Last Modified: March 4, 2022
MyOwnDoctor, LLC
AUTHORIZATION AND CONSENT FOR ENROLLED PROGRAMS
(Care Coordination and Remote Patient Monitoring) I understand that MYOWNDOCTOR, LLC (“MOD”) offers certain care coordination and remote patient monitoring services in connection with access to and use of MOD Products (as defined in the MOD Terms and Conditions), including any services, features, functionality, resources, materials, and information offered by MOD, and any third-party monitoring hardware (i.e., Medical Devices (as defined in the MOD Terms and Conditions) used or obtained, in connection with the Products (collectively, the “Services”).
I understand that I, or the individual on whose behalf I am legally authorized to give consent (as applicable, “User”), may be eligible for enrollment in the Care Coordination Program (“CC Program”) and/or Remote Patient Monitoring Program (“RPM Program”, and together with the CC Program, the “Programs”) and to receive certain care coordination services (“CC Services”) and/or remote patient monitoring services (“RPM Services”) (as applicable) in connection with User’s enrollment in one or both Program(s) (as applicable) as further described below.
I understand that the CC Program and CC Services are designed to assist User and User’s healthcare providers in understanding User’s health needs and preferences through management and organization of the Healthcare Services (as defined below) that User may receive from User’s healthcare providers. I further understand that Users enrolled in the CC Program will be assigned and have access to a care coordination team to address User’s medical and/or mental and behavioral health conditions (as applicable).
I understand that the RPM Program and RPM Services are designed to help User’s healthcare providers monitor User’s health on an on-going basis. I further understand that RPM services include collection of User’s health data (e.g. your blood pressure) outside of a health care facility via one or more Medical Device(s) that sends User’s health data directly to User’s healthcare provider, allowing User’s healthcare provider to better monitor User’s health without requiring User to visit a health facility as often.
I understand that if User is eligible to enroll in one or both Program(s) (as applicable) and elects to receive CC Services and/or RPM Services (as applicable) in connection with User’s access to or use of the Products and Services, User may enroll in one or both Program(s) (as applicable) and receive CC Services and/or RPM Services (as applicable) following the creation of a User Account (as defined in the MOD Terms and Conditions.
I understand that, if User is eligible to receive CC Services and/or RPM Services (as applicable) and chooses to enroll in one or both Program(s), I have the right to withdraw my authorization for User’s enrollment in the CC Program and/or RPM Program at any time and that I may do so by calling (773) 395-1829 and/or sending an email to compliance@myowndoctor.com. I further understand that if I withdraw my authorization for User’s enrollment in the CC Program and/or RPM Program (as applicable), User will not receive any CC Services and/or RPM Services (as applicable).
I understand that if I withdraw my authorization for User’s enrollment in the CC Program and/or RPM Program (as applicable), User will still have access to and be able to use the Products and Services offered by MOD for which User may be eligible other than CC Services and/or RPM Services (as applicable).
I understand that if User is enrolled in one or both Program(s) (as applicable), I have the right to revoke my consent for User to receive CC Services and/or RPM Services (as applicable) in connection with User’s enrollment in the applicable Program(s) at any time and that I may do so by calling (773) 395-1829 and/or sending an email to compliance@myowndoctor.com. I further understand that if I revoke my consent for User to receive CC Services and/or RPM Services (as applicable) following User’s enrollment in one or both Program(s) (as applicable), that User will no longer receive any CC Services and/or RPM Services (as applicable).
