Informed Consent

Welcome

Last modified: July, 2022

Hello, and welcome to Galileo!

Galileo is a technology company that offers exceptional and comprehensive clinical care directly from your phone.

This Informed Consent agreement explains the benefits and certain limitations of using virtual visits to receive medical care. As a courtesy, we want to call your attention to several parts of it. You should know though that these highlights are not part of our official, binding legal terms. The official legal terms follow under the “Informed Consent” heading below.

Remote digital healthcare allows you to receive health care service in the convenience of your home, get timely and efficient appointments, and can help you better navigate the health system. However, there are also potential limitations like, in rare cases, your doctor could find the information you transmitted is insufficient to make a medical decision, meaning you will have to go in-person to a doctor, or that despite our strong security measures, your information could be breached by a bad actor.

The Medical Group that you (or your child, if applicable) will be connected to through Galileo uses a team-based approach. All care teams consist of multiple licensed physicians and other healthcare professionals, and in any given encounter you may interact with multiple healthcare professionals. This allows you (or your child, if applicable) to get better care faster. You (or your child, if applicable) can identify the doctor(s) involved in your medical visit and his or her credentials by clicking on the Galileo icon at any time during a telehealth visit in the app.

If you (or your child, if applicable) are a Medicaid patient, you (or your child, if applicable) may be entitled to receive the same digital healthcare services at little or no cost to you. By using the Galileo service, you authorize Galileo to bill you directly for the digital healthcare services as a private patient.

You have a right to refuse to participate in services delivered via telehealth.

Last modified: January, 2023

Informed Consent

Telehealth involves the use of electronic communications to enable healthcare providers at different locations than their patients to share individual patient medical information for the purpose of improving patient care. Such electronic communications may involve asynchronous or synchronous text-based, live audio-visual, and/or audio-only communications. Telehealth services offered by Galilea Medical Group, P.A. and its related practices (collectively “Galileo”) may include medical history review, evaluation and assessment, physical examination, record review, diagnosis, remote prescribing, provision of a treatment plan, health information sharing, therapy, follow-up, referrals, and patient education. The information you provide may be used for any of the aforementioned services, and may include any combination of the following: (1) health records and test results; (2) interactive asynchronous or synchronous chat communications; (3) live two-way communications; and/or (4) images. The electronic communication systems we use will incorporate network and software security protocols to protect the confidentiality of patient data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

Galileo uses a team-based approach, with care teams consisting of multiple licensed physicians and other healthcare professionals. In any given encounter you may interact with multiple healthcare professionals, which allows you to get better care faster. You can view individual provider names and backgrounds by clicking on the Galileo icon in the Galileo Health mobile application (“App”).

You should be aware that there are both benefits and risks associated with telehealth. Remote digital healthcare allows you to receive timely and efficient health care service in the convenience of your home and can help you better navigate the health system. However, there are also potential limitations. For example, your provider might need more complete medical records to optimize their decision-making or provide treatment, and they may need to refer you to an in-person doctor. Delays in evaluation and treatment could occur due to deficiencies or failures of the equipment and technologies. Or, despite our strong privacy and security measures, your information could be improperly accessed or used by a bad actor. You understand that no results can be guaranteed or assured.

In the event of an inability to communicate as a result of a technological or equipment failure, please contact Galileo through the App or by email at care@galileohealth.com. If you are experiencing an emergency, please call 911 for immediate access to emergency services. Galileo providers are not able to connect you directly to any local emergency services.

If you are a Medicaid enrollee, you may be entitled to receive the same digital healthcare services from a provider enrolled in your state’s Medicaid program at little or no cost to you. By using the Galileo service, you authorize Galileo to bill you directly for digital healthcare services as a private patient. If you are a Medicaid patient enrolled in a Medicaid managed care plan, your plan can confirm whether and to what extent they provide coverage for Galileo’s services.

All Telehealth Services

By clicking to accept this consent, you attest that you are at least 18 years of age and have legal authority to agree to this consent on behalf of yourself if you are the patient, or on behalf of your minor child if you are the parent/guardian of the patient, and you acknowledge and agree to the following:

I hereby consent to Galileo providing its services via telehealth technologies. I understand that the risks and benefits of any particular treatment will be identified at the time of care plan provision, that recommended care plans can always be directly accessed via the Galileo app, and that if I do not consent to proceed with a particular care plan, I should share my specific concerns with my provider so that they may discuss them with me and consider an alternative care plan if medically appropriate. I understand that Galileo and its providers offer telehealth-based medical services, but that these services are not intended to constitute a primary care provider relationship if I (or my child, as applicable) have not designated, or been assigned to, Galileo as my (or my child’s, as applicable) primary care provider. I also understand Galileo’s providers will determine whether or not my (or my child’s, if applicable) specific clinical needs are appropriate for a telehealth encounter, and I understand that Galileo is not intended to replace my in-person provider(s) for services which a Galileo provider determines are not appropriate for a telehealth encounter.

