Workit Health Consent For Care
DRUG AND/OR ALCOHOL TESTING
I hereby agree, upon a request made under the drug/alcohol testing policy of Workit Health, to submit to a drug or alcohol test and to furnish a sample of my urine, breath, and/or blood for analysis. I understand and agree that if I at any time refuse to submit to a drug or alcohol test under company policy, or if I otherwise fail to cooperate with the testing procedures, I will be subject to consequences that may include immediate termination from the Workit Health Program. I further authorize and give full permission to have Workit Health and/or its contracted physicians and other qualified medical staff send the specimen or specimens so collected to a laboratory for a screening test for the presence of any prohibited substances under the policy, and for the laboratory or other testing facility to release any and all documentation relating to such test to Workit Health.
I understand that only duly-authorized Workit Health officers, employees, and agents will have access to information furnished or obtained in connection with the test; that they will maintain and protect the confidentiality of such information to the greatest extent possible; and that they will share such information only to the extent necessary to make treatment eligibility decisions.
I will hold harmless Workit Health, its contracted physician and other qualified medical staff, and any testing laboratory Workit Health might use, meaning that I will not sue or hold responsible such parties for any alleged harm to me that might result from such testing, including loss of employment or any other kind of adverse actions that might arise as a result of the drug or alcohol test, even if a Workit Health or laboratory representative makes an error in the administration or analysis of the test or the reporting of the results. I will further hold harmless Workit Health, its contracted physicians and other qualified medical staff, and any testing laboratory Workit Health might use for any alleged harm to me that might result from the release or use of information or documentation relating to the drug or alcohol test, as long as the release or use of the information is within the scope of this policy and the procedures as explained in the paragraph above.
This policy and authorization have been explained to me in a language I understand, and I have been told that if I have any questions about the test or the policy, they will be answered.
I UNDERSTAND THAT WORKIT HEALTH WILL REQUIRE A DRUG SCREEN AND/OR ALCOHOL TESTS UNDER THIS POLICY RANDOMLY AND I AGREE TO SUBMIT TO ANY SUCH TEST.
REGISTRATION; COMPUTER EQUIPMENT AND INTERNET SERVICES; CONSENT TO RECEIVE EMAIL/PHONE COMMUNICATION
As a condition to using the Workit Program, you will be required to register with Company and select a password and screen name (“Company User ID”). You shall provide Company with true, accurate, complete, and current registration information any time you register to use the Workit Program and maintain and update promptly any changes to such information. Failure to do so shall constitute a breach of these Terms, which may result in immediate termination of your account.
You shall not (a) select or use as a Company User ID a name of another person with the intent to impersonate that person; (b) use as a Company User ID a name subject to any rights of a person other than you without appropriate authorization; or (c) use as a Company User ID a name that is otherwise offensive, vulgar or obscene. Company reserves the right to refuse registration of or cancel a Company User ID in its sole discretion. You are solely responsible choosing your Company User ID and for activity that occurs on your account. Additionally, you shall be responsible for setting your account password, as well as maintaining its confidentiality – any sharing, disclosing, permitting access to or otherwise facilitating the use by any person of your username and password is expressly prohibited. You shall never use another user’s account without such other user’s express permission. You will immediately notify Company in writing of any unauthorized use of your password or account or any other security breach of which you become aware.
As a condition of using our Site and/or Mobile App and participating in our Services, you will be required to provide Company with your email address and phone number as part of registration. As part of the Services, you will receive from us email and other communications (e.g., SMS messages, voice calls and push notifications) relating to your use of our Site, the Mobile App and/or your participation in our Services. By disclosing this contact information or otherwise participating in the Services or sending electronic communications through the Services, including the Site or the Mobile App, you acknowledge and agree that we may send you communications through registered mail, email and other electronic communications, SMS messages, voice calls, push notifications or otherwise, that we determine, in our sole discretion, are related to your use of or participation in our Services. As part of using our Services, you agree to receive all agreements, notices, disclosures and other communications that we provide to you in electronic form and acknowledge that receipt of such documents in electronic form satisfies any legal requirement that such communications be in writing. Your consent to receive electronic notices, disclosures and communications includes (i) any notice, record or other type of communication or information that is provided to you in connection with your application, registration or enrollment in the Services, (ii) all communications and disclosures relating to your use of or participation in the Services and (iii) all communications and disclosures relating to the Services that we are required by law or these Terms to provide to you. Any electronic communications that we send you will be deemed to have been provided on the date that we deliver the electronic communication to you.
With the exception of the Services, you are responsible for obtaining, installing, maintaining and operating all software, hardware or other equipment (collectively, “Systems”) necessary for you to access and use the Services, as well as Internet services via the Internet service provider of your choice and any wireless services your require (the “Connections”). This responsibility includes, without limitation, your utilizing current versions of web-browsers and appropriate encryption, antivirus, anti-spyware, and Internet security software. By checking the checkbox affirming your consent to these Terms, you demonstrate that you can access information that we provide to you by posting electronic communications on the Site or via email and otherwise confirm that you are able to access and use the Site and the Services and receive emails from us.
