PWNHEALTH WILL NOT PROVIDE ANY SERVICES FOR MEDICAL EMERGENCIES OR URGENT SITUATIONS. IF YOU ARE EXPERIENCING A MEDICAL EMERGENCY, CALL YOUR DOCTOR OR 911 IMMEDIATELY.
YOU SHOULD CONTACT YOUR HEALTHCARE PROVIDER IF YOUR SYMPTOMS GET WORSE OR YOU EXPERIENCE ANY NEW SYMPTOMS.
BY CLICKING “I ACCEPT,” YOU ACKNOWLEDGE THAT YOU HAVE READ, ACCEPTED, AND AGREED TO BE BOUND BY THIS INFORMED CONSENT. IF YOU DO NOT CLICK “I ACCEPT”, YOU WILL NOT BE ABLE TO USE OR RECEIVE THE SERVICES.
I agree to receive the services provided by PWNHealth, LLC (the administrative services provider of the professional entities), PWN Remote Care Services, PW Medical Professional and certain other affiliated professional entities (collectively, “PWNHealth”, “we” or “us”) relating to physician oversight of testing for COVID-19 or Antibody (“Tests”), including, without limitation, evaluation of the test request, ordering of Tests (if appropriate), receipt of Test results (“Results”), consultations via telemedicine with physicians or healthcare providers (“Consults”), customer support and any other related services provided by PWN or its service providers and partners (the “PWNHealth Services”). All clinical services, including services provided by physicians, will be provided through PWN Remote Care Services, PW Medical Professional or their contractually affiliated professional entities.
Throughout this Informed Consent, “you”, “your”, and “I” refer to the person whose information and sample is being provided for this Test and who will receive the PWNHealth Services, unless otherwise expressly provided. If you are a parent or guardian requesting a Test and PWNHealth Services for a minor, “you” will refer to “your child”, as the context requires.
I acknowledge and agree to the following:
- I am the individual who will provide the sample for the Test(s) that I am requesting or I am the parent or legal guardian of a minor who is providing the sample for testing.
- I am at least eighteen (18) years of age or I am the parent or legal guardian of a minor who is providing the sample for testing.
- I have read and understand the information provided about the Test(s) that I have been provided on the website where I requested the Test. Additional information is also available at the CDC website https://www.cdc.gov/coronavirus/2019-ncov/index.html.
- The information I have provided in connection with the PWNHealth Services is correct to the best of my knowledge. I will not hold PWNHealth or its health care providers responsible for any errors or omissions that I may have made in providing such information.
- My health information and results may be shared with other PWNHealth health care providers, including physicians, and counselors for purposes of providing care to me.
- The PWNHealth Services do not constitute treatment of any condition, disease or illness.
- While PWNHealth and the laboratories implement safeguards to avoid errors, as with all laboratory tests, there is a chance of a false positive or false negative result.
- I am responsible for checking my email for results notification and logging on to my account to view my results when available.
- If I receive an abnormal result on a COVID-19 PCR Test, I understand that a PWNHealth care coordinator will attempt to call me to review the results, offer education and explain the next steps I should take. The PWNHealth care coordinator may leave me a voicemail but will not include my test results in any voicemail message. If I receive an abnormal result and have not connected with a PWNHealth care coordinator, I understand that I should not delay following up with my personal physician. I also understand that if I am not able to be reached, PWNHealth’s Care Coordination Team will mail a follow-up letter to the residential address I provided when I requested my Test (the letter will not include my Test Results). I understand that I will not receive an alert call for any results of an Antibody Test.
- I understand that after receiving my Results, I will have the opportunity for a telemedicine Consult with a PWNHealth physician or other licensed healthcare provider to answer any questions I may have.
- I certify that throughout the duration of the PWNHealth Services I receive, including my Consult, I will be physically present in the state of residence I provided or other state of which I have notified PWNHealth.
- I am responsible for forwarding any results to my primary care or other personal physician (or, if I am the parent or legal guardian of a minor who is providing the sample for testing, the minor’s pediatrician) and for initiating follow up with such physician for care, diagnosis or medical treatment.
- I will not make medical decisions without consulting a healthcare provider or disregard medical advice from my healthcare provider or delay seeking such advice based on information as a result of the use of the PWNHealth Services.
- If I receive an abnormal result, my name, result and additional required information may be disclosed to my state, local and/or federal health agency in accordance with applicable law.
I understand that PWNHealth Services, including Consults, are delivered by health care providers who are not in the same physical location as I am using electronic communications, information technology or other means, including the electronic transmission of personal health information. I also understand that:
- A PWN physician will determine whether or not Test(s) and PWNHealth Services are appropriate for me.
- For Consults, the scope of services will be at the sole discretion of the healthcare provider conducting the Consult, with no treatment or prescription. The healthcare provider will determine whether or not the PWNHealth Services being rendered are appropriate for a telehealth encounter.
- I have the right to withdraw my consent to the use of telehealth in the course of my care at any time by emailing the PWNHealth’s Care Coordination Team at email@example.com.
- Any video feed from the Consult will not be retained or recorded by PWNHealth.
- I may need to see a health care provider in-person for diagnosis, treatment and care.
- There are potential risks associated with the use of technology, including disruptions, loss of data and technical difficulties.
- There are alternative services, such as visiting a primary care provider, an emergency room, or an urgent care facility; however, I chose to proceed with the PWNHealth Services at this time.
I understand that if I have any questions before or after my Test, I can email firstname.lastname@example.org and I will be connected or directed to a member of the PWNHealth Care Coordination Team, including a physician, if requested or as otherwise applicable.
I authorize PWNHealth to use the email address and phone number I provided at the time I requested the Test (or that I updated by contacting PWN at the email below) to contact me in connection with the PWNHealth Services, including followup after a Consult. I am responsible for contacting PWN at the email address below to notify them of any changes to my mailing address, email address, phone number or other information that I provided in connection with the PWNHealth Services.
I understand that testing is voluntary and that I may withdraw my consent to testing at any time prior to the completion of the Test(s) by contacting PWNHealth’s Care Coordination Team by emailing email@example.com.
I specifically authorize the transfer and release of my information as described herein and in the PWNHealth Notice of Privacy Practices, including my medical history that I provided, my Test Results and other identifiable health information, submitted by me or about me in connection with the PWNHealth Services, to, between and among myself and the following individuals, organizations and their representatives: (a) the company from whom I requested the Test and its affiliates, their staff and agents; (b) PWNHealth and its affiliates, and their staff, agents, and health care providers, including physicians, and (c) the laboratory conducting the laboratory testing services, to facilitate and execute the PWNHealth Services requested by me or performed with my consent and as required or permitted by law.
I understand that I have a right to receive a copy of the above data disclosure authorization. I have the right to refuse to agree to this authorization in which case my refusal may affect the PWNHealth Services provided to me. When my information is used or disclosed pursuant to this authorization, it may be subject to re-disclosure by the recipient and may no longer be protected by privacy laws. I have the right to revoke this authorization in writing at any time, except that the revocation will not apply to any information already disclosed by the parties referenced in this authorization. This authorization will expire ten (10) years from the date of signature. My written revocation must be submitted to PWNHealth’s General Counsel at:
PWN Remote Care Services
c/o PWNHealth, LLC
Attn: General Counsel
123 West 18th Street, 8th Floor
New York, NY 10011