Last Updated: April 9th, 2026
CONSENT TO TELEHEALTH, TREATMENT-SPECIFIC CONSENT, CONSENT TO TEXT OR EMAIL COMMUNICATION, AUTHORIZATION TO USE AND DISCLOSE MY MEDICAL INFORMATION, and ASSIGNMENT OF BENEFITS
This Telehealth Consent Form applies to telehealth services provided by independent providers and affiliated medical practices (the “Practice”) using technology facilitated by Helix Seven, LLC (“Helix Seven”). Helix Seven works with third-party administrative and technology service providers, including OpenLoop Health, to support the delivery of telehealth services.
HELIX SEVEN IS NOT A MEDICAL PROVIDER OR PRACTISE. OUR HEALTHCARE PROVIDERS DO NOT ADDRESS MEDICAL EMERGENCIES. IF YOU BELIEVE YOU ARE HAVING A MEDICAL EMERGENCY, YOU SHOULD DIAL 911 OR GO TO THE NEAREST EMERGENCY ROOM.
BY CLICKING “I AGREE,” CHECKING A RELATED BOX TO SIGNIFY YOUR ACCEPTANCE, USING ANY OTHER ACCEPTANCE PROTOCOL PRESENTED THROUGH THE SERVICE OR OTHERWISE AFFIRMATIVELY ACCEPTING THIS CONSENT, YOU ACKNOWLEDGE THAT YOU HAVE READ, ACCEPTED, AND AGREED TO BE BOUND BY THIS CONSENT. IF YOU DO NOT AGREE TO THIS CONSENT, DO NOT CREATE AN ACCOUNT OR USE THE SERVICE. YOU HEREBY GRANT AGENCY AUTHORITY TO ANY PARTY WHO CLICKS ON THE “I AGREE” BUTTON OR OTHERWISE INDICATES ACCEPTANCE TO THIS CONSENT ON YOUR BEHALF.
Telehealth is a mode of delivering healthcare services via communication technologies to facilitate diagnosis, consultation, treatment, education, care management, and self-management of a patient’s healthcare.
The purpose of this consent form (“Consent”) is to provide you with information about telehealth and to obtain your informed consent to the use of telehealth in the delivery of healthcare and/or mental health services to you by physicians, physician assistants, nurse practitioners, and/or mental health professionals (“Providers”) using the online platforms and services made available through Helix Seven (the “Service”).
In this Consent, the terms “you” and “yours” refer to the person using the Service, or in the case of use of the Service by or on behalf of an individual minor between the ages of thirteen (13) and eighteen (18) (or higher age of majority under applicable state law), “you” and “yours” refer to and include:
(i) the parent or legal guardian who provides consent to the use of the Service by such minor or uses the Service on behalf of such minor; and
(ii) the minor for whom consent is being provided or on whose behalf the Service is being utilized.
You are reviewing and acknowledging this Telehealth Consent Form because you are seeking healthcare services from the Practice utilizing telehealth technologies facilitated through the Helix Seven website, mobile app(s), web app(s), or partner platforms that integrate the Helix Seven experience (collectively, the “Platform”).
This Telehealth Consent Form supplements but does not modify or supersede any Terms of Use, Privacy Policy, Notice of Privacy Practices, or other policies of the Practice, Helix Seven, or any other healthcare providers offering services via the Platform.
By clicking “I consent to telehealth,” you indicate that you have reviewed this Telehealth Consent Form (or had it explained to you), you understand the risks and limitations of using telehealth technologies, you have been given the opportunity to ask questions (and those questions have been answered to your satisfaction), you have been given the opportunity to exercise opt-out rights where appropriate, and you consent to receiving services from licensed Providers who may be located at sites remote from you.
If you would like to speak to the privacy team, please send an email to support@helixseven.com with the subject line of “Attn: Privacy Policy Telehealth Consent.” A member of our privacy team will reach out to you via email or schedule a call where applicable.
By clicking “I consent to telehealth,” you understand and agree to the following:
1. Telehealth modality. I understand that the Practice offers telehealth visits conducted through videoconferencing, telephone, and asynchronous technology, and my Provider will not be present in the room with me.