I understand that if I revoke my consent for User to receive CC Services and/or RPM Services (as applicable) in connection with User’s enrollment in one or both Program(s) (as applicable), that such revocation of my consent will not affect User’s ability to access and use other MOD Products and Services for which User may be eligible, other than CC Services and/or RPM Services (as applicable). I understand that, if User is eligible to enroll in one or both Program(s) (as applicable) and I withdraw my authorization for User’s enrollment in the CC Program and/or RPM Program (as applicable) and/or if I revoke my consent for User to receive CC Services and/or RPM Services (as applicable) in connection with User’s enrollment in one or both Program(s) (as applicable), such withdrawal of my authorization for User’s enrollment in one or both Program(s) (as applicable) and/or revocation of my consent for User to receive CC Services and/or RPM Services (as applicable) will not affect User’s eligibility (as applicable) to later enroll in the CC Program and/or RPM Program (as applicable) and to receive CC Services and/or RPM Services (as applicable) in connection with such future enrollment of User in one or both Program(s) (as applicable). I understand that the information I elect to provide and/or MOD collects in connection with User’s access to and/or use of the Products and Services, including User’s enrollment in one or more Program(s) (as applicable) and/or User’s receipt of CC Services and/or RPM Services (as applicable), and which shall specifically include (as applicable) personal health data collected from any Medical Device used in connection with User’s receipt of the RPM Services, may contain sensitive personal information, including protected health information of User (collectively, “Personal Information”). I further understand that MOD’s use and disclosure of User’s Personal Information is governed by and subject to MOD’s Privacy Policy.
I understand that User’s Personal Information will be considered part of User’s medical record and that User’s Personal Information will be shared with User’s healthcare providers in connection with User’s receipt of the CC Services and/or RPM Services (as applicable).
I understand that MOD is not a healthcare provider or a manufacturer of Medical Devices and does not offer or provide any kind of medical advice, health insurance, or other professional healthcare service, including without limitation, any counseling, testing, medication, procedure, or therapy related to the prevention, diagnosis, or treatment of any acute or chronic illness, disease, or condition (collectively, “Healthcare Services”). I further understand that the role of MOD is limited to providing the Products and Services, including the CC Services and RPM Services, as an intermediary between User and healthcare providers and, as a result, MOD has no control over the appropriateness, accuracy, quality, timeliness, scope, price, or risks of or associated with any Healthcare Services provided to User by any healthcare provider or with any Medical Devices used or obtained in connection with User’s receipt of the RPM Services (if applicable).
I understand that the MOD Products and Services, including the CC Services and RPM Services, are not a substitute for professional Healthcare Services. I further understand that User must always seek the advice of User’s physician or other qualified healthcare provider with questions regarding any medical condition, or call 911 in an emergency.
I understand that User’s enrollment and participation in one or both of the Program(s) (as applicable) and User’s access to and use of any Products and Services, including User’s receipt of CC Services and/or RPM Services (as applicable) is governed by and subject to the MOD Terms and Conditions. I further understand that MOD and its affiliates reserve the right to discontinue operation of and/or User’s enrollment in one or both Program(s) at any time and for any reason. I understand that MOD and its affiliates further reserve the right to discontinue the performance of the CC Services and/or RPM Services (as applicable) at any time and for any reason, and that in such event User will need to seek care coordination and/or remote patient monitoring services (as applicable) elsewhere.
THIS AUTHORIZATION BECOMES EFFECTIVE WHEN YOU CHECK THE BOX TO ACCEPT OR AGREE TO THE TERMS OF THIS AUTHORIZATION WHEN THIS OPTION IS MADE AVAILABLE TO YOU OR BY ENROLLING IN ONE OR BOTH OF THE PROGRAM(S) AND SHALL REMAIN IN FULL FORCE AND EFFECT UNTIL YOU WITHDRAW AUTHORIZATION FOR ENROLLMENT OF USER IN ALL OF THE PROGRAMS OR YOU REVOKE YOUR CONSENT FOR USER’S RECEIPT OF ALL OF THE CC SERVICES AND RPM SERVICES (WHICHEVER OCCURS FIRST).
