Consent to TELEHEALTH, mydrsnote.com
Last updated 4/12/2023

PURPOSE

The purpose of this form is to obtain your consent for our telemedicine service. The purpose of our telemedicine service is to provide you a real doctor’s excuse note or FMLA certification upon submission of the online form and approving your request by a medical doctor.

We expect you to read entirely the Consent to Telehealth, Terms and Conditions, as well the Privacy Notice. We also expect you to understand our model of care from the information provided on our Website and what information you will be expected to provide.

Please also understand, we will only be able to provide excuse notes for days you’ve had to miss work, school, or a flight due to mild conditions or illnesses. You and your employer must meet criteria for FMLA for us to support you in your FMLA certification.

I understand this service is for the purpose of providing my a real doctor’s note or FMLA certification under the direction of a medical doctor. I understand before using this service, I must read and understand this Consent to Telehealth, the Terms and Conditions, and Privacy Notice. I also acknowledge I must read the information that is provided on the Website for my full understanding of the service and what information is expected of me. I also understand I will only be able to be provided excuse notes for mild conditions or illnesses as well as FMLA certification, if needed.

BACKGROUND

HealthSource Medical Associates, PLLC through MY DR’S NOTE, LLC provides services by US Board Certified Licensed Physicians. Our service is available in all 50 states.

We do not diagnose or treat any new medical conditions. We are not an emergency medical service. If you are experiencing a medical emergency you will need to call 911 or go to the Emergency Room. We are here to help patients obtain a doctor’s note to excuse them from work, school, or a flight while recovering from their illness.

We do not provide Leave of Absence letters or forms, Disability letters or forms or Work Injury related letters or forms.

I understand this service is available in all 50 states. I understand that by using this service, I am requesting a real doctor’s note to excuse my absence from work, school, or a flight while I have been recovering from being sick with a mild illness. I understand this service does not provide letters or forms for Leave of Absence, Disability, or Work Injuries.

NATURE OF TELEMEDICINE CONSULTATION

Telemedicine is the use of digital technology to provide medical services to patients who otherwise would not be able to obtain in person.

Our service requires you to submit all relevant and personal information digitally. Our Providers will review the submissions. A signed doctor’s note will be sent to your email securely once approved.

I understand I will need to use an electric device such as a computer, tablet or smart phone to use this service. I understand my care begins when the provider reviews my request. I understand I will receive a secure email with my note once my request has been approved.

RISKS AND BENEFITS

There are many benefits to using a Telehealth service like ours. It is convenient, quick, and easy.

Certain situations may delay having your requests reviewed by the doctor. We review all requests from 6am to 6pm PST from Sunday to Thursday and 6 am to 1 pm PST on Fridays. We are closed on Saturdays. If you submit your request outside of these hours you will have to wait for your request to be processed by the provider the next available day. For example, if you submit a request at 7 pm PST Thursday night, it will be reviewed between 6am to 1 pm PST on Friday. If you submit a request at 3 pm PST on Friday, your request will be reviewed between 6am to 6pm PST the following Sunday.

Situations may arise where our website or service may fail due to unforeseen circumstances. These unforeseen circumstances may include but are not limited to: acts of God, failures of internet connectivity, power outages, acts or omissions of any government. We will take all reasonable efforts to promptly notify you in such circumstances.

Using our website on a device that has been “hacked,” “jailbroken,” or modified, puts you at risk for have your Personally-Identifying Information and/or Protected Health Information (PHI) unintentionally disclosed to unauthorized personnel. It is your sole responsibility to make sure your device is in conformity to the most up to date security features. We will have no liability for any breach of your personal data or PHI that occurs due to the lack of proper security features on your device.

I understand there could be a delay in having my requests reviewed depending on the day and time I submit my request. I understand I will be notified of any unforeseen circumstances causing a failure of this service. I understand I will do my utmost to make sure I am not using a device that has been “hacked,” “jailbroken,” or modified that puts me at risk for having my Personal Health Information being unintentionally disclosed.

MEDICAL INFORMATION

We rely on you to provide true, accurate, current and complete information in order for us to provide you with the safest outcome. Inappropriate use of our service may jeopardize your health, putting you at great risks, including death, if the information provided is false or inaccurate. We will authorize absence from work or school for a maximum of 5 days per 30 day period. You may select dates starting from 2 days prior to and 5 days after the date of submission for a regular Doctor’s note. For COVID-19 notes you will be able to select from 5 days prior to up to 5 days after the date of submission as well. For a Travel note you will select only one date on which you missed or had to cancel a flight.

I understand the information I provide needs to be true, accurate, current and complete. I understand if I provide any false or inaccurate information I can be putting myself at risk including death. I understand I will only be allowed to select dates for my excuse from 2 days prior to and up to 5 days after the date of my submission for a maximum of 5 days for a regular Doctor’s Note. For a COVID-19, I will be able to select dates from 5 days prior to and up to 5 days after the date of my submission as well. For a Travel note I understand I will only be able to select one day.