Telehealth Informed Consent

Telehealth is the delivery of health care services, including evaluation, consultation, diagnosis, and treatment, using electronic communication technologies when you and your Clinician are in different locations. It lets you receive care without traveling to an office or scheduling a separate in-person appointment.

Asynchronous telehealth, often called “store-and-forward,” is care in which you and your Clinician send and review information at different times rather than in a live conversation. Examples include completing a secure medical questionnaire, uploading photos, and exchanging secure messages. It differs from synchronous telehealth, which is a live audio or video visit.

Through the MediRX platform, your care may include:

• Secure, store-and-forward medical questionnaires and uploads;
• Secure messaging with your Clinician and care team in the patient portal, and text (SMS/MMS) or email messages; and
• Live audio or video visits when your Clinician or your state's law requires them.

Price includes a professional telehealth consultation by an independent licensed clinician. A portion of the price represents a medical consult fee paid to the clinician.

• Convenient access to a licensed clinician without travel or waiting rooms;
• Faster evaluation and follow-up; and
• Ongoing access to your care team for questions, side effects, and dose changes.

As with any medical care, telehealth has risks. The likelihood of these risks is low, but they include:

• No physical exam. Your Clinician cannot examine you in person and relies on the information you provide. This may limit their ability to diagnose some conditions.
• Incomplete information. If you do not fully disclose your medical history, medications, supplements, allergies, or pregnancy status, you may experience adverse reactions, drug interactions, or other harm.
• Delays. Technology failures, internet outages, or poor-quality information may delay evaluation or treatment.
• Security. Despite safeguards, electronic systems could fail, causing a breach of your private health information.
• Not for emergencies. Telehealth services are not emergency services, and messages are not monitored 24/7. If you think you are having a medical emergency, call 911 or go to the nearest emergency room. If you are in crisis, call or text 988.

THE CARE YOU RECEIVE IS AT THE SOLE DISCRETION OF YOUR CLINICIAN. THERE IS NO GUARANTEE OF DIAGNOSIS, TREATMENT, OR PRESCRIPTION. YOUR CLINICIAN WILL DECIDE WHETHER YOUR CONDITION IS APPROPRIATE FOR TELEHEALTH AND MAY REFER YOU FOR IN-PERSON CARE.

By giving this consent, I understand and agree that:

1. I have the same privacy rights in telehealth as in an in-person visit. My identifiable information will not be shared with researchers or others without my written consent, except as permitted by law and described in the HIPAA Notice of Privacy Practices.
2. My medical information may be sent electronically to clinicians and pharmacies who may be located in a different state.
3. I may expect the benefits of telehealth, but no results are guaranteed.
4. I must be physically located in a state where the Services are offered at the time of each visit, and I will tell my care team if I move or travel.
5. My Clinician may require a live video or phone visit, lab work, or other information before or during treatment.
6. Everything I submit, including questionnaire answers and messages, and everything my Clinician enters, becomes part of my medical record. I may request a copy by emailing care@medirx.org.
7. My Clinician's first message to me will include their name and credentials, which will be recorded in my medical record.
8. I should maintain a relationship with a primary care provider and inform them of my treatment.
9. I have the right to refuse or stop telehealth at any time without affecting my right to future care, and I may seek in-person care instead.
10. I may withdraw this consent at any time by emailing care@medirx.org. Withdrawing consent does not affect care already provided, and medical records must be kept as required by law.
11. My health information may be disclosed without my consent as required or permitted by law, including in response to a valid court order, to report suspected abuse, neglect, or domestic violence, or to prevent or reduce a serious threat to anyone's health or safety.

This Telehealth Informed Consent remains in effect for the entire course of my treatment through the MediRX platform unless I withdraw it.