BY CHECKING THE BOX TO ACCEPT OR AGREE TO THE TERMS OF THIS AUTHORIZATION WHEN THIS OPTION IS MADE AVAILABLE TO YOU OR BY ENROLLING IN ONE OR BOTH OF THE PROGRAM(S) YOU: (A) ACKNOWLEDGE THAT YOU HAVE READ THIS AUTHORIZATION COMPLETELY AND UNDERSTAND ALL OF ITS PROVISIONS; (B) REPRESENT AND WARRANT THAT: (1) YOU HAVE REACHED THE AGE OF MAJORITY, YOU ARE OF SOUND MIND, YOUR JUDGMENT IS NOT IMPAIRED, YOU AND USER (IF DIFFERENT THAN YOU) HAVE THE NECESSARY KNOWLEDGE AND SKILLS TO BENEFIT FROM ENROLLMENT IN THE PROGRAM(S) FOR WHICH YOU OR USER (IF DIFFERENT THAN YOU) ARE ELIGIBLE AND YOUR OR USER’S (IF DIFFERENT THAT YOU) RECEIPT OF CC SERVICES AND/OR RPM SERVICES (AS APPLICABLE), AND YOU ARE ENTERING INTO THIS AUTHORIZATION FREELY, AND HAVE HAD YOUR QUESTIONS REGARDING ENROLLMENT IN THE PROGRAM(S) AND RECEIPT OF CC SERVICES AND/OR RPM SERVICES (AS APPLICABLE) ANSWERED TO YOUR SATISFACTION; (2) YOU HAVE THE RIGHT, POWER AND AUTHORITY TO ENTER INTO THIS AUTHORIZATION; AND (3) IF THE USER IS NOT YOU, THAT YOU ARE THE PARENT OR LEGAL GUARDIAN OF USER, WHO IS YOUR MINOR CHILD AND/OR WARD, THAT YOU HAVE THE LEGAL AUTHORITY TO ENTER INTO THIS AUTHORIZATION FOR AND ON BEHALF OF USER, AND THAT YOU HEREBY AUTHORIZE AND GIVE YOUR CONSENT FOR USER TO BE ENROLLED IN THE PROGRAM(S) FOR WHICH USER IS ELIGIBLE AND FOR USER TO RECEIVE THE CC SERVICES AND/OR RPM SERVICES (AS APPLICABLE) IN CONNECTION WITH USER’S ENROLLMENT IN ONE OR BOTH OF THE PROGRAM(S) (AS APPLICABLE); AND (C) ACCEPT THIS AUTHORIZATION AND AGREE THAT YOU AND USER (IF DIFFERENT THAN YOU) ARE LEGALLY BOUND BY ALL OF ITS PROVISIONS.
MyOwnDoctor, LLC
AUTHORIZATION AND CONSENT FOR ENROLLED PROGRAMS
(Care Coordination and Remote Patient Monitoring) I understand that MYOWNDOCTOR, LLC (“MOD”) offers certain care coordination and remote patient monitoring services in connection with access to and use of MOD Products (as defined in the MOD Terms and Conditions), including any services, features, functionality, resources, materials, and information offered by MOD, and any third-party monitoring hardware (i.e., Medical Devices (as defined in the MOD Terms and Conditions) used or obtained, in connection with the Products (collectively, the “Services”).
I understand that I, or the individual on whose behalf I am legally authorized to give consent (as applicable, “User”), may be eligible for enrollment in the Care Coordination Program (“CC Program”) and/or Remote Patient Monitoring Program (“RPM Program”, and together with the CC Program, the “Programs”) and to receive certain care coordination services (“CC Services”) and/or remote patient monitoring services (“RPM Services”) (as applicable) in connection with User’s enrollment in one or both Program(s) (as applicable) as further described below.
I understand that the CC Program and CC Services are designed to assist User and User’s healthcare providers in understanding User’s health needs and preferences through management and organization of the Healthcare Services (as defined below) that User may receive from User’s healthcare providers. I further understand that Users enrolled in the CC Program will be assigned and have access to a care coordination team to address User’s medical and/or mental and behavioral health conditions (as applicable).
I understand that the RPM Program and RPM Services are designed to help User’s healthcare providers monitor User’s health on an on-going basis. I further understand that RPM services include collection of User’s health data (e.g. your blood pressure) outside of a health care facility via one or more Medical Device(s) that sends User’s health data directly to User’s healthcare provider, allowing User’s healthcare provider to better monitor User’s health without requiring User to visit a health facility as often.
I understand that if User is eligible to enroll in one or both Program(s) (as applicable) and elects to receive CC Services and/or RPM Services (as applicable) in connection with User’s access to or use of the Products and Services, User may enroll in one or both Program(s) (as applicable) and receive CC Services and/or RPM Services (as applicable) following the creation of a User Account (as defined in the MOD Terms and Conditions.