2. Records access. I consent to the Practice importing and accessing my medical records and medication list, including prescription records, where permitted by law and necessary for my care.
3. Privacy during visits. To protect confidentiality, I agree to undertake my telehealth visit in a private location, and I understand my Provider will similarly be in a private location. If any other individuals are present (e.g., for technical or translation assistance), I will be informed of their presence and role and given the opportunity to consent.
4. Technology risks & hold harmless (platform-related). I understand there are potential risks to the use of telehealth technology, including interruptions, delays, unauthorized access, technical difficulties, data processing errors, AI misinterpretation, recording failures, and ambient listening inaccuracies. I understand that either my Provider or I can discontinue the appointment if the connection is not adequate.
I AGREE TO HOLD HARMLESS THE PRACTICE AND HELIX SEVEN, LLC (AS THE TECHNOLOGY/ADMINISTRATIVE SERVICES PROVIDER), AND EACH OF THEIR RESPECTIVE EMPLOYEES, CONTRACTORS, AGENTS, DIRECTORS, MEMBERS, MANAGERS, SHAREHOLDERS, OFFICERS, REPRESENTATIVES, ASSIGNS, PREDECESSORS, AND SUCCESSORS, FOR DELAYS IN EVALUATION OR INFORMATION LOST DUE TO SUCH TECHNICAL FAILURES, OR FOR ISSUES ARISING FROM THE USE OF PERMITTED AI TECHNOLOGIES, RECORDINGS, OR AMBIENT LISTENING SYSTEMS, TO THE EXTENT ALLOWED BY LAW.
5. AI use (general). I understand my visit may involve AI technologies for purposes including transcription, analysis of medical information, clinical decision support, quality assurance, and improvement of telehealth services. AI systems may process, analyze, and store information from my visit, including my voice, image, and information shared. AI processing may occur in real time and/or after the visit. Information processed by AI will be protected in accordance with applicable privacy laws and the Practice’s policies. I may request information about what AI technologies are being used and how my information is processed.
6. AI decision support limitations. I understand my Provider may use AI tools to assist with analyzing data, supporting clinical decision-making, generating summaries or documentation, or recommending potential diagnoses or treatment options. AI tools support—not replace—professional judgment. I understand my Provider will review AI-assisted outputs before making clinical decisions, and I may ask questions about AI use and request that AI not be used in certain aspects of care where feasible.
7. Recording. I understand my telehealth visit may be recorded (audio and/or video) for purposes including quality assurance, provider training, clinical documentation, and care coordination. I understand I will be notified at the beginning of any recorded session. Recordings may be retained consistent with law and retention policies. I may request access to recordings, subject to applicable laws and the Practice’s policies.
8. Ambient listening. I understand ambient listening technologies may be used to capture relevant clinical information during my visit, including through third parties contracted by the Practice and/or Helix Seven. I can request ambient listening be disabled during portions of my visit by notifying my Provider. I have the right to know when ambient listening is active.
9. Provider type. I understand that in some cases my Provider may be a nurse practitioner or physician assistant and not a physician.
10. Limits of telehealth. I understand I could seek in-office care instead. I understand my Provider may not have a complete copy of my records and cannot perform an in-person exam, which could result in negative outcomes (e.g., drug interactions or allergic reactions). No benefits or specific results are guaranteed, and my condition may not improve.
11.Beta/technology limitations. Certain technology may be in beta or development and may contain bugs or errors that could limit functionality, produce erroneous results, cause downtime, create incorrect records or transmissions, or cause data to be corrupted or lost—potentially impacting quality, accuracy, and/or effectiveness of care.
12. Evolving field. Telehealth is evolving and may include uses of technology not specifically described here. No benefits or specific results can be guaranteed, including lab results or related diagnosis or treatment. Some conditions may not be appropriate for telehealth.
13. Accuracy of information. I agree that the information I provide is accurate, true, and complete.
14. Inappropriate determination. I understand my Provider may determine telehealth is not appropriate for my concern. In that case: (i) I may receive an alert that I cannot use the Services for that issue; (ii) my request may not be submitted to a Provider; (iii) the Provider may not receive what I submitted; and (iv) I must seek care another way.
