Telehealth &

Consent

Telegra MD, LLC

1. Choice of Telehealth. The Patient has elected to have a telehealth visit instead of an in-office visit. The Patient agrees that the Practice will determine whether the Patient's condition is appropriate for telehealth and acknowledges that the Practice may recommend an in-person visit in lieu of, or in addition to, the telehealth visit.
2. Provider Credentials. The Patient has had an opportunity to review the Practice's and the providers' credentials and has selected their preferred provider.
3. Potential Risks. The Patient acknowledges potential risks associated with telehealth, including: (a) information transmitted may be less comprehensive than during an in-person visit, which may affect diagnosis; (b) delays could occur due to failures of telehealth equipment; (c) security protocols could fail, causing a breach of privacy; and (d) miscommunication may occur due to technology issues, and certain diagnostic tests may not be possible to perform remotely.
4. Protected Health Information ("PHI"). The Patient understands that telehealth often involves electronic transmission of PHI, including individually identifiable health information, medical history, diagnoses, and communications with other health care providers. PHI may be lost due to technical failures, cyber intrusion, or other issues. The Patient assumes these risks and holds the Practice and its Providers harmless from any claims arising out of the use of telehealth. PHI obtained during the telehealth visit will not be disclosed without the Patient's consent unless permitted by law and in accordance with the Practice's Notice of Privacy Policies.
5. Communication with Primary Care Physician. The Patient has the right to request that information about their treatment be submitted to their primary care physician. Upon request and consent, the Practice will send the Patient's medical record and/or a report to the Patient's primary care physician within seventy-two (72) hours of the consultation.
6. Emergency Situations. The telehealth visit is not intended for emergency situations. In the event of a clinical emergency, the Patient must dial 911 immediately. The Patient agrees that: (a) the telehealth service is not a replacement for their existing relationship with their primary provider; (b) they will contact their primary provider if their condition changes or worsens; and (c) if emergency care is required, they will contact local emergency services immediately.
7. Right to Withdraw Consent. The Patient has the right to withhold or withdraw consent for telehealth at any time without affecting their right to future care, treatment, benefits, or programs. If others are present at the Patient's location during the visit, the confidentiality of the visit may be compromised.
8. Understanding of Alternatives. The Patient understands the alternatives to telehealth, such as an in-person encounter. In choosing to participate in a telehealth visit, the Patient understands that some parts of the exam may require in-person physical testing at the direction of the Practice providers.
9. Payment Terms. THE PATIENT UNDERSTANDS THAT THEY WILL BE RESPONSIBLE FOR PAYMENT. THE PRACTICE DOES NOT ACCEPT INSURANCE. ALL OUT-OF-POCKET EXPENSES ASSOCIATED WITH THE TELEHEALTH VISIT ARE DUE PRIOR TO THE TELEHEALTH VISIT.
10. Location Compliance. The Patient must be physically located in their home state (the state associated with their primary residence in their Brello profile) during telehealth consultations, and represents they will be located there for the entirety of each visit. If not physically located in their home state at the time of the visit, the Practice may decline to treat them via telehealth.
11. Prescribing Medication. The Practice's healthcare professionals may exercise their professional judgment to prescribe medication to treat the Patient's diagnosed condition, but there is no guarantee that medication will be prescribed. If prescribed, the Patient may request that their medication be filled at a pharmacy of their choice.
12. Acknowledgement of Risks and Questions. The Patient has been advised of all potential risks, consequences, and benefits of telehealth, including risks related to the security of electronic communications. The Patient has had the opportunity to ask questions about the information presented within this Telehealth Consent document, all questions have been answered, and the Patient understands the information contained herein.