TELEHEALTH CONSENT

DO NOT USE THIS SERVICE FOR EMERGENCY MEDICAL CONDITIONS OR NEEDS.  IF YOU ARE CURRENTLY EXPERIENCING A MENTAL HEALTH OR OTHER MEDICAL EMERGENCY, IMMEDIATELY CALL 911.

If you are considering suicide or thinking about taking an action that may cause harm or danger to you or to others, you must immediately call 911. If you are considering suicide, we urge you to call the National Suicide Prevention Hotline at 1-800-273-TALK (8255).  Please also see Support Resources for additional support. 

Only use our service if you’ve read this information and subsequently made an informed decision that our service is right for you. If you have any questions, please send us a message through the ravkoo Health App or at supprt@ravkoohealth.com.

By signing and/or opting to agree to this form, I understand and agree with the following:

Telehealth/Telemedicine (“telehealth”) involves the use of electronic communications to enable Authorized Providers at different locations to share individual patient medical information for the purpose of improving patient care.  I consent to receive treatment via telehealth from ravkoo Health Authorized Providers.  Authorized Providers may include primary care practitioners, specialists and/or subspecialists, nurse practitioners, registered nurses, medical assistants and other healthcare providers who are part of my clinical care team.  In addition to myself and the members of my clinical care team, I may choose to have my family members, caregivers, or other legal representatives or guardians join and participate in the telehealth service, and I may agree to share my personal information with such family members, caregivers, legal representatives or guardians if I choose to have them join in my telehealth services.  The information may be used for diagnosis, therapy, follow-up and/or education.

Telehealth/Telemedicine requires transmission, via Internet or tele-communication device, of health information, which may include:

  • Progress reports, assessments, or other intervention-related documents; and
  • Videos, pictures, text messages, audio and any digital form of data

The laws that protect the privacy and confidentiality of health and care information also apply to telehealth.  Information obtained during telehealth services that identify me will only be provided to someone with consent, except for purposes of treatment and healthcare operations.  By agreeing to use the telehealth services, I am consenting to the sharing of my protected health information with certain third parties as more fully described in ravkoo Health’s Privacy Policy.  I understand and expressly consent to ravkoo Health obtaining, using, storing, and disseminating to necessary third parties, information about me, as necessary to provide the telehealth services and as specified in the Privacy Policy.

I understand that I must check the App or Website for messages because this is the way that the Authorized Provider will communicate important information to me.  I understand that if I do not check the App or Website regularly, then my care may be delayed.

I understand that if I have any questions relating to my care that are not urgent, I can message the Authorized Provider through the App or Website.  I understand that the Authorized Provider may not review and respond to my messages until the next business day depending on when the message was sent.

Telehealth sessions may not always be possible.  Disruptions of signals or problems with the Internet’s infrastructure may cause broadcast and reception problems (e.g., poor picture or sound quality, dropped connections, audio interference) that prevent effective interaction between the Authorized Provider, participant, patient or care team. 

I hereby release and hold harmless ravkoo Health and all members of my care team from any loss of data or information due to technical failures associated with the telehealth service. I understand and agree that the health information I provide at the time of my telehealth service may be the only source of health information used by the Authorized Provider during the course of my evaluation and treatment at the time of my telehealth visit, and that such Authorized Provider may not have access to my full medical record or information.

For more details about how ravkoo Health protects and uses your health information see our Privacy Policy.

I understand that I will be given information about tests, treatments, and procedures, as applicable, including the benefits, risks, possible problems or complications, and alternate choices for my medical care through the telehealth visit.

I have the right to withhold or withdraw consent to the use of telehealth services at any time and revert back to traditional in-person clinic services. I understand that if I withdraw my consent for telehealth, it will not affect any future services or care benefits to which I am entitled.

I hereby consent to the use of telehealth in the provision of care and the above terms and conditions.

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The ravkoo Health mobile app is a secure, HIPAA-compliant platform, offering you all essential healthcare services at one place and providing you access to your personal health records. Soon to be available on App Store and Play Store.

ravkoo Notifies Patients of Data Security Incident

Auburndale, Florida: January 3, 2022 – ravkoo recently discovered that a data security incident on ravkoo’s AWS hosted portal may have resulted in the unintentional exposure of personal information. ravkoo sent notification of this incident to potentially impacted individuals and has provided resources to assist them.  Please be assured that ravkoo takes the protection and proper use of personal information very seriously, and we sincerely apologize for any inconvenience this may cause.

