Last Updated: February 24, 2023.
Telehealth involves the use of secure 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 clinical care. This “Telehealth Informed Consent” informs the patient (“patient,” “you,” or “your”) concerning the treatment methods, risks, and limitations of using a telehealth platform, as well as the means by which the healthcare provider and affiliates may communicate with you.
Telehealth services offered by Pippen Health of Delaware, P.A, Pippen Health of California, P.C., Pippen Health of Texas, P.A., other affiliated medical groups, as well as subcontractors working for other health provider entities or health systems (collectively, “Medical Group”), and the Medical Group’s engaged providers (our “Providers” or your “Provider”) may include a patient consultation, diagnosis, treatment recommendation, prescription, and/or a referral to in-person care, as determined clinically appropriate (the “Services”). Your Provider will be licensed in the state where you are located at the time of your consultation, or otherwise meet a professional licensure exception under applicable state law, and will establish a provider-patient relationship in accordance with the laws and rules in the applicable state.
Found Health, Inc. (“Found”) does not provide the Services; it performs administrative, payment, and other supportive activities for Medical Group and our Providers.
The types of electronic transmissions that may occur using the telehealth Platform (defined below) include, but are not limited to:
- Appointment scheduling;
- Completion, exchange, and review of medical intake forms and other clinically relevant information (for example: health records; images; output data from medical devices; sound and video files; diagnostic and/or lab test results) between you and your Provider via:
- asynchronous communications;
- two-way interactive audio in combination with store-and-forward communications; and/or
- two-way interactive audio and video interaction;
- Treatment recommendations by your Provider based upon such review and exchange of clinical information;
- Delivery of a consultation report with a diagnosis, treatment and/or prescription recommendations, as deemed clinically relevant;
- Prescription refill reminders (if applicable); and/or
- Other electronic transmissions for the purpose of rendering clinical care to you.
- Improved access to care by enabling you to remain in your preferred location while your Provider consults with you.
- Convenient access to follow-up care. If you need to receive non-emergent follow-up care related to your treatment, please contact our Providers by directly sending a message through the secure message service in the Platform;
- More efficient care evaluation and management.
- The primary difference between telehealth and direct in-person service delivery is the Provider’s inability to have direct, physical contact with the patient. Accordingly, some clinical needs may not be appropriate for a telehealth visit and your Provider will make that determination.
- Medical group Providers do not address medical emergencies. If you believe you are experiencing a medical emergency, you should dial 9-1-1 and/or go to the nearest emergency room. Please do not attempt to contact Found Health, INC., Medical Group, or your Provider. After receiving emergency healthcare treatment, you should visit your local primary care Provider.
- If you are not experiencing an emergency or do not require immediate or urgent care, you can communicate with Providers through the secure message service in the Platform. If a technical failure prevents you from communicating with your Providers through the Platform, please email us immediately at email@example.com.
- Our Providers are an addition to, and not a replacement for, your local primary care provider. Responsibility for your overall medical care should remain with your local primary care provider, if you have one, and we strongly encourage you to locate one if you do not.
- Medical Group does not have any in-person clinic locations for patient care.
The electronic communication systems we use will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption. All the Services delivered to the patient through telehealth will be delivered over a secure connection that complies with the requirements of the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”).
- Delays in evaluation and treatment could occur due to deficiencies or failures of the equipment and technologies, or Provider availability.
- In the event of an inability to communicate as a result of a technological or equipment failure, please contact the Medical Group at firstname.lastname@example.org.
- In rare events, your Provider may determine that the transmitted information is of inadequate quality, thus necessitating a rescheduled telehealth consult or an in-person meeting with your local primary care doctor.
- In very rare events, security protocols could fail, causing a breach of privacy of personal medical information.
I further acknowledge and understand the following:
- Prior to the telehealth visit, I will be given an opportunity to select a provider as appropriate, including a review of the provider’s credentials, or I have elected to visit with the next available provider from the Medical Group, and have been given my Provider’s credentials.
- If I am experiencing a medical emergency, I will be directed to dial 9-1-1 immediately and my Provider is not able to connect me directly to any local emergency services.
- I may elect to seek services from a medical group or provider with in-person clinics as an alternative to receiving telehealth services.
- 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.
- Federal and state law requires health care providers to protect the privacy and the 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.
- Medical Group will take steps to make sure that my health information is not seen by anyone who should not see it. Telehealth may involve electronic communication of my personal health information to other health practitioners who may be located in other areas, including out of state.
- Dissemination of any patient identifiable images or information from the telehealth visit to researchers or other educational entities will not occur without my affirmative consent.
