Happy Head

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Telehealth Consent

Telehealth involves the use of electronic communications to enable healthcare providers at different locations to share individual patient medical information for the purpose of improving patient care.

Telehealth services offered by Club View Capital dba Happy Head  (“Happy Head”) may also include chart review, remote prescribing, appointment scheduling, health information sharing, and non-clinical services, such as patient education. The information you provide may be used for diagnosis, therapy, follow-up and/or patient education, and may include any combination of the following: (1) health records and test results; (2) images and asynchronous communications; (3) live two-way audio and video; (4) interactive audio with store and forward; and (5) output data from medical devices and sound and video files. The electronic communication systems we use will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

The providers who provide care through Club View Capital dba Happy Head are in addition to, and not a replacement for, your primary care physician. Responsibility for your overall medical care should remain with your local primary care doctor, if you have one, and we strongly encourage you to locate one if you do not.

Expected Benefits:

● Improved access to care by enabling you to remain in your home while the provider consults and obtains test results at distant/other sites

● More efficient care evaluation and management

● Obtaining the expertise of a specialist as appropriate

Possible Risks:

● Delays in evaluation and treatment could occur due to deficiencies or failures of the equipment and technologies.

● In rare events, our provider may determine that the transmitted information is of inadequate

quality, thus necessitating a rescheduled telehealth consult or a meeting with your local primary care doctor.

● In very rare events, security protocols could fail, causing a breach of the privacy of personal

medical information.

● In rare events, a lack of access to complete medical records may result in adverse drug

interactions or allergic reactions or other judgment errors.

If you need to receive follow-up care, assistance in the event of an adverse reaction to the treatment, or in the event of an inability to communicate as a result of a technological or equipment failure, please contact [email protected]

By creating your account, you acknowledge that you understand and agree with the following:

1. I hereby consent to receiving Happy Head’s services via telehealth technologies. I understand that providers who use Happy Head offer telehealth-based medical services, but that these services do not replace the relationship between me and my primary care doctor. I also understand it is up to the Happy Head doctor to determine whether or not my specific clinical needs are appropriate for a telehealth encounter.

2. I understand that federal and state law requires health care providers to protect the privacy and the security of health information. I understand that Happy Head will take steps to make sure that my health information is not seen by anyone who should not see it. I understand that

telehealth may involve electronic communication of my personal medical information to other

health practitioners who may be located in other areas, including out of state.

3. I understand there is a risk of technical failures during the telehealth encounter beyond the

control of Happy Head. I agree to hold harmless Happy Head for delays in evaluation or for

information lost due to such technical failures.

4. I understand that I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time, without affecting my right to future care or treatment. I understand that I may suspend or terminate use of the telehealth services at any time for any reason or for no reason. I understand that if I am experiencing a medical emergency, that I will be directed to dial 9-1-1 immediately and that the Happy Head doctors are not able to connect me directly to any local emergency services.

5. I understand that alternatives to telehealth consultation, such as in-person services are available

to me, and in choosing to participate in a telehealth consultation, I understand that some parts

of the services involving tests may be conducted by individuals at my location, or at a testing

facility, at the direction of the providers (e.g. labs or bloodwork).

6. I understand that I may expect the anticipated benefits from the use of telehealth in my care, but that no results can be guaranteed or assured.

7. I understand that my healthcare information may be shared with other individuals for

scheduling and billing purposes. Persons may be present during the consultation other than the provider Happy Head in order to operate the telehealth technologies. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history/examination that are personally sensitive to me; (2) ask non-medical personnel to leave the telehealth examination; and/or (3) terminate the consultation at any time.

8. I understand that I will not be prescribed any narcotics for pain, nor is there any guarantee that I will be given a prescription at all.

9. I understand that if I participate in a consultation, that I have the right to request a copy of my medical records which will be provided to me at reasonable cost of preparation, shipping and delivery.

10. Location: Club View Capital dba Happy Head 11669 Santa Monica Blvd., Suite 101 Los Angeles Ca 90024

11. Patient location: See registration information

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