Telehealth Consent

I understand that Helix Seven separately engages telehealth companies, which are independently owned by licensed physicians (“telehealth partners”). Helix Seven does not own these medical practices, employ or in any way supervise or control the telehealth partners rendering care. Through its technology platform, Helix Seven facilitates the provision of telehealth services but it is not itself, a source of healthcare, medical advice, or care. This Consent is effective and binding across all telehealth sessions or services rendered by the telehealth partners via Helix Seven’s technology platform.

Telehealth or telemedicine (the terms will be used interchangeably throughout this Consent) involves the use of electronic communications, information technology, or other means to enable a healthcare provider and a patient at different locations to communicate and share individual patient health information for the purpose of rendering health care services. Telehealth or telemedicine may be used for assessment, treatment, diagnosis, prescription, follow-up, and/or patient education. This Consent informs you concerning the treatment methods, risks, and limitations of using a telehealth platform.

1. Electronic Transmissions. The types of electronic transmissions that may occur using the telehealth platform include, but are not limited to:
   1. Completion, exchange, and review of relevant medical information (for example: health records; images; output data from medical devices; sound and video files; diagnostic and/or lab test results) between you and a healthcare provider via: asynchronous or synchronous communications; two-way interactive audio; and/or two-way interactive audio and video interaction;
   2. Treatment recommendations by a healthcare provider based upon such review and exchange of clinical information;
   3. Delivery of a consultation report with a diagnosis, treatment and/or prescriptions, as deemed medically relevant;
   4. Prescription refill reminders (if applicable); and/or
   5. Other electronic transmissions for the purpose of rendering health care services to you.
2. Recording. With this consent, the telehealth session may be recorded for quality review, operations, training, research, and safety purposes.
3. Benefits. Telehealth provides an array of benefits to you, including
   1. improved access to healthcare providers by allowing you to consult a provider from your home or office; and
   2. improved efficiency for access to medical evaluation and management.
4. Risks. As with any medical procedure, there are potential risks associated with the use of telemedicine. These risks may include, without limitation, the following:
   1. Technical problems: digital issues such as video quality, sound quality, or connectivity issues that may require an encounter to be rescheduled;
   2. Although measures are in place to prevent a breach of privacy, security protocols could fail, causing a breach of privacy of personal medical information; and/or
   3. Provider’s inability to conduct a hands-on physical examination of me and my condition.
5. Patient Acknowledgments. I further acknowledge and understand the following:
   1. If I am experiencing a medical emergency, I will be directed to dial 9-1-1 immediately and the provider is not able to connect me directly to any local emergency services.
   2. I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time without affecting my right to future care or treatment.
   3. Federal and state law requires health care providers to protect the privacy and security of health information. I am entitled to all confidentiality protections under applicable federal and state laws. I understand all medical reports resulting from the telehealth visit are part of my medical record.
   4. Any provider’s advice, recommendations, and/or decisions may be based on factors not within his/her control, including incomplete or inaccurate data provided by me. I understand that the provider only relies on information provided by me during our telehealth encounter and that I must provide information about my medical history, condition(s), and current or previous medical care that is complete and accurate to the best of my ability. I also understand that the provider may not have access to my full medical record or information.
   5. A healthcare provider will provide care consistent with the prevailing standards of medical practice but makes no assurances or guarantees as to the results of treatment.
   6. There is no guarantee that all treatment of all patients will be effective.
   7. The laws of the state in which I am located will apply to my receipt of telehealth services.
   8. I have the right to review and receive copies of my medical records, including all information obtained during a telehealth interaction, subject to our standard policies regarding request and receipt of medical records and applicable law.
   9. The telehealth services are not a replacement for my primary care physician or annual office check-ups. Should I desire to seek in-office care through other providers, including my primary care physician, I can do so.
   10. Neither Helix Seven nor the telehealth partners are online pharmacies. However, Helix Seven does not control or supervise any prescription decision made by a telehealth partner.
   11. Any prescription obtained through the Helix Seven platform prescribed by a telehealth partner will be used only for its intended use.
   12. Neither Helix Seven nor the telehealth partners guarantee that a specific medication will be prescribed if requested.
   13. I hereby release and hold harmless Helix Seven and the telehealth providers from any loss of data or information due to technical failures associated with the telehealth/telemedicine service.
   14. I will be given information about test(s) and treatments(s), as applicable, including the benefits, risks, possible problems or complications, and alternate choices for my medical care through the telehealth/telemedicine visit.
   15. Failure to comply with the terms of this Consent may result in the termination of my ability to use the telehealth services.
6. Consent to Email, Cellular Telephone, or Text Usage for Healthcare Communications. If at any time I provide an email address or cellphone number at which I may be contacted, I consent to receiving unsecure instructions and other healthcare communications at the email or text address I have provided or Helix Seven or the telehealth partners have obtained, at any text number forwarded, or transferred from that number. These instructions may include, but are not limited to: follow-up instructions, educational information, and prescription information. Note: You may opt out of these communications at any time. The practice/clinic does not charge for this service, but standard text messaging rates or cellular telephone minutes may apply as provided in your wireless plan (contact your carrier for pricing plans and details).
7. Duration. This consent will remain fully effective until it is revoked.
8. Patient Consent to the Use of Telemedicine. I have read and understand the information provided above and understand the risks and benefits of telemedicine services. By accepting these terms, I hereby give consent to telehealth as an acceptable form of delivering healthcare services to me and that this consent will cover any and all of my sessions using telehealth.

This consent forms part of the Helix Seven Terms of Use.