent or legal guardian of Your Child, You agree to immediately notify the other parent or legal guardian that EndoMD Health is providing Telehealth Services to Your Child, as required by law or court order. If requested, You also agree to provide a copy of the most recent custody decree that establishes Your custody rights or otherwise demonstrates that You have the right to authorize treatment for Your Child. You understand that it is Your responsibility to promptly notify EndoMD Health of any changes concerning You as the parent or legal guardian of Your Child.
One risk of pediatric endocrinology care involves disagreement among parents and/or disagreement between parents and the child’s clinician regarding the child’s treatment. You agree to notify EndoMD Health immediately if such a disagreement occurs. If such disagreements occur, EndoMD Health will strive to listen carefully so that We can understand Your perspectives and fully explain Our perspective. If either parent or legal guardian decides that the Telehealth Services should end, EndoMD Health will endeavor to honor that decision, unless the health of the Child is in jeopardy.
During the treatment, EndoMD Health may meet with Your Child’s parents or legal guardians either separately or together. Please be aware that EndoMD Health’s patient is Your Child – not You, the other parent or legal guardian, or any siblings or other family members of the child. Furthermore, EndoMD Health may disclose any communication by a parent or legal guardian to the other parent or legal guardian. Therefore, a parent or legal guardian should NOT share any information which he or she is not willing to have disclosed to the other parent or legal guardian.
You hereby certify that You have legal authority to authorize EndoMD Health to provide the Telehealth Services to Your Child. You further certify that You are not a party to or otherwise the subject of any agreement or court order that requires the written approval of Your Child’s other parent or any third party to authorize medical treatment or services for Your Child.
Complaint Policy
You and Your Child have the right to communicate grievances regarding care. Should You wish to make a formal complaint about anyone at EndoMD Health, please submit Your concerns in writing to EndoMD Health at [email protected]
Agreement and Consent
If You have questions about any of the contents of this Clinical Services and Practice Policies Agreement, Our procedures, or Your role in this process, please discuss them with the Critical Care Team. Please remember that the best way to ensure quality treatment is to keep communication open and direct with Your Child’s clinicians.
You consent to be bound to the terms of this Clinical Services and Practice Policies Agreement, and acknowledge that You understand them. You further certify that if You are signing as a personal representative of Your Child You have legal authority to provide consent for the treatment of Your Child.
2- Telehealth Informed Consent
You understand that Your Child’s primary care provider, EndoMD Health, wishes Us to provide telehealth consultations with and for Your Child. This means that through an interactive video connection, You and Your Child will be able to consult with EndoMD Health’s medical team about Your Child’s health and wellness concerns. The Clinical Care Team may prescribe Your Child medication or recommend other treatment, as needed
You understand that all existing laws and protections for services received in-person apply to telehealth, including confidentiality of information, access to medical records, and dissemination of identifiable information for You and Your Child. You have a right to know who is attending each telehealth visit and exclude those whom You do not wish to be present. You will have access to all of Your Child’s medical records resulting from these services. You may decide that You do not want to use Telehealth Services at any time. If You do, You will not lose Your health program benefits or Your right to future health care.
You acknowledge that EndoMD Health has explained to You how Telehealth Services work and how to use the EndoMD Health Platform and website for the telehealth consultation and future telehealth sessions.
You understand some of the benefits of a telehealth include:
You and Your Child do not need to travel to the healthcare provider’s location.
You and Your Child will have easier access to a specialist.
You and Your Child can stop using telehealth at any time, even during the telehealth consultation, without compromising access to future care.
To the extent that in-person care entails the risk of exposure to infectious diseases, You and Your Child avoid those risks.
You also understand there are potential risks with telehealth technology, including the following:
The video connection may not work or it may stop working during a session.
The video picture or information transmitted may not be clear enough to be useful.
The Clinical Care Team may not have enough information to make health care decision. The physical examination of Your Child that the healthcare provider can perform, for example, is necessarily more limited than is possible in an in-person setting. To the extent that diagnosis depends on physical exam, this means the chance of a diagnostic error may increase.
There is a risk, potentially greater than with in-person care, that the privacy of Your Child’s health and healthcare information might be compromised.
Obtaining lab work or diagnostic imaging may be more difficult than it is in an in-person setting.
You also understand other individuals may use the EndoMD Platform and website, and that EndoMD Health will take reasonable steps to maintain the confidentiality of the information obtained during the telehealth consultation and future telehealth sessions.
