CONSENT ANGREEMENT (Remote Eczema Coaching)

FOR PROVISION OF Remote Eczema Coaching By signing this, you consent to a clinical care team (referred to as “Provider”) providing Eczema coaching services (referred to as “Coaching Services”) as fully described below. Coaching Services are available to you because you have been diagnosed Eczema. Coaching Services can help in managing your Eczema under the supervision of a care provider. Coaching Services include logging of Eczema severity, triggers and care routine with regular physician review available through the EczemaLess App for patients who meet the following criteria:
  • You must have Eczema
  • You must have an Android or iOS device with internet access which you can operate daily (including use a password)
  • You must have an email address
Provider’s Obligations: When providing Coaching Services, the Provider must:
  • If you revoke this Agreement, provide you with a written confirmation of the revocation, stating the effective date of the revocation.
Beneficiary Acknowledgement and Authorization: By agreeing to this Agreement, you agree to the following:
  • You consent to the Provider providing Coaching Services to you.
  • You authorize electronic communication of your medical information with other treating providers as part of coordination of your care.
  • You acknowledge that only one practitioner can furnish Coaching Services to you during a calendar month. · You understand there might be costs associated with the Coaching Services, so you may be billed for it based on your plan.
Beneficiary Rights: You have the following rights with respect to Coaching Services:
  • You have the right to stop Coaching Services at any time by revoking this Agreement effective at the end of the then-current month. You may revoke this agreement verbally (by calling the provider) or in writing. Upon receipt of your revocation, the Provider will give you written confirmation (including effective date) of revocation.