15. Prescriptions not guaranteed. I understand telehealth is not a guarantee of a prescription; prescribing decisions are made by the Provider’s professional judgment.
16. Pharmacy/lab choice. If the Platform provides access to certain pharmacies or labs, I may request to use any pharmacy or lab of my choice, where permitted.
17. Payment responsibility. I am responsible for payment of amounts due for services I receive.
18. No emergencies. Providers do not address medical emergencies via the Platform, and may direct me to emergency services.
19. Minor consent. If I am a parent/legal guardian of a minor, I authorize consent to medical orders, lab orders, diagnosis, or treatment and confirm I have legal authority to consent.
20. Third-party beneficiary. I understand and agree that Helix Seven, LLC is a third-party beneficiary of this Telehealth Consent Form and has the right to enforce it against me.
21. Authorization to use/disclose PHI for telehealth treatment. I give permission to the Practice and Providers to use and disclose my protected health information, including my medical record, for telehealth treatment purposes.
a. If the recipient is not a healthcare provider or health plan covered by HIPAA, the information may be redisclosed and no longer protected by HIPAA.
b. I may refuse to sign this authorization. Refusal will not affect payment, treatment, or eligibility for benefits, unless permitted exceptions apply (e.g., research-related treatment, enrollment, or services solely for third-party disclosure).
c. I may inspect or copy PHI to be used or disclosed under this authorization, subject to law (including clinical trial limitations).
d. I may revoke this authorization in writing at any time by notifying the Privacy Officer by emailing support@helixseven.com with the subject line “Request to Revoke PHI Authorization.” Please include your full name, date of birth, and the email address associated with your account so we can verify and process your request. Revocation may not apply to actions taken before receipt.
This section applies if a Provider prescribes compounded medications:
1. I understand the FDA does not approve or review compounded products for safety, effectiveness, or quality.
2. I understand compounding pharmacies are licensed and subject to state and federal regulations and must follow quality standards.
3. Safety information about prescribed medications is available at Safety Information.
If I receive telehealth consultation related to mental/behavioral health (“Teletherapy”):
1. I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment.
2. The laws that protect the confidentiality laws o m medical information also apply to Teletherapy. As such, I understand that the information disclosed by me during the course of a Teletherapy session generally is confidential unless an exception to confidentiality applies (e.g., mandatory reporting of child, elder or vulnerable adult abuse; if my Provider believes I may be a danger to myself or others; or if I raise emotional or mental health as an issue in a legal proceeding).
3. In addition, I understand that Teletherapy services and care may not be as complete as face-to-face services. I also understand that if my Provider believes I would be better served by another form of therapeutic services (e.g., face-to-face services) I will be referred to a professional who can provide such services in my area.
4. I understand that I may benefit from Teletherapy, but that results cannot be guaranteed or assured. I understand that there are potential risks and benefits associated with any form of counseling, and that despite my efforts and the efforts of my Provider, my condition may not improve, and in some cases may even get worse.
5. I accept that Teletherapy is not meant to cover emergency situations. If I am having suicidal thoughts or making plans to harm myself, I can call the National Suicide Prevention Lifeline at 1.800.273.TALK (8255) for free 24 hour hotline support. Patients who are actively at risk of harm to self or others are not suitable for Teletherapy services. If this is the case or becomes the case in future, my Provider will recommend more appropriate services.
6. I understand that dissemination of any personally identifiable images or information from the Teletherapy interaction to researchers or other entities shall not occur without my written consent.
7. I understand that my Provider may need to contact my emergency contact and/or the appropriate authorities in case of an emergency. I agree to inform my Provider of the address where I am located at the beginning of each session, and agree to provide the name of a contact person who my Provider may contact on my behalf in an emergency situation.
The following consent applies to patients accessing the Services to receive a telehealth consultation related to Human Immunodeficiency Virus (“HIV”) testing.
HIV is the virus that causes acquired immunodeficiency syndrome (“AIDS”) and can be transmitted through unprotected sex with some who has HIV; contact with blood, including via contaminated hypodermic needles or blood transfusions; by HIV-infected pregnant women to their infants during pregnancy or delivery; or while breastfeeding.