You acknowledge that You have read this Telehealth Informed Consent form and understand the risk and benefits of using telehealth, confirm that all of Your questions regarding the Telehealth Services and EndoMD Health’s Platform have been answered to Your satisfaction in a language You understand, confirm that at the time of signing that You are not under the influence of alcohol or of any other drug or substance that might interfere with Your ability to understand the information presented, and hereby consent to participate and to allow Your Child to participate in the telehealth consultation and future telehealth sessions.
3- Consent to Treat A Minor
If Your Child remains under the age of 18 years while receiving Telehealth Services, it is EndoMD Health’s policy to secure Your consent for medical treatment. By signing this Consent to Treat a Minor form, You are giving Your consent for necessary medical evaluation and treatment to foster the continued health of the Child.
CONSENT FOR TREATMENT OF A MINOR
You hereby agree and give consent to EndoMD Health to provide health and medical care and treatment EndoMD Health considers necessary and proper to Your Child, in diagnosing and/or treating his or her physical and mental condition.
You have the right to refuse any medical treatment or procedure for Your Child, and You may discuss any and all medical treatments or procedures with his or her healthcare provider.
CONSENT FOR THE USE AND DISCLOSURE OF HEALTH INFORMATION
You hereby authorize EndoMD Health to release any information acquired in the course of Your Child's examinations and treatments to any authorized agent for the purposes of treatment, payment, or healthcare operations as permitted or required by law.
CONSENT TO BILL, ASSIGNMENT OF BENEFITS, AND PAYMENT
You agree to allow EndoMD Health to file a claim for insurance benefits to pay for the care that Your Child receives from Us and authorize payment of benefits directly to Us, for services provided to Your Child.
You acknowledge the following:
EndoMD Health will send the medical record information of Your Child to the insurance company to file for insurance benefits for the care provided.
You are responsible for paying any amount for the cost of Telehealth Services that insurance does not cover and for paying the full cost of these services if Your Child does not have eligible insurance coverage.
RISKS OF TREATMENT
You acknowledge that in caring for Your Child, there are always risks, just as there are risks in not treating him or her.
Pediatric Endocrinology Risks:
1. Growth Disorders (e.g., Short Stature, Growth Hormone Deficiency):
Inaccurate Growth Measurement: Reliance on parent-reported height and weight can lead to inaccurate tracking of growth, potentially delaying diagnosis or mismanagement of growth disorders.
Delayed Identification of Physical Signs: Certain physical markers (e.g., physical features of a genetic problem or disproportionate growth) critical for diagnosing growth disorders may be missed or improperly assessed in a virtual environment.
2. Thyroid Disorders (e.g., Hypothyroidism, Hyperthyroidism):
Missed Physical Signs: Key physical signs of thyroid dysfunction, such as enlargement of the thyroid gland, abnormal heart rate, blood pressure or other vital signs, in addition to eye abnormalities in hyperthyroidism, might be overlooked in virtual consultations without a thorough in-person examination.
Delayed Lab Interpretation: In telehealth, delays in obtaining and interpreting lab results (e.g., TSH, free T4) (hormones whose levels help doctors make diagnoses) can slow down the diagnosis and treatment process for thyroid disorders.
3. Obesity and Metabolic Disorders:
Inaccurate BMI (Body Mass Index, an indicator of the degree of overweight or obesity) Calculation: Incorrect measurements of height and weight at home may lead to an inaccurate BMI assessment, impacting diagnosis and management of obesity or related metabolic conditions.
Delayed Identification of Comorbidities: Virtual visits may miss critical signs of obesity-related comorbidities such as insulin resistance (lowered sensitivity to a hormone that controls blood sugar levels), sleep apnea (interruption of normal breathing during sleep), or orthopedic issues that are better detected through a physical exam.
4. Puberty Disorders (e.g., Precocious Puberty, Delayed Puberty):
Missed Physical Maturity Signs: Key pubertal markers like breast development in girls or testicular enlargement in boys can be challenging to assess virtually, leading to potential delays in diagnosing puberty disorders.
Missed Subtle Symptoms: Virtual settings may make it difficult to identify subtle changes in physical appearance or behavior that could signal puberty-related hormonal imbalances.
General Risks:
1. Miscommunication: There is a risk of miscommunication between healthcare providers, parents, and children due to the virtual nature of appointments, which may lead to misinterpretation of symptoms or treatment instructions.
2. Delayed Diagnosis: Virtual consultations can limit the ability to conduct thorough physical examinations, potentially leading to delayed or missed diagnoses of critical conditions like growth disorders, diabetes complications, or thyroid issues.
3. Inaccurate Data: Reliance on patient-provided data (like home glucose monitoring or growth measurements) might result in inaccurate information that can affect treatment decisions.
