Please indicate your approval and understanding before starting your AI Based Telemedicine visit with a Lighthouse Associates, PLLC health care provider.
I ACKNOWLEDGE THAT AI Based Telemedicine visit ARE NOT DESIGNED OR INTENDED OR APPROPRIATE TO ADDRESS SERIOUS, EMERGENCY, OR LIFE-THREATENING MEDICAL CONDITIONS AND SHOULD NOT BE USED IN THOSE CIRCUMSTANCES.
I acknowledge that I will answer questions truthfully and that if I do not understand a question, I will stop using AI Based Telemedicine visit.
I acknowledge that I am in the State of Mississippi at the time I start this AI Based Telemedicine visit.
I understand and acknowledge that my AI Based Telemedicine visit will establish a clinician patient relationship and that my visit information will result in the creation of a medical record of Lighthouse Associates, PLLC.
I will have a chance to discuss and / or refuse the care recommended by my AI Based Telemedicine visit provider. AI Based Telemedicine visit providers cannot promise specific results. To provide this care, my AI Based Telemedicine visit provider will rely on information I provide about my health, including genetic information such as family health history.
I consent to treatment involving the use of electronic communications to enable health care providers at different locations to share my individual patient medical information for diagnosis, therapy, follow-up, and/or education purposes. I consent to forwarding patient identifiable information to a third party as needed to receive telemedicine services. I acknowledge that while telemedicine can be used to provide improved access to medical care, as with any medical procedure, there are potential risks and no results can be guaranteed or assured. These risks include, but are not limited to: technical problems with the information transmission; equipment failures that could result in lost information or delays in treatment; and in very rare instances, breaches of privacy of personal medical information could occur despite security measures taken such as encrypting data, password protections, and implementation of other reliable authentication techniques. I understand that I have a right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future treatment. I also understand that I have a right to access all information resulting from telemedicine services.
I understand that AI Based Telemedicine visit uses electronic medical records, which allow providers using this record to store, update and use my health information when needed at the time I am seeking care. The electronic medical record allows better access to my health information. I acknowledge that any provider who uses the electronic record may access and use my health records as needed to provide treatment (including coordinating my care).
For more information on how your medical information may be used and disclosed and how you can get access to this information, please see the Lighthouse Associates, PLLC notice of privacy policies.
My consent for treatment will remain valid until I revoke (withdraw) it in writing or until the law states it has expired. Any records created prior to this withdrawal of consent will be maintained by AI Based Telemedicine visit for a period defined by Lighthouse Associates, PLLC and/or DDXRX.
I may get help with this process at any time by contacting AI Based Telemedicine visit at (228) 202-7872.
NOTE: You may access your medical record related to the telemedicine visit through your account at any time.
By signing this form, I consent to and authorize the AI Based Telemedicine visit provider to assess and recommend treatment if necessary.