Last updated: February, 2022

Terms and Conditions including Informed Consent to Telehealth Services and JASE Medical, LLC Policies

This describes JASE Medical LLC‘s Telehealth treatment and payment policies and includes:

  1. Your consent to receive medical treatment from contracted professional health care providers (and your other rights and responsibilities);
  2. Your agreement to receive services using telehealth technology; and Your agreement to pay in full any charges that are your responsibility.
  3. Your agreement to use the prescribed medications ONLY in the event of an emergency and under the guidance of a qualified healthcare professional.

By clicking “I agree to Terms of Use” on the JASE Medical telehealth portal or health questionnaire, I understand and agree that I am signing this Consent electronically and that (i) I have reviewed, understand and accept the risks and benefits of telehealth services as described below and wish to receive such services, and (ii) I agree to the remaining terms of this Consent, including the terms of the JASE Medical Privacy Notice described below.

If I am signing on behalf of an incapacitated or otherwise legally dependent patient, I certify that I am a person with legal authority to act on behalf of the patient, including the authority to consent to medical services, and I accept full financial responsibility for services rendered.

JASE Medical Telehealth Portal

By using the JASE Medical telehealth portal, I agree to receive telehealth services. Telehealth involves the delivery of health care services, including assessment, treatment, diagnosis, and education, using interactive digital communications. During my visit, my JASE Medical contracted provider and I will be able to communicatewith each other from remote locations.

I understand and agree that:

  1. I will not be in the same location or room as my medical provider. 
  2. My JASE Medical contracted provider is licensed in the state in which I am receiving services. 
  3. I will report my location accurately during registration.

Potential benefits of telehealth (which are not guaranteed or assured) include: (i) access to medical care if I am unable to travel to my JASE Medical’s contracted provider’s office; (ii) more efficient medical evaluation and management; and (iii) during the COVID-19 pandemic, reduced exposure to patients, medical staff and other individuals at a physical location.

Potential risks of telehealth include: (i) limited or no availability of diagnostic laboratory, x-ray, EKG, and other testing, and some prescriptions, to assist my medical provider in diagnosis and treatment; (ii) my provider’s inability to conduct a hands-on physical examination of me and my condition; and (iii) delays in evaluation and treatment due to technical difficulties or interruptions, distortion of diagnostic images or specimens resulting from electronic transmission issues, unauthorized access to my information, or loss of information due to technical failures. 

I will not hold JASE Medical or its contracted health care providers responsible for lost information due to technological failures. 

I consent to the use of potential non-secure forms of communication that may contain sensitive health data.

I further understand that my Provider’s advice, recommendations, and or decisions may be based on factors not within his/her control, including incomplete or inaccurate data provided by me. 

I understand that my provider relies on information provided by me before and during our telehealth encounter and that I must provide information about my medical history, condition(s), and current or previous medical care that is complete and accurate to the best of my ability.

I may discuss these risks and benefits with the provider and will be given an opportunity to ask questions about telehealth services. 

I have the right to withdraw this consent to telehealth services or end the telehealth session at any time without affecting my right to present or future treatment by JASE Medical, LLC or its contracted health care providers.

I understand that the level of care provided by my JASE Medical contracted provider is to be the same level of care that is available to me through an in-person medical visit. However, if my provider believes I would be better served by face-to-face services or another form of care, I will be referred to the nearest medical center, hospital emergency department or other appropriate health care provider.

In case of an emergency, I will dial 911 or go directly to the nearest hospital emergency room.

I consent to, understand, and agree that: I have the right to discuss the risks and benefits of all procedures and courses of treatment proposed by my health care provider(s), together with any available alternatives.

Contracted health care providers will provide care consistent with the prevailing standards of medical practice but make no assurances or guarantees as to the results of treatment.

My JASE Medical contracted provider will not prescribe any controlled substances including opioids to me during a telehealth visit.

Emergency Use of Antibiotics

I agree, if antibiotics or other medications are prescribed as a result of this TELEHEALTH VISIT, that I will use said antibiotics or medications ONLY in an emergency situation, after first seeking to secure the assistance of a qualified health care professional and determining that qualified health care assistance is not readily available.

Further, I will promptly inform the TELEHEALTH PROFESSIONAL of any significant change in my health. 

I understand and agree that these antibiotics and other medications should be stored properly and kept securely out of the reach or access of children.

Any questions relating to the use of the antibiotics or medications should be directed to the TELEHEALTH PROFESSIONAL.

I have the right to review and receive copies of my medical records, including all information obtained during a telehealth interaction, subject to JASE Medical’s standard policies regarding request and receipt of medical records and applicable law.

The laws of the state in which I am located will apply to my receipt of telehealth services.

JASE Medical Notice of Privacy Practices 

(“Privacy Notice”)

JASE Medical will protect the privacy of my health information and will not use or disclose it except as permitted by law. JASE Medical’s privacy policies are more fully described in the Privacy Notice, which is available for review and download here: 

By signing this Consent, I acknowledge receipt of the Privacy Notice and consent to JASE Medical’s use and disclosure of my health information in accordance with its terms. 

I understand that all existing confidentiality protections that apply to in-person treatment apply also to telehealth services.

Liability Waiver

I hereby release and agree to hold harmless the Physician and all Physician assistants and staff from any liability, injury, damages, loss, accidents, delay or irregularity related to or arising out of my storage or use of the antibiotics and other medicines prescribed or issued pursuant to my telehealth encounter with Physician and any subsequent prescriptions and treatment.

Payment Policy

I acknowledge, understand and agree that:

  1. I will pay at the time of service. 
  2. By providing my credit card information and receiving telehealth services, I (i) authorize JASE Medical to charge my credit card for any and all unpaid amounts that JASE Medical determines are my responsibility, and (ii) agree to pay all amounts charged pursuant to this consent and authorization in accordance with the issuing bank cardholder agreement. 
  3. I agree that JASE Medical may charge my credit card for such amounts at the end of my telehealth visit or at a later date.
  4. I will be billed for all unpaid balances deemed by JASE Medical to be my responsibility and agree to pay such amounts in full. 
  5. Delinquent accounts may be turned over to a collection agency at which time I am responsible for a $40 collections charge and all associated legal fees in addition to the amount owed.
  6. JASE Medical reserves the right to deny non-emergency services if my account is delinquent.

I understand that I may access and print a copy of these Terms and Conditions including Informed Consent to Telehealth Services by clicking here:

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