I understand that I can review the provider(s) involved in an encounter and their credentials by clicking on the Galileo icon at any time during a telehealth encounter in the app. I may review any Galileo provider’s credentials in the message section of the app. If I would like to speak to a different provider than the one involved in my encounter, I have the right to select another provider, although there could be a delay in service. If I would like to see an in-person provider, I may request a referral and will need to arrange for travel to the in-person provider’s location.

I understand that it is my responsibility to keep my physical address updated within the App, and I will ensure it reflects the state in which I am physically located, as well as the state in which my preferred pharmacy is located, whenever consulting with a Galileo provider.

I understand the importance of Galileo’s providers having accurate medical history and current medication information, and will keep my health profile updated. I understand that there is no guarantee that any prescription for any medication will be ordered, and that Galileo does not prescribe controlled substances (e.g., narcotics for pain).

I understand that federal and state law requires health care providers to protect the privacy and the security of health information. I understand that Galileo’s Notice of Privacy Practices describes how Galileo protects, uses and discloses medical information and how I can get access to this information. I understand that my healthcare information may be shared with other individuals for treatment, payment, or healthcare operations purposes, and that persons may be present during the consultation other than my provider in order to operate the telehealth technologies. I have a right to ask for the identities of parties present during the consultation.

I understand that I have the opportunity to provide my PCP’s information through the app. If I do so, I consent to Galileo sharing all my medical records with my PCP, including any sensitive records related to mental health, reproductive health, substance use, HIV, and STDs/STIs.

I hereby assign to and authorize payment of all insurance and health care benefits available to me directly to Galileo for services provided to me. I understand that benefits may be payable to me directly if I do not provide this authorization. I understand that the information Galileo may share with my health plan for treatment, payment, or healthcare operations purposes may include sensitive records related to mental health, reproductive health, substance use, HIV, and STDs/STIs, and I specifically consent to such information being shared.

I understand and agree that I am financially responsible for payment of all charges incurred which are not paid by insurance or health care benefits, including any and all products (e.g. medications) provided or services rendered to me which are not eligible for payment (non-covered) under health care plans, Medicare, Medicaid, or other insurance or payers (e.g., services rendered by health care providers who do not participate with my insurance plan). Non-covered products and non-covered services also may include those products and services Galileo providers initially determined to be medically necessary but are later determined unnecessary or denied by my insurance or payer. Galileo reserves the right to refuse to provide services on accounts that are delinquent.

I understand there is a risk of technical failures during the telehealth encounter beyond the control of Galileo. I agree to hold harmless the Medical Group for delays in evaluation or for information lost due to such technical failures.

I understand that I have the right to withhold or withdraw this consent to the use of telehealth at any time, and I may suspend or terminate use of the telehealth services at any time for any reason or for no reason. I understand that alternatives to telehealth consultation, such as in-person services, are available.

I understand that if I am agreeing to this consent as a parent/guardian on behalf of my child, I am consenting to Galileo’s provision to my child of any services which Galileo deems appropriate to be provided to my child via telehealth, except for services which my child confidentially consents to, on their own behalf, to the extent permitted by applicable state law. I further understand that the Children’s Online Privacy Protection Act (COPPA) requires parental or legal guardian consent for the online collection, use, and disclosure of personal information of children under 13 years of age, and I hereby authorize Galileo to collect personal information about my child when my child uses Galileo’s online services, including to access care via video visits or secure messaging. I have reviewed the COPPA statement incorporated into Galileo’s Privacy Policy, and by providing this consent, I attest that I am the parent or legal guardian of the registered child. I understand and consent to the collection, use and/or disclosure of my child’s personal information as described in Galileo’s Privacy Policy. I may revoke my consent at any time by contacting support@galileo.io, but if I revoke my consent while my child is under 13 years of age, my child may not continue to access or use Galileo’s online services.

I understand that I have the right to request a copy of any medical records Medical Group has regarding any services provided to me (or my child, if applicable). Requested medical records will be provided to at reasonable cost of preparation, shipping and delivery.

I understand that the Medical Group is not affiliated with any third-party sources of information, and therefore Galileo makes no promise that third-party sources will be accurate or fault free. Further, I understand that Galileo is not responsible for the accuracy of health records or health data that are created by any third-party sources.