What Happened:  ravkoo utilizes AWS cloud services for online hosting of its prescription portal. On September 27, 2021, ravkoo detected that this portal was the target of a cybersecurity attack. An unauthorized third party attempted to infiltrate the portal. ravkoo immediately engaged outside cybersecurity experts to conduct an investigation and to assist in its mitigation, restoration, and remediation efforts.  ravkoo’s responsive forensic investigation subsequently revealed that certain prescription and health information could have been compromised. Notably, we have found no evidence that any individual’s Social Security Number was accessed or compromised as ravkoo does not maintain this information within the impacted portal.  Further, ravkoo does not have any evidence to indicate that any information involved in the incident has been or will be misused as a result of this incident. 

What We Are Doing:  ravkoo worked with forensic experts to assess and increase the security of its AWS hosted portal.  Further, ravkoo reported the incident to the Federal Bureau of Investigation and is committed to assisting the FBI’s investigation into this matter.

As a safeguard, we have arranged for the potentially impacted individuals to enroll in a complimentary, online credit monitoring service provided by Kroll.  With this protection, Kroll will help resolve issues if your identity is compromised.

What You Can Do:  The notification letters that were sent to potentially affected individuals include resources and steps that they can take to help protect their personal and protected health information.  Security recommendations include the following:

  • Credit Report – Obtain a copy of your credit report, free of charge, whether or not you suspect any unauthorized activity on your account.
  • Security Freezes – You have the right to place a security freeze on your credit report. A security freeze is intended to prevent credit, loans, and services from being approved in your name without your consent.
  • Fraud Alerts – Fraud alerts tell creditors to follow certain procedures, including contacting you, before they open any new accounts or change your existing accounts.
  • Monitoring – Remain vigilant and monitor your accounts for suspicious or unusual activity.

Again, at this time, there is no evidence that any sensitive information has been misused.  However, we encourage the potentially impacted individuals to take full advantage of this service offering.  Kroll representatives have been fully versed on the incident and can answer questions or concerns regarding protection of personal information.

For More Information:  Please know that the protection of your personal information is a top priority, and we sincerely regret any concern or inconvenience that this matter may cause you. If you have any questions, please do not hesitate to call Kroll at 1-855-545-2509, Monday – Friday, 9:00am to 6:30pm Eastern Standard Time.

Sincerely,

Alpesh Patel

Alpesh Patel

CEO

Additional Information

Credit Reports: You may obtain a copy of your credit report, free of charge, whether or not you suspect any unauthorized activity on your account. You may obtain a free copy of your credit report from each of the three nationwide credit reporting agencies. To order your free credit report, please visit www.annualcreditreport.com, or call toll-free at 1-877-322-8228. You can also order your annual free credit report by mailing a completed Annual Credit Report Request Form (available at https://www.consumer.ftc.gov/articles/0155-free-credit-reports ) to: Annual Credit Report Request Service, P.O. Box 105281, Atlanta, GA, 30348-5281.

Security Freeze: You also have the right to place a security freeze on your credit report. A security freeze is intended to prevent credit, loans, and services from being approved in your name without your consent. To place a security freeze on your credit report, you need to make a request to each consumer reporting agency. You may make that request by certified mail, overnight mail, regular stamped mail, or by following the instructions found at the websites listed below. The following information must be included when requesting a security freeze (note that if you are requesting a credit report for your spouse or a minor under the age of 16, this information must be provided for him/her as well): (1) full name, with middle initial and any suffixes; (2) Social Security number; (3) date of birth; (4) current address and any previous addresses for the past five years; and (5) any applicable incident report or complaint with a law enforcement agency or the Registry of Motor Vehicles. The request must also include a copy of a government-issued identification card and a copy of a recent utility bill or bank or insurance statement. It is essential that each copy be legible, display your name and current mailing address, and the date of issue. As of September 21, 2018, it is free to place, lift, or remove a security freeze. You may also place a security freeze for children under the age of 16. You may obtain a free security freeze by contacting any one or more of the following national consumer reporting agencies:

