Last Updated: January 27, 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 Helix Seven’s Independent Providers & Practices and/or its affiliated professional entities (collectively, the “Practice”) through technology facilitated by Helix Seven, LLC (“Helix Seven”).
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: [LINK OR LOCATION WHERE SAFETY INFO IS PROVIDED]
If I receive telehealth consultation related to mental/behavioral health (“Teletherapy”):
1. I may withhold or withdraw consent at any time without affecting my right to future care.
2. Confidentiality laws apply to Teletherapy, with exceptions (e.g., mandatory reporting; danger to self/others; court/legal proceedings where mental health is at issue).
3. Teletherapy may be less complete than in-person services; I may be referred locally if appropriate.
4. Results cannot be guaranteed; my condition may not improve and may worsen.
5. Not for emergencies. If I have suicidal thoughts or plans, I can call 988 (U.S. Suicide & Crisis Lifeline). Patients actively at risk are not suitable for Teletherapy, and more appropriate services may be recommended.
6. No dissemination of personally identifiable images/info to researchers/others without my written consent.
7. My Provider may contact my emergency contact/authorities in an emergency. I agree to provide my location address at the start of each session and provide an emergency contact.
If HIV testing is offered:
HIV is the virus that causes AIDS and can be transmitted through unprotected sex with an infected person, contact with blood, pregnancy/delivery, or breastfeeding.
HIV antibody testing may be performed via blood testing. Positive results indicate infection; it does not mean you have AIDS. Treatment is available.
Negative results may require retesting due to the time needed to develop antibodies.
Testing is voluntary. This is not anonymous testing. For anonymous testing, contact your local health department.
Confidentiality laws apply; results may be disclosed as required by law (e.g., public health reporting). Anti-discrimination protections may apply.
If genetic testing is offered:
I understand genetic testing can be complex; collection methods vary by test. My Provider will explain my specific test, and I may obtain professional genetic counseling prior to completing testing to understand risks and benefits.
Certain services may require an at-home diagnostic test provided by third-party laboratories. Neither Helix Seven nor the Practice can guarantee accuracy or reliability of tests. Tests may produce false negative, false positive, or inconclusive results that could affect diagnosis or treatment. Defects may also affect care decisions.
By clicking “I accept,” I confirm the information I provided is true, correct, and complete to the best of my knowledge.
I authorize the Practice to bill my insurance company directly and authorize any third-party payer to make payment directly to the Practice. I understand I am financially responsible for any balance. I also authorize the Practice or my insurance company to use and disclose healthcare information for payment and benefit determination. Services provided by outside companies (e.g., 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:
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
Treatment Records (Certain States): 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 the Practice may securely send a copy to my primary care provider or other treating physician. For help sending records, call [RECORDS PHONE].
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 / Idaho / Indiana / Iowa / Kentucky / Maine / Oregon / Rhode Island / Vermont / 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 (and where applicable, osteopathic board site here).
New York: I have been informed that to get information regarding my rights and how to report professional misconduct, I should visit here.
Oklahoma: I have been informed that I should visit the medical board’s website here; or the Oklahoma Board of Osteopathic Examiners’ website here.
Texas Notice Concerning Complaints (English / Spanish)
NOTICE CONCERNING COMPLAINTS — Complaints about physicians and other licensees/registrants of the Texas Medical Board (including PAs, acupuncturists, surgical assistants) may be reported to: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018. Assistance: 1-800-201-9353. Website: www.tmb.state.tx.us.
AVISO SOBRE LAS QUEJAS — Las quejas sobre médicos y otros profesionales acreditados e inscritos del Consejo Médico de Tejas (incluyendo asistentes de médicos, practicantes de acupuntura y asistentes de cirugía) se pueden presentar en: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018. Ayuda: 1-800-201-9353. Sitio web: www.tmb.state.tx.us.
The information provided on this website is for educational purposes only and is not intended as medical advice. Helix Seven does not provide emergency medical services. Treatment eligibility is determined by a licensed healthcare provider following a medical review. Compounded medications are prescribed only when clinically appropriate and are not FDA-approved; however, they are prepared by FDA-registered pharmacies in accordance with applicable regulations. Individual results may vary. Prescriptions are issued at the discretion of licensed providers.
%203%20(2).png)