I understand that, if User is eligible to receive CC Services and/or RPM Services (as applicable) and chooses to enroll in one or both Program(s), I have the right to withdraw my authorization for User’s enrollment in the CC Program and/or RPM Program at any time and that I may do so by calling (773) 395-1829 and/or sending an email to compliance@myowndoctor.com. I further understand that if I withdraw my authorization for User’s enrollment in the CC Program and/or RPM Program (as applicable), User will not receive any CC Services and/or RPM Services (as applicable).
I understand that if I withdraw my authorization for User’s enrollment in the CC Program and/or RPM Program (as applicable), User will still have access to and be able to use the Products and Services offered by MOD for which User may be eligible other than CC Services and/or RPM Services (as applicable).
I understand that if User is enrolled in one or both Program(s) (as applicable), I have the right to revoke my consent for User to receive CC Services and/or RPM Services (as applicable) in connection with User’s enrollment in the applicable Program(s) at any time and that I may do so by calling (773) 395-1829 and/or sending an email to compliance@myowndoctor.com. I further understand that if I revoke my consent for User to receive CC Services and/or RPM Services (as applicable) following User’s enrollment in one or both Program(s) (as applicable), that User will no longer receive any CC Services and/or RPM Services (as applicable).
I understand that if I revoke my consent for User to receive CC Services and/or RPM Services (as applicable) in connection with User’s enrollment in one or both Program(s) (as applicable), that such revocation of my consent will not affect User’s ability to access and use other MOD Products and Services for which User may be eligible, other than CC Services and/or RPM Services (as applicable). I understand that, if User is eligible to enroll in one or both Program(s) (as applicable) and I withdraw my authorization for User’s enrollment in the CC Program and/or RPM Program (as applicable) and/or if I revoke my consent for User to receive CC Services and/or RPM Services (as applicable) in connection with User’s enrollment in one or both Program(s) (as applicable), such withdrawal of my authorization for User’s enrollment in one or both Program(s) (as applicable) and/or revocation of my consent for User to receive CC Services and/or RPM Services (as applicable) will not affect User’s eligibility (as applicable) to later enroll in the CC Program and/or RPM Program (as applicable) and to receive CC Services and/or RPM Services (as applicable) in connection with such future enrollment of User in one or both Program(s) (as applicable). I understand that the information I elect to provide and/or MOD collects in connection with User’s access to and/or use of the Products and Services, including User’s enrollment in one or more Program(s) (as applicable) and/or User’s receipt of CC Services and/or RPM Services (as applicable), and which shall specifically include (as applicable) personal health data collected from any Medical Device used in connection with User’s receipt of the RPM Services, may contain sensitive personal information, including protected health information of User (collectively, “Personal Information”). I further understand that MOD’s use and disclosure of User’s Personal Information is governed by and subject to MOD’s Privacy Policy.
I understand that User’s Personal Information will be considered part of User’s medical record and that User’s Personal Information will be shared with User’s healthcare providers in connection with User’s receipt of the CC Services and/or RPM Services (as applicable).
I understand that MOD is not a healthcare provider or a manufacturer of Medical Devices and does not offer or provide any kind of medical advice, health insurance, or other professional healthcare service, including without limitation, any counseling, testing, medication, procedure, or therapy related to the prevention, diagnosis, or treatment of any acute or chronic illness, disease, or condition (collectively, “Healthcare Services”). I further understand that the role of MOD is limited to providing the Products and Services, including the CC Services and RPM Services, as an intermediary between User and healthcare providers and, as a result, MOD has no control over the appropriateness, accuracy, quality, timeliness, scope, price, or risks of or associated with any Healthcare Services provided to User by any healthcare provider or with any Medical Devices used or obtained in connection with User’s receipt of the RPM Services (if applicable).
I understand that the MOD Products and Services, including the CC Services and RPM Services, are not a substitute for professional Healthcare Services. I further understand that User must always seek the advice of User’s physician or other qualified healthcare provider with questions regarding any medical condition, or call 911 in an emergency.
