BY CLICKING “I ACCEPT,” YOU ACKNOWLEDGE THAT YOU HAVE READ, ACCEPTED, AND AGREED TO BE BOUND BY THIS INFORMED CONSENT. IF YOU DO NOT CLICK “I ACCEPT”, YOU WILL NOT BE ABLE TO USE OR RECEIVE THE SERVICES.
General Informed Consent (Including Telehealth Consent)
I agree to receive the services provided by PWNHealth (the administrative services provider of the professional entities), PWNHealth Remote Care Services, PW Medical Professional and certain other affiliated professional entities (collectively, “PWNHealth”, “we” or “us”) relating to ordering a Cologuard laboratory test (“Test”), including, without limitation, evaluation of the Test request, ordering of the Test (if appropriate), receipt and evaluation of Test results (“Results”), healthcare provider consultations via telemedicine (“Consults”), any customer support or counseling and any other related services provided by PWNHealth or its service providers and partners (the "PWNHealth Services”). All clinical PWNHealth Services, including PWNHealth Services provided by healthcare providers, will be provided through PWNHealth Remote Care Services, PW Medical Professional or their contractually affiliated professional entities.
I acknowledge and agree to the following:
- I am the individual who will provide the sample for the Test(s) that I am ordering.
- I am at least eighteen (18) years of age.
- I have read and understand the information provided about the Test(s) that I am ordering at cologuard.com.
- Due to Medicare regulations, I may also be contacted by Exact Sciences for more information in order to complete the order.
- In order to utilize the PWNHealth Services, I must provide an appropriate sample for the Test(s) via the Cologuard test kit provided by Exact Sciences.
- The information I have provided in connection with the PWNHealth Services is correct to the best of my knowledge. I will not hold PWNHealth or its health care providers or Exact Sciences responsible for any errors or omissions that I may have made in providing such information.
- My health information and Results may be shared with other PWNHealth health care providers, including healthcare providers, and counselors for purposes of providing care to me.
- The PWNHealth Services do not constitute treatment or diagnosis of any condition, disease or illness.
- While PWNHealth and Exact Sciences implement safeguards to avoid errors, as with all laboratory tests, there is a chance of a false positive or false negative Result.
- I am responsible for checking my email for Results notification and logging on to my account to view my Results when available.
- I am not a beneficiary of a Medicaid or Tricare plan.
- I will not make medical decisions without consulting a healthcare provider, disregard medical advice from my healthcare provider or delay seeking such advice based on information as a result of the use of the PWNHealth Services.
I understand that PWNHealth Services, including Consults, are delivered by health care providers who are not in the same physical location as I am using electronic communications, information technology or other means, including the electronic transmission of personal health information. I also understand that:
- I may be required to complete a pre-test telemedicine Consult with a PWNHealth healthcare provider. I may also elect to receive a pre-test and/or a post-test telemedicine Consult with a PWNHealth healthcare provider.
- A PWNHealth healthcare provider will determine whether or not the Test and PWNHealth Services are appropriate for me based on the information provided by me, including information provided during a pre-test Consult, if applicable.
- I understand that, after the Test is performed, my Results will be available in my Exact Sciences account. If my Results are abnormal PWNHealth's Care Coordination Team will attempt to call me to discuss the Results, provide educational information, and discuss plans for managing my health moving forward, including to advise me to reach out to a healthcare provider, such as my primary care or personal healthcare provider, to obtain an interpretation of the Results and for care, diagnosis, and medical treatment. If I do not answer the phone, PWNHealth’s Care Coordination Team may leave me a voicemail but will not include my test Results in any voicemail message. If I receive my Results and have not connected with PWNHealth’s Care Coordination Team, I understand that I should not delay following up with my personal healthcare provider. I understand that I may contact PWNHealth’s Care Coordination Team at any time with questions and to participate in a Consult.
- I am responsible for forwarding any Results to my primary care or other personal healthcare provider and for initiating follow up with such healthcare provider for care, diagnosis, medical treatment or to obtain an interpretation of the Results.
- After receiving my Results, I understand that I may elect to request a telemedicine Consult with a PWNHealth healthcare provider.
- I certify that (i) I am a resident of the United States and (ii) when I receive PWNHealth Services, including throughout the duration of my Consult, I will be physically present in the state (or U.S. territory) of residence I provided or other state (or U.S. territory) of which I have notified PWNHealth.
- The scope of services for the Consult will be at the sole discretion of the healthcare provider. The healthcare provider will not provide a diagnosis, treatment, or prescription. The healthcare provider will determine whether or not the PWNHealth Services being rendered are appropriate for a telehealth encounter.
- I have the right to withdraw my consent to the use of telehealth in the course of my care at any time by contacting the PWNHealth's Care Coordination Team by calling +1 (718) 210-9716 or emailing email@example.com.
- Any video feed from the Consult will not be retained or recorded by PWNHealth.
- I may need to see a health care provider in-person for diagnosis, treatment and care.
- There are potential risks associated with the use of technology, including disruptions, loss of data and technical difficulties. I agree to hold PWNHealth harmless for information lost due to technical failures.
- There are alternative services, such as visiting a primary care provider, an emergency room, or an urgent care facility; however, I chose to proceed with the PWNHealth Services at this time.
I understand that if I have any questions before or after my Test, I can contact PWNHealth's Care Coordination Team by calling +1 (718) 210-9716 or emailing firstname.lastname@example.org.
I authorize PWNHealth to use the email address and phone number I provided in connection with my Exact Sciences account at the time I purchased my Test(s) (or that I updated by contacting PWNHealth's Care Coordination Team as described below) to contact me in connection with the PWNHealth Services, including follow-up after receiving the PWNHealth Services. I am responsible for contacting PWNHealth's Care Coordination Team by calling +1 (718) 210-9716 or emailing email@example.com to notify them of any changes to my mailing address, email address, phone number or other information that I provided in connection with the PWNHealth Services. changes to my mailing address, email address, phone number or other information that I provided in connection with the PWNHealth Services.
PWNHealth may contact you after your Consult via email with a survey which may include questions regarding customer satisfaction and follow up care. You understand that this email survey may refer to the Cologuard test. If you would prefer to receive the survey via another method of communication, please contact the PWNHealth Care Coordination Team. PWNHealth may contact you via phone or other communication based on your responses to the survey.
I understand that testing is voluntary and that I may withdraw my consent to testing at any time prior to the completion of the Test(s) by contacting PWNHealth's Care Coordination Team by calling +1 (718) 210-9716 or emailing firstname.lastname@example.org.
I understand that I have a right to receive a copy of the above data disclosure authorization. I have the right to refuse to agree to this authorization in which case my refusal may affect the PWNHealth Services provided to me. When my information is used or disclosed pursuant to this authorization, it may be subject to re-disclosure by the recipient and may no longer be protected by privacy laws. I have the right to revoke this authorization in writing at any time, except that the revocation will not apply to any information already disclosed by the parties referenced in this authorization. This authorization will expire ten (10) years from the date of signature. My written revocation must be submitted to PWNHealth’s General Counsel at:
PWNHealth Remote Care Services
c/o PWNHealth, LLC
Attn: General Counsel
123 West 18th Street, 8th Floor
New York, NY 10011