HIV can be detected via an HIV antibody test. The HIV antibody test is a blood test that shows whether you have antibodies to the virus that causes AIDS. A sample of blood will be taken from your arm with a needle. If the first test shows that you have antibodies, a series of tests will then be done on the same blood sample to ensure the first test was correct. A positive result means that you have been exposed to the virus and are infected with HIV. It does not mean that you have AIDS or that you will become sick with AIDS in the future. While HIV can lead to AIDS, this test does not say whether you have AIDS. However, a positive result also means you could pass the virus to other people. There is treatment for HIV that can help you stay healthy. Individuals with HIV and/or AIDS can adopt safe practices to protect uninfected and infected people in their lives from becoming infected, or being infected themselves with different strains of HIV.
A negative test means you are unlikely to be infected with the virus. It takes time for the body to produce HIV antibodies. If you have been exposed to HIV recently, you will need to be retested in several months to be sure you’re not infected. Your Provider will explain this to you.
Taking an HIV test is entirely voluntary. If you do not wish to take the test, you may decline and we will not perform the test. This test is not provided on an anonymous basis. Please seek an anonymous test site if you prefer for your HIV test information and results to remain anonymous. Anonymous testing sites are places where you can receive counseling and the HIV test without giving your name or address. You can find the nearest anonymous test site by contacting your local health department.
There are federal and state laws that protect the confidentiality of your HIV test results and related information. Please note, however, that we may disclose your results as required by law for reporting to appropriate public health authorities. There are federal and state laws that prohibit discrimination based on your HIV status and there may be services available to help with any such discrimination.
The following consent applies to patients accessing the Services to receive a telehealth consultation related to genetic testing.
I acknowledge that I may be offered genetic testing as part of the Services. Testing for genetic conditions can be complex and the specifics of the test, including the methods for collecting a biologic specimen, will vary depending on the condition tested for. There are risks and benefits to genetic testing. If I am offered genetic testing as part of the Services, my Provider will explain the specifics of my particular test to me, and I will have the opportunity to obtain professional genetic counseling prior to completing the test to fully understand the risks and benefits.
Certain healthcare services provided to you by Providers via the Service may require that you complete an at-home diagnostic test. These diagnostic tests are provided by third-party laboratories, and neither Helix Seven, it's subsidaries, nor your Provider(s) can guarantee the accuracy or reliability of these tests. These laboratory tests can provide false negative, false positive, or inconclusive results that could impact your Provider(s) ability to correctly diagnose or treat your medical conditions. A failure or defect of these tests could also impact your Provider(s) ability to correctly diagnose or treat your medical conditions.
By clicking “I accept,” I confirm the information I provided is true, correct, and complete to the best of my knowledge.
I authorize Helix Seven's third party providers to bill my insurance company directly and I further authorize any third-party payer through which I have benefits to make payment directly to Practice. I understand that I am financially responsible for any balance. I also authorize Practice or my insurance company to use and disclose any healthcare information for the purpose of obtaining payment for services and determining insurance benefits. Services provided by outside companies (i.e., lab, pathology, radiology) are billed separately by those companies.
By clicking “I accept,” I authorize the Practice (and, where applicable, Helix Seven acting on the Practice’s behalf for administrative communications) to contact me via phone call, SMS/text message, or email at the contact information I provided for:
Appointment reminders
Patient feedback requests
General health and wellness information
I understand and agree to the following:
These communications may be generated in part by automated systems or AI.
Standard messaging and data rates may apply.
This authorization remains effective unless I revoke it in writing.
I may opt out at any time by following opt-out instructions in messages or contacting the Practice directly.
Text/email communications may present security risks of unauthorized access to PHI. I accept this risk and consent to receive communications this way.
If you prefer not to receive reminders or health information via text/email, notify us in writing or email support@helixseven.com
The following consents apply to patients receiving telehealth services within the listed states, as required by state law:
Alaska: I understand my primary care provider may obtain a copy of my telehealth encounter records.