Parental Consent for Pediatric Services

By registering an account for a minor, you acknowledge and agree to the following additional terms:

I understand that if I am agreeing to this consent as a parent/guardian on behalf of my child, I am consenting to Galileo’s provision to my child of any services which Galileo determines are appropriate to be provided to my child via telehealth. I understand it is my responsibility to manage the login credentials for my child’s account on my mobile device and to be present for any pediatric encounter through the Galileo app. I further understand that if I share the login credentials with my child and/or permit my child to chat directly with a provider, I can always access the chat history for each case opened in the Galileo app, and I can stay apprised of new messages, care plans, prescriptions, lab results, and other account activity, by turning on Galileo app notifications in my mobile device settings. If I do not consent to a particular care plan, it is my responsibility to let my child’s care team know by sending them a message in the applicable case in the Galileo app, so that an alternative care plan can be discussed. I understand that there are limitations to the scope of pediatric services available through Galileo, and that my child may be referred for in-person care for various reasons, such as if an in-person physical examination is necessary or if confidential reproductive health services are sought.

I understand that the Children’s Online Privacy Protection Act (COPPA) requires parental or legal guardian consent for the online collection, use, and disclosure of personal information of children under 13 years of age, and I hereby authorize Galileo to collect personal information about my child when my child uses Galileo’s online services, including to access care via video visits or secure messaging. I have reviewed the COPPA statement incorporated into Galileo’s Privacy Policy, and by providing this consent, I attest that I am the parent or legal guardian of the registered child. I understand and consent to the collection, use and/or disclosure of my child’s personal information as described in Galileo’s Privacy Policy. I may revoke my consent at any time by contacting support@galileo.io, but if I revoke my consent while my child is under 13 years of age, my child may not continue to access or use Galileo’s online services.

Behavioral Health Services

By requesting therapy services, you acknowledge and agree to the following additional terms:

Behavioral health services available through Galileo are primarily for conditions that fall within primary care. My Galileo therapist will determine whether my condition is appropriate for Galileo’s behavioral health services..I understand that as my condition evolves, my care team may determine that I would be better served through in-person care, and if so, they can provide me a referral and connect me with Patient Support Associates who can assist me with care coordination. In certain circumstances that are more appropriate for in-person care, I may be offered limited, temporary services intended to be a bridge while I identify and establish a therapeutic relationship with an in-person provider. In the event that I need more in-depth service outside of the scope available through the Galileo app, I agree to expediently make diligent efforts to seek face to face counseling or emergency help.

Therapy services will be primarily text-based, but may also involve phone or video as needed and appropriate. Text-based services are generally available between [days/hours]. Phone or video sessions must be scheduled in advance and will ordinarily be [X] minutes in duration. If I need to cancel or reschedule a phone or video session, I will provide at least 24 hours notice.

I understand that the counseling practice includes but is not limited to the practice of education, needs assessment, goal setting, accountability, referral to resources, problem solving, skills training, and help with decision making. Because Galileo uses a team-based approach, my behavioral health services may involve establishing a therapeutic relationship with multiple therapists through the Galileo app. I may also separately establish care with medical providers who can order prescriptions for me through the Galileo app. However, I understand that in order to receive safe and effective care, it is important for all my psychotropic medications from one medical group, whether through Galileo or a third-party provider.

I understand that there are potential risks and benefits associated with any form of counseling. Psychotherapy can help improve emotional state and personal awareness, reduce feelings of distress, increase satisfaction in interpersonal relationships, sharpen communication skills, and improve skills for managing stress and resolutions to specific problems. But, there are no guarantees about what will happen. Psychotherapy requires a very active effort on my part, and I understand that I will have to work on things discussed with my therapist on my own time. Risks may include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness, because the process of psychotherapy often requires discussing the unpleasant aspects of life.

I understand I have the right to considerate, safe and respectful care, without discrimination as to race, ethnicity, color, gender, sexual orientation, age, religion, national origin, or source of payment. I agree to be considerate and respectful when speaking with my therapist, but understand that I always have the right to ask questions about any aspects of therapy and about my therapist’s specific training and experience.

I understand that depression and other mental health symptoms can sometimes lead to despair and thoughts of self harm. Although Galileo clinicians empathize with those who are going through this experience, Galileo’s care design is not well-suited for acute mental health emergencies such as suicidal thoughts and intentions, or for acute mania or episodes of psychosis. If I am in emotional distress, I can contact the National Suicide Prevention Hotline: Crisis Text Line at 1-800-273-8255, or text “Home” to 741-741, to obtain immediate assistance.

If my therapist believes I may be a danger to myself or others, or if I am not responding to attempts to contact me in urgent situations, Galileo may need to share information with my emergency contact or send care to me by calling 911 or initiating a welfare check. I understand that Galileo does not take this responsibility lightly, and that it is critical that I respond punctually to Galileo’s attempts to help me in situations that may be perceived as dangerous. I understand that if my therapist believes I pose a threat of child abuse, public peril, or danger to others, they may waive the confidentiality privilege of the therapeutic relationship to report such endangerment to appropriate authorities.

I agree that neither Galileo nor any therapist shall have any responsibility or liability to any person or entity with respect to any loss or damage alleged to be caused directly or indirectly by the advice or information provided to me through my therapy sessions.