I understand that User’s enrollment and participation in one or both of the Program(s) (as applicable) and User’s access to and use of any Products and Services, including User’s receipt of CC Services and/or RPM Services (as applicable) is governed by and subject to the MOD Terms and Conditions. I further understand that MOD and its affiliates reserve the right to discontinue operation of and/or User’s enrollment in one or both Program(s) at any time and for any reason. I understand that MOD and its affiliates further reserve the right to discontinue the performance of the CC Services and/or RPM Services (as applicable) at any time and for any reason, and that in such event User will need to seek care coordination and/or remote patient monitoring services (as applicable) elsewhere.
THIS AUTHORIZATION BECOMES EFFECTIVE WHEN YOU CHECK THE BOX TO ACCEPT OR AGREE TO THE TERMS OF THIS AUTHORIZATION WHEN THIS OPTION IS MADE AVAILABLE TO YOU OR BY ENROLLING IN ONE OR BOTH OF THE PROGRAM(S) AND SHALL REMAIN IN FULL FORCE AND EFFECT UNTIL YOU WITHDRAW AUTHORIZATION FOR ENROLLMENT OF USER IN ALL OF THE PROGRAMS OR YOU REVOKE YOUR CONSENT FOR USER’S RECEIPT OF ALL OF THE CC SERVICES AND RPM SERVICES (WHICHEVER OCCURS FIRST).
BY CHECKING THE BOX TO ACCEPT OR AGREE TO THE TERMS OF THIS AUTHORIZATION WHEN THIS OPTION IS MADE AVAILABLE TO YOU OR BY ENROLLING IN ONE OR BOTH OF THE PROGRAM(S) YOU: (A) ACKNOWLEDGE THAT YOU HAVE READ THIS AUTHORIZATION COMPLETELY AND UNDERSTAND ALL OF ITS PROVISIONS; (B) REPRESENT AND WARRANT THAT: (1) YOU HAVE REACHED THE AGE OF MAJORITY, YOU ARE OF SOUND MIND, YOUR JUDGMENT IS NOT IMPAIRED, YOU AND USER (IF DIFFERENT THAN YOU) HAVE THE NECESSARY KNOWLEDGE AND SKILLS TO BENEFIT FROM ENROLLMENT IN THE PROGRAM(S) FOR WHICH YOU OR USER (IF DIFFERENT THAN YOU) ARE ELIGIBLE AND YOUR OR USER’S (IF DIFFERENT THAT YOU) RECEIPT OF CC SERVICES AND/OR RPM SERVICES (AS APPLICABLE), AND YOU ARE ENTERING INTO THIS AUTHORIZATION FREELY, AND HAVE HAD YOUR QUESTIONS REGARDING ENROLLMENT IN THE PROGRAM(S) AND RECEIPT OF CC SERVICES AND/OR RPM SERVICES (AS APPLICABLE) ANSWERED TO YOUR SATISFACTION; (2) YOU HAVE THE RIGHT, POWER AND AUTHORITY TO ENTER INTO THIS AUTHORIZATION; AND (3) IF THE USER IS NOT YOU, THAT YOU ARE THE PARENT OR LEGAL GUARDIAN OF USER, WHO IS YOUR MINOR CHILD AND/OR WARD, THAT YOU HAVE THE LEGAL AUTHORITY TO ENTER INTO THIS AUTHORIZATION FOR AND ON BEHALF OF USER, AND THAT YOU HEREBY AUTHORIZE AND GIVE YOUR CONSENT FOR USER TO BE ENROLLED IN THE PROGRAM(S) FOR WHICH USER IS ELIGIBLE AND FOR USER TO RECEIVE THE CC SERVICES AND/OR RPM SERVICES (AS APPLICABLE) IN CONNECTION WITH USER’S ENROLLMENT IN ONE OR BOTH OF THE PROGRAM(S) (AS APPLICABLE); AND (C) ACCEPT THIS AUTHORIZATION AND AGREE THAT YOU AND USER (IF DIFFERENT THAN YOU) ARE LEGALLY BOUND BY ALL OF ITS PROVISIONS.