UpScript Health7033 E. Greenway Parkway, Suite 310Scottsdale, AZ 85254480-707-4549priorauth@upscripthealth.com
Parent of Minor/Guardianship Patient Informed Consent to Telehealth Services and GetNerivio Health Policies
This form describes UpScript (USH) Telehealth treatment and payment policies for minor and/or incapacitated patients and includes:
- Your consent on behalf of the patient to receive medical treatment from GetNerivio.com.
- Your agreement on behalf of the patient to receive services using telehealth technology.
- Your agreement to pay in full any charges that are your responsibility; and
- Your agreement to upload a copy of your driver’s license or state identification card
By signing and clicking “I agree to Terms of Use” on the GetNerivio.com website, I
- Understand and agree that I am signing this consent electronically.
- 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 accept financial responsibility.
- Certify I have reviewed, understand, and accept the risks and benefits of telehealth services.
- Agree to the remaining terms of this Consent; including terms of the UpScript Privacy Notice described below.
- By using GetNerivio.com, I agree for my child to receive telehealth services. Telehealth involves the delivery of health care services, including assessment, treatment, and diagnosis using interactive audio, video, and data communications. During my visit, my GetNerivio.com provider and I will be able to see and speak with each other from remote locations.
- I agree to follow telehealth policies applicable to minor patients:
- I will remain with the patient and available to the provider during the entire visit. If I am not present and/or available, I understand that the visit may not be completed.
- I will provide a valid email address for post-visit communications.
- I understand and agree that:
- I will not be in the same location or room as my medical provider.
- My GetNerivio.com provider is licensed in the state in which my minor child is receiving services. I will report my location accurately during registration.
- I further understand that the GetNerivio.com health provider 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 the GetNerivio.com provider relies on information provided by me before and during the telehealth virtual visit and that I must provide information about my minor child’s medical history, conditions, and current or previous medical care that is complete and accurate to the best of my ability.
- I understand that the level of care provided by the GetNerivio.com provider is to be a similar level of care that is available through an in-person medical visit. If my provider believes my minor child would be better served by in person care or another form of care, I will be referred to my primary care physician, hospital, 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 treatments proposed by my health care provider(s).
- GetNerivio.com will provide care consistent with the prevailing standards of medical practice but makes no assurances as to the result of treatment.
GetNerivio.com Notice of Privacy Practices (Privacy Notices)
GetNerivio.com will protect the privacy of my health information and will not disclose it except as permitted by law. GetNerivio.com Privacy Notice, is available for review here: https://www.getnerivio.com/legal-documents/privacy-policy
I consent to, understand, and agree to GetCGDTested.com Agreement of Self Payment Services which can be found here: https://www.getnerivio.com/legal-documents/self-payment-of-services
Need Help?
Speaking with the telemedicine team is fast and easy. Email, call us, or start a live chat below.
Start Live Chat