- There is a risk of technical failures during the telehealth visit beyond the control of Medical Group. I AGREE TO HOLD HARMLESS MEDICAL GROUP AND ITS PROVIDERS, EMPLOYEES, CONTRACTORS, AGENTS, DIRECTORS, MEMBERS, MANAGERS, SHAREHOLDERS, OFFICERS, ASSIGNS, REPRESENTATIVES, PARENTS, PRE- DECESSORS, AND SUCCESSORS FOR DELAYS IN EVALUATION OR FOR INFORMATION LOST DUE TO SUCH TECHNICAL FAILURES.
- In choosing to participate in a telehealth visit, I understand that some parts of the Services involving tests (e.g., labs or bloodwork) may be conducted at another location such as a testing facility, my home, at the direction of my Provider. or when clinically appropriate.
- Persons may be present during the telehealth visit other than my Provider in order to operate the telehealth technologies. If another person is present during the telehealth visit, I will be informed of the individual’s presence and his/her role and I have the right to request the following: (i) omit specific details of my medical history/examination that are personally sensitive to me; (ii) ask non-medical personnel to leave the telehealth consultation; and/or (iii) terminate the consultation at any time.
- My Provider will explain my diagnosis and its evidentiary basis, and the risks and benefits of various treatment options.
- I have the right to request a copy of my medical records. I can request to obtain or send a copy of my medical records to my primary care or other designated health care provider by contacting the Medical Group at: email@example.com. A copy will be provided to me at reasonable cost of preparation, shipping and delivery.
- There is no guarantee that I will be issued a prescription and that the decision of whether a prescription is appropriate will be made in the professional judgment of my Provider. If my Provider issues a prescription, I have the right to select the pharmacy of my choice. Found Health, Inc. has commercial relationships with certain third-party pharmacies. Found leverages these third party pharmacies to fulfill orders directly to your door; however, you are free to obtain your prescription from any pharmacy of your choice by contacting us at firstname.lastname@example.org.
- There is no guarantee that I will be treated by a Medical Group Provider. My Provider reserves the right to deny care for potential misuse of the Services or for any other reason if, in the professional judgment of my Provider, the provision of the Services is not medically or ethically appropriate.
- I agree to receive invitations, notifications, reminders and other communications from my Provider, Medical Group and Found Health, Inc. and any of its affiliates or agents through the Found websites or mobile application (the “Platform” or “Found App”), or by email, text message (including any short message service), fax, phone or other method of communication. I agree and authorize my Provider, Medical Group and Found to make such communications through use of an automatic telephone dialing system and/or an artificial or prerecorded voice message system (“Automated Messages”) at any of the contact information provided to Found or my Provider or to other service providers who are working with Found or the Medical Group. I will immediately notify my Provider if there are any changes to my mobile phone or other contact information.
- I understand that Automated Messages may include (without limitation) an invitation to download and use the Found App. I understand that I may receive multiple messages per day, and that I am responsible for any message and data rates charged by my mobile carrier. These communications may not be secure (not encrypted). Unsecured communications may pose a risk to the confidentiality and privacy of the information being sent because they might be intercepted by a third party. I also understand that my consent to receive Automated Messages is optional and is not a condition to getting treatment or to my ability to use the Found App. I can opt out of receiving Automated Messages at any time, including by contacting Found or the Found Medical Group at email@example.com or replying “STOP” to an automated text message.
Additional State-Specific Consents and Disclosures.
The following consents apply to patients accessing Medical Group’s website for the purposes of participating in a telehealth consultation as required by the states listed below:
Alaska: I understand that my primary care provider may obtain a copy of my records of my telehealth encounter. 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.
Connecticut: I understand that my primary care provider may obtain a copy of my records of my telehealth encounter.
Florida: To view your rights under Florida’s Patient Bill of Rights and Responsibilities, I should visit the Florida Agency for Health Care Administration, 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.
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.
Indiana: 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.
Kansas: I understand that if I have a primary care provider or other treating physician, the person providing telemedicine services must send a report to such primary care or other treating physician of the treatment and services rendered to me during the telemedicine encounter within three days of me providing consent to the person providing telemedicine services to send such report.
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; or, the Maine Board of Osteopathic Licensure’s website, here.
New Hampshire: I understand that my primary care provider or treating provider may obtain a copy of my records of my telehealth encounter.
Ohio: I understand that my primary care provider may obtain a copy of my records of my telehealth encounter.
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.
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.
South Carolina: I understand that my medical records may be distributed only with my consent and in accordance with applicable laws and regulations to other treating health care 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.
I have also been informed of the following notice:
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 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.
I understand that I have the right to receive a consult with a distant-site provider and will receive one upon request immediately or within a reasonable time after the results of the initial consult. I understand that receiving telemedicine services via Found’s Platform does not preclude me from receiving real-time telemedicine or face-to-face services with the distant provider at a future date. (VT Stat. Ann. § 9361).
I have been informed that if I want to register a formal complaint about a provider, I should visit the Vermont Board of Medical Practice website, here or the Vermont Board of Osteopathic Examiners, here.