California: The Open Payments database is a federal tool to search certain payments made by drug/device companies to physicians and teaching hospitals: https://openpaymentsdata.cms.gov
For informational purposes only, a link to the federal Centers for Medicare and Medicaid Services (CMS) Open Payments web page is provided above. The federal Physician Payments Sunshine Act requires that detailed information about payment and other payments of value worth over ten dollars ($10) from manufacturers of drugs, medical devices, and biologics to physicians and teaching hospitals be made available to the public.
If I live in one of the following states, my primary care provider or other treating physician may obtain a copy of my telehealth treatment records with my consent, and Practice may securely send a copy of my telehealth treatment records to my primary care provider or other treating physician. If I need help sending my telehealth treatment records to my primary care provider I can contact call 1-855-597-1248 If I would like Practice to do so, I can contact call 1-855-597-1248 and provide information necessary for Practice to securely send my records.
Connecticut: I understand my primary care provider may obtain a copy of my telehealth encounter records.
Kansas: I understand that if I have a primary care provider or other treating physician, the telemedicine provider must send a report to such provider of the treatment and services rendered during the encounter within three days of me providing consent to send such report.
New Hampshire: I understand my primary care provider or treating provider may obtain a copy of my telehealth encounter records.
New Jersey: I understand I may request a copy of my medical information, and it may be forwarded to my primary care provider/provider of record, or to other providers upon my request.g opt-out instructions in messages or contacting the Practice directly.
Ohio: I understand my primary care provider may obtain a copy of my telehealth encounter records.
South Carolina: I understand my medical records may be distributed only with my consent and in accordance with law to other treating practitioners.
Texas: I understand that with my consent my medical records may be sent to my primary care physician within 72 hours after receiving services.
Billing (NJ, NY, RI)
Patients in New Jersey, New York, and Rhode Island have the right under each state’s billing laws to request an itemized price list for laboratory results.
California: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website here, or the physician assistant board’s website here.
Georgia: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here.
Idaho: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here.
ndiana: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here.
Iowa: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here.
Kentucky: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here.
Maine: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here.
New York: I have been informed that to get information regarding your rights and how to report professional misconduct, I should visit here.
Oklahoma: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here; or, the Oklahoma Board of Osteopathic Examiners’ website, here.
Oregon: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here.
Rhode Island: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here.
Texas: NOTICE CONCERNING COMPLAINTS - Complaints about physicians, as well as other licensees and registrants of the Texas Medical Board, including physician assistants, acupuncturists, and surgical assistants may be reported for investigation at the following address: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018, Assistance in filing a complaint is available by calling the following telephone number: 1-800-201-9353, For more information, please visit our website at www.tmb.state.tx.us.
AVISO SOBRE LAS QUEJAS - Las quejas sobre médicos, asi como sobre otros profesionales acreditados e inscritos del Consejo Médico de Tejas, incluyendo asistentes de médicos, practicantes de acupuntura y asistentes de cirugia, se pueden presentar en la siguiente dirección para ser investigadas: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018, Si necesita ayuda para presentar una queja, llame al: 1-800-201-9353, Para obtener más información, visite nuestro sitio web en www.tmb.state.tx.us.
Vermont: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here; or, the Vermont Board of Osteopathic Examiners’ website, here.
Wyoming: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here.
Privacy Officer
Email: support@helixseven.com
Mailing Address:
6316 College Blvd
Overland Park, KS 66211, US
For privacy-related inquiries or questions about this consent, please contact Helix Seven using the information above. Certain healthcare services are provided by independent providers and affiliated medical groups, which may use third-party administrative and technology service providers, including OpenLoop Health.
For General Inquiries:
hello@helixseven.comFor Existing Customers:
support@helixseven.com
The assessment on this website does not create a doctor–patient relationship or replace medical advice. Helix Seven does not provide emergency medical services. Clinical eligibility is determined by U.S.-licensed healthcare providers following medical review. Providers retain full discretion to prescribe or decline treatment. Compounded medications, when prescribed, are prepared by U.S. FDA-registered pharmacies but are not FDA-approved. The FDA does not review compounded drugs for safety, effectiveness, or quality. Medications are prescribed by licensed healthcare providers when clinically appropriate. Individual results may vary. Medical services are provided by licensed healthcare providers affiliated with OpenLoop Health. Helix Seven does not provide medical care.
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