In connection with your use of the Services, you understand and acknowledge the following:
- There are certain security, corruption, transmission error, and access availability risks associated with using open networks such as the Connections, and you hereby expressly assume such risks.
- You are responsible for the data security of the Systems used to access the Services and for the transmission and receipt of information using such Systems.
- You have requested access to the Services, made your own independent assessment of the adequacy of the Connections and Systems, and are satisfied with that assessment.
- We are not responsible for any errors or problems that arise from the malfunction or failure of the Connections or the Systems.
- We may enable the use of geolocation services with our Mobile App. We may use this geolocation information to provide features of the Services and to improve and customize the Services. If you do not want us to use geolocation data from you mobile device, you may set your location preferences on your device accordingly.
WHEN YOU CONTACT US BY EMAIL OR TEXT, WE HAVE NO WAY OF PROTECTING YOUR INFORMATION UNTIL IT REACHES US SINCE EMAIL AND TEXT MESSAGING AND THE COMMUNICATION LINES SUCH COMMUNICATIONS TRAVEL OVER DO NOT HAVE THE SECURITY FEATURES THAT ARE BUILT INTO OUR SERVICES AND MAY NOT BE SECURE. BY SENDING ANY INFORMATION TO US VIA EMAIL OR TEXT, OR AGREEING TO RECEIVE ELECTRONIC COMMUNICATIONS FROM US THROUGH EMAIL OR TEXT, YOU ACKNOWLEDGE AND ACCEPT ANY RISK AND DAMAGE ARISING FROM DISCLOSURE OF SUCH INFORMATION IN THE COURSE OF TRANSMISSION.
TEXT MESSAGING AND EMAIL MESSAGING CONSENT FORM
Workit Health uses text messaging and email services as a way to communicate with patients in a quick and convenient manner. By consenting to receive text and email communications from Workit Health, you (the patient) agree to the following:
Scheduling appointments still rests with me.
Texts or emails are generated using a secure platform. I understand that they are transmitting over a public network onto a personal device that may not be secure.
Workit Health will not transmit any information which would enable an individual patient to be identified.
I agree to advise Workit Health if my mobile number or email changes or if it is no longer in my possession.
Workit Health does not share mobile phone contact details or email addresses with any external organizations.
I CAN I consent to Workit Health contacting me by text message or email.
I acknowledge that text or email communications are an additional service, and that the responsibility of attending or cancel. REVOKE THIS CONSENT AT ANY TIME BY EMAILING CLINIC@WORKITHEALTH.COM.
INFORMED CONSENT FOR TELEMEDICINE SERVICES
Telemedicine is the use of electronic information and communication technologies by a healthcare provider to deliver services to an individual when he/she is located at a different site than the provider.
The information may be used for diagnosis, therapy, follow-up and/or education, and may include any of the following:
- Patient medical records
- Medical images
- Live two-way audio and video
- Output data from medical devices and sound and video files
Electronic systems used 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.
- Improved access to medical care by enabling a patient to remain in location while the physician provides care, obtains test results, and consults with healthcare practitioners from a remote site.
- More efficient medical evaluation and management.
- Obtaining expertise of a distant specialist.
As with any medical procedure, there are potential risks associated with the use of telemedicine. These risks include, but may not be limited to:
• In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision making by the physician and consultant(s);
• Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment;
• In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information;
• In rare cases, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors;
By signing this form, I understand the following:
1. I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine, and that no information obtained in the use of telemedicine which identifies me will be disclosed to researchers or other entities without my consent.
2. I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. The above mentioned people will all maintain confidentiality of the information obtained.
3. I understand that I have the 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 care or treatment. I may revoke my consent orally or in writing at any time by contacting Workit Clinic at email@example.com or 855-659-7734.
4. I understand that I have the right to inspect all information obtained and recorded in the course of a telemedicine interaction, and may receive copies of this information for a reasonable fee.
5. I understand that a variety of alternative methods of medical care may be available to me, and that I may choose one or more of these at any time. My physician has explained the alternatives to my satisfaction.
6. I understand that telemedicine may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas, including out of state.
7. I understand that it is my duty to inform my physician of electronic interactions regarding my care that I may have with other healthcare providers.
8. I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured.
9. I understand that I will be responsible for any payments, copayments, or co-insurances that apply to my telemedicine visits.
Patient Consent To The Use of Telemedicine
I have read and understand the information provided above regarding telemedicine, have discussed it with my physician or such assistants as may be designated, and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of telemedicine in my medical care. As long as this consent is in force (has not been revoked) Diane Hallinen and other health care providers contracted with Workit Health may provide health care services to me via telemedicine without the need for me to sign another consent form.
I hereby authorize Diane Hallinen and other Workit Health contracted medical providers to use telemedicine in the course of my diagnosis and treatment.
MAPS (Michigan Automated Prescription System)
I hereby authorize my Workit physician and qualified medical staff to look up my prescription history in the state of Michigan before my first scheduled appointment and on a weekly basis thereafter if I continue treatment.
Release of Information
I understand that my treatment with Workit Health requires communication between my peer recovery coaches, counselors, and physicians and NP’s. I hereby authorize this communication to take place.