Equifax Security FreezeExperian Security FreezeTransUnion Security Freeze
P.O. Box 105788P.O. Box 9554P.O. Box 160
Atlanta, GA 30348Allen, TX 75013Woodlyn, PA 19094
1-800-349-99601-888-397-37421-800-909-8872
https://www.equifax.com/personal/credit-report-services/credit-freeze/www.experian.com/freeze/center
.html
www.transunion.com/credit-
freeze

Fraud Alerts: You can place fraud alerts with the three credit bureaus by phone and online with:

A fraud alert tells creditors to follow certain procedures, including contacting you, before they open any new accounts or change your existing accounts. For that reason, placing a fraud alert can protect you, but also may delay you when you seek to obtain credit. As of September 21, 2018, initial fraud alerts last for one year. Victims of identity theft can also get an extended fraud alert for seven years. The phone numbers for all three credit bureaus are at the bottom of this page.

Monitoring: You should always remain vigilant and monitor your accounts for suspicious or unusual activity.

File Police Report: You have the right to file or obtain a police report if you experience identity fraud. Please note that in order to file a crime report or incident report with law enforcement for identity theft, you will likely need to provide proof that you have been a victim. A police report is often required to dispute fraudulent items. You can generally report suspected incidents of identity theft to local law enforcement or to the Attorney General.

FTC and Attorneys General: You can further educate yourself regarding identity theft, fraud alerts, security freezes, and the steps you can take to protect yourself, by contacting the consumer reporting agencies, the Federal Trade Commission, or your state Attorney General.

The Federal Trade Commission can be reached at: 600 Pennsylvania Avenue NW, Washington, DC 20580, www.identitytheft.gov, 1-877-ID-THEFT (1-877-438-4338), TTY: 1-866-653-4261. The Federal Trade Commission also encourages those who discover that their information has been misused to file a complaint with them. You can obtain further information on how to file such a complaint by way of the contact information listed above. You have the right to file a police report if you ever experience identity theft or fraud. Please note that in order to file a report with law enforcement for identity theft, you will likely need to provide some proof that you have been a victim. Instances of known or suspected identity theft should also be reported to law enforcement. This notice has not been delayed by law enforcement.

For Maryland residents, the Attorney General can be contacted at 200 St. Paul Place, 16th Floor, Baltimore, MD 21202, 1-888-743- 0023, and www.oag.state.md.us.

For New Mexico residents, you have rights pursuant to the Fair Credit Reporting Act, such as the right to be told if information in your credit file has been used against you, the right to know what is in your credit file, the right to ask for your credit score, and the right to dispute incomplete or inaccurate information. Further, pursuant to the Fair Credit Reporting Act, the consumer reporting agencies must correct or delete inaccurate, incomplete, or unverifiable information; consumer reporting agencies may not report outdated negative information; access to your file is limited; you must give your consent for credit reports to be provided to employers; you may limit “prescreened” offers of credit and insurance you get based on information in your credit report; and you may seek damages from violators. You may have additional rights under the Fair Credit Reporting Act not summarized here.

Identity theft victims and active duty military personnel have specific additional rights pursuant to the Fair Credit Reporting Act. We encourage you to review your rights pursuant to the Fair Credit Reporting Act at www.consumerfinance.gov/f/201504_cfpb_summary_your-rights-under-fcra.pdf or by writing Consumer Response Center, Room 130-A, Federal Trade Commission, 600 Pennsylvania Ave. N.W., Washington, D.C. 20580.

For North Carolina residents, the Attorney General can be contacted at 9001 Mail Service Center, Raleigh, NC 27699-9001, 1-877- 566-7226 or 1-919-716-6400, and www.ncdoj.gov.

For New York residents, the Attorney General may be contacted at Office of the Attorney General, The Capitol, Albany, NY 12224- 0341, 1-800-771-7755, and https://ag.ny.gov/.

For Rhode Island residents, the Rhode Island Attorney General can be reached at 150 South Main Street, Providence, Rhode Island 02903, www.riag.ri.gov, and 1-401-274-4400. Under Rhode Island law, you have the right to obtain any police report filed in regard to this incident.

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