4. Technology Failures: Technical difficulties such as poor internet connections, software issues, or device malfunctions could disrupt consultations or lead to incomplete medical assessments.
5. Emergency Situations: Virtual settings may be less effective in handling acute endocrine emergencies, such as severe hypoglycemia (dangerously low blood sugar levels) or diabetic ketoacidosis (DKA) (dangerously high blood sugar levels), which require immediate, hands-on medical intervention.
6. Inadequate Monitoring: Continuous monitoring of conditions such as diabetes or growth disorders may be more challenging in a virtual format, potentially leading to complications if symptoms are not caught early.
You consent to be bound to the terms of this Consent to Treat a Minor form, and acknowledge that You understand them.
4- Authorization for Use or Disclosure of Information
Authorization to Inform You About Health-Related Products and Services
By agreeing to this authorization (the “Authorization”), You, as the lawful parent, guardian, conservator, or custodian and on behalf of Your Child, authorize EndoMD Health to share with You information about products and services provided by organizations other than EndoMD Health that may be of interest to You, such as information about health-related products and services offered by other companies, organizations, and health care providers. EndoMD Health will use (but not disclose) Your information, including the information You provide us during or after the registration process and Your treatment of Your Child, to provide You with information about specific products and services for Your Child.
By signing this Authorization, You further understand that:
EndoMD Health may receive compensation relating to the activities and communications described above. EndoMD Health will not, pursuant to this Authorization, share any information with third parties. You have the right to revoke and/or receive a copy of this Authorization at any time by providing written notice to [email protected]. However, a revocation of this Authorization will not affect any prior action taken by EndoMD Health in reliance on this Authorization. This Authorization will remain in force and effect for one year from the date this form is accepted and signed by You, and will automatically renew annually, unless and until You revoke it. Your Child’s treatment and any payment, enrollment, or eligibility for benefits will not be conditioned on whether You provide this Authorization.
You can learn more about EndoMD Health’s privacy policies by viewing our Notice of Privacy Practices, and Privacy Policy.
You consent to be bound to the terms of this Authorization, and You acknowledge that You understand them.
5- Financial Agreement
This Financial Agreement discusses billing, scheduling, and cancellation procedures for EndoMD Health’s Telehealth Services. If You have any questions please ask for clarification before signing this Financial Agreement.
Payment of all fees is expected at the time of service or via a credit card on file. We will assist You in submitting claims to Your insurance carrier. By providing EndoMD Health with Your credit card information, You are authorizing Us to charge Your credit card for agreed upon purchases and save Your credit card information for future transactions on Your account. However, We do not provide services based on the assumption that insurance will cover our charges. It is Patient's responsibility to ensure proper resolution with their insurance and to verify whether our practice is in-network or out-of-network.
It is Your responsibility to check insurance benefits and coverage for Your Child. You will be responsible for any non-covered services, deductibles, co-payments, or co-insurances, as determined by Your insurance carrier. Accounts unpaid by the insurance carrier greater than 90 days will be billed to You. Your medical insurance policy is a contract between You and Your insurance company, and EndoMD Health is not a party to that contract. Therefore, EndoMD Health is not responsible for how Your insurance handles claims.
You hereby authorize payment of medical benefits directly to EndoMD Health for all Telehealth Services rendered to Your Child. No refunds will be issued for any appointments or services. Both members and non-members may reschedule an appointment once as long as the request is made at least 24 hours in advance of the scheduled time. Same-day cancellations or rescheduling are not permitted.
You are responsible for paying a $100 fee for any missed or canceled appointment with EndoMD Health not made at least 24 hours in advance prior to the scheduled appointment time.
If You default on any outstanding balance owed to EndoMD Health, You understand that You will be subject to finance and/or legal fees in addition to the total outstanding balance.
In the case of default, You are responsible for full payment of the balance, interest accrued, and any collection costs and legal fees incurred to collect on Your account.
You are responsible for notifying EndoMD Health of any changes in Your insurance, including but not limited to, change in coverage, change in insurance company address, or a change in Your employment, as soon as possible.
You consent to be bound to the terms of this Financial Agreement, and acknowledge that You understand them.
6- Authorization for Communication
You authorize EndoMD Health, and any of its third-party contractors, to contact you via phone call, text message, and email at the contact information below regarding Your Child’s care. These communications may include information about Your Child’s treatment plan or recommendations, test results, outstanding balances, and other information about your Child’s healthcare. Additionally, you authorize EndoMD Health to leave voice messages on Your phone and/or mobile phone.
You have the right to revoke and/or receive a copy of this Authorization at any time by providing written notice to [email protected].
