TELEHEALTH CONSENT
Effective Date: 03/01/2025
1. INTRODUCTION
This Telehealth Consent Form (“Consent”) outlines the terms and conditions for receiving telehealth services from DrGmed, Inc through GloriaONeill.com. Telehealth allows healthcare providers to evaluate, diagnose, and treat patients remotely using electronic communication.
By signing or electronically agreeing to this Consent, you acknowledge that you have read, understood, and agree to the terms outlined below.
2. NATURE OF TELEHEALTH SERVICES
Telehealth services involve the use of video conferencing, audio calls, electronic messaging, and other remote communication technologies to provide service. These services may include but are not limited to:
• Evaluations, diagnosis, and treatment recommendations
• Management, including Medication-Assisted Treatment (MAT)
• Follow-up visits and care coordination
• Behavioral health and psychiatric consultations
• Patient education and self-management support
3. RISKS & BENEFITS OF TELEHEALTH
Potential Benefits:
•Increased access to healthcare providers without requiring travel.
•Convenience of receiving medical care from home or other private locations.
•Continuity of care with healthcare providers for ongoing treatment.
Potential Risks:
•Technology limitations (e.g., poor internet connection, dropped calls) that may impact quality of care.
•Incomplete assessment due to the inability to perform a full physical examination.
•Security risks inherent in electronic communication, though efforts are made to ensure confidentiality.
4. PATIENT RESPONSIBILITIES
By agreeing to telehealth services, you understand and acknowledge that:
•You must be physically located in the state of New Mexico at the time of the telehealth consultation.
•You must provide accurate and complete information about your medical history and symptoms.
•You must use a secure, private environment for your telehealth session to protect your privacy.
•You must have access to a stable internet connection and compatible device (computer, tablet, or smartphone).
• You must comply with treatment recommendations and follow-up care instructions.
5. CONFIDENTIALITY & PRIVACY
•Telehealth services are HIPAA-compliant and all protected health information (PHI) will be kept confidential.
• Your telehealth session may be documented and stored in your medical record.
•Electronic communications (emails, texts, or chat messages) should not be used for urgent medical concerns.
•DrGmed, Inc will not record or share your telehealth sessions without your written consent.
6. PRESCRIPTIONS & MEDICATION MANAGEMENT
• Prescriptions, including controlled substances, will only be issued after a provider has conducted a full assessment.
•Controlled substances will only be prescribed in compliance with DEA and state regulations.
•If an in-person evaluation is required by law, you may need to schedule an in-person visit before receiving a prescription.
7. TELEHEALTH APPOINTMENTS & CANCELLATION POLICY
•Appointments must be scheduled in advance unless otherwise specified.
•If you need to cancel or reschedule, you must provide at least 24 hours’ notice.
•Missed appointments without prior notice may result in a cancellation.
8. EMERGENCY SITUATIONS
• Telehealth is not intended for medical emergencies.
•If you experience a medical emergency, call 911 or go to the nearest emergency room.
•Your telehealth provider may refer you to in-person care if your condition requires a physical examination or other intervention.
9. CONSENT TO TREATMENT
By navigating this website and its consent, you understand and agree that:
•You voluntarily consent to receive telehealth services from a licensed provider affiliated with DrGmed, Inc.
•You understand that you may withdraw consent at any time by notifying your provider in writing.
•You acknowledge that telehealth is an alternative to in-person care and accept its limitations.
•You have had the opportunity to ask questions and receive answers regarding this Consent.
10. CONTACT INFORMATION
For any questions or concerns regarding telehealth services, please contact:
DrGmed, Inc
400 Gold Ave SW, Albuquerque, NM 87102
Simms Building (Office # 1060)
Phone: (505) 601-5662
—
Gloria O’Neill
DNP, APRN, FNP, PMHNP-BC
TELEHEALTH CONSENT
Effective Date: 03/01/2025
1. INTRODUCTION
This Telehealth Consent Form (“Consent”) outlines the terms and conditions for receiving telehealth services from DrGmed, Inc through GloriaONeill.com. Telehealth allows healthcare providers to evaluate, diagnose, and treat patients remotely using electronic communication.
By signing or electronically agreeing to this Consent, you acknowledge that you have read, understood, and agree to the terms outlined below.
2. NATURE OF TELEHEALTH SERVICES
Telehealth services involve the use of video conferencing, audio calls, electronic messaging, and other remote communication technologies to provide service. These services may include but are not limited to:
• Evaluations, diagnosis, and treatment recommendations
• Management, including Medication-Assisted Treatment (MAT)
• Follow-up visits and care coordination
• Behavioral health and psychiatric consultations
• Patient education and self-management support
3. RISKS & BENEFITS OF TELEHEALTH
Potential Benefits:
•Increased access to healthcare providers without requiring travel.
•Convenience of receiving medical care from home or other private locations.
•Continuity of care with healthcare providers for ongoing treatment.
Potential Risks:
•Technology limitations (e.g., poor internet connection, dropped calls) that may impact quality of care.
•Incomplete assessment due to the inability to perform a full physical examination.
•Security risks inherent in electronic communication, though efforts are made to ensure confidentiality.
4. PATIENT RESPONSIBILITIES
By agreeing to telehealth services, you understand and acknowledge that:
•You must be physically located in the state of New Mexico at the time of the telehealth consultation.
•You must provide accurate and complete information about your medical history and symptoms.
•You must use a secure, private environment for your telehealth session to protect your privacy.
•You must have access to a stable internet connection and compatible device (computer, tablet, or smartphone).
• You must comply with treatment recommendations and follow-up care instructions.
5. CONFIDENTIALITY & PRIVACY
•Telehealth services are HIPAA-compliant and all protected health information (PHI) will be kept confidential.
• Your telehealth session may be documented and stored in your medical record.
•Electronic communications (emails, texts, or chat messages) should not be used for urgent medical concerns.
•DrGmed, Inc will not record or share your telehealth sessions without your written consent.
6. PRESCRIPTIONS & MEDICATION MANAGEMENT
• Prescriptions, including controlled substances, will only be issued after a provider has conducted a full assessment.
•Controlled substances will only be prescribed in compliance with DEA and state regulations.
•If an in-person evaluation is required by law, you may need to schedule an in-person visit before receiving a prescription.
7. TELEHEALTH APPOINTMENTS & CANCELLATION POLICY
•Appointments must be scheduled in advance unless otherwise specified.
•If you need to cancel or reschedule, you must provide at least 24 hours’ notice.
•Missed appointments without prior notice may result in a cancellation.
8. EMERGENCY SITUATIONS
• Telehealth is not intended for medical emergencies.
•If you experience a medical emergency, call 911 or go to the nearest emergency room.
•Your telehealth provider may refer you to in-person care if your condition requires a physical examination or other intervention.
9. CONSENT TO TREATMENT
By navigating this website and its consent, you understand and agree that:
•You voluntarily consent to receive telehealth services from a licensed provider affiliated with DrGmed, Inc.
•You understand that you may withdraw consent at any time by notifying your provider in writing.
•You acknowledge that telehealth is an alternative to in-person care and accept its limitations.
•You have had the opportunity to ask questions and receive answers regarding this Consent.
10. CONTACT INFORMATION
For any questions or concerns regarding telehealth services, please contact:
DrGmed, Inc
400 Gold Ave SW, Albuquerque, NM 87102
Simms Building (Office # 1060)
Phone: (505) 601-5662
—
Gloria O’Neill
DNP, APRN, FNP, PMHNP-BC