Telehealth Informed Consent

Effective [EFFECTIVE DATE]  ·  Last updated [DATE]

This Consent applies when you receive care from a licensed provider through Omni Health System by telehealth — video, phone, or secure messaging. Please read it before your first encounter. You will be asked to acknowledge it in the app.

What telehealth is

Telehealth is the delivery of health care using electronic communications when you and your provider are in different locations. It may include live video or phone visits, secure messaging, and review of information you have shared — including data from your connected devices, labs, and health record.

Expected benefits

• Access to care without travelling to an office.
• Care informed by your own longitudinal data rather than a single point in time.
• More timely follow-up and adjustment of your plan.

Risks and limitations

• A provider cannot physically examine you. Some conditions cannot be properly assessed without an in-person exam, and a provider may determine that telehealth is not appropriate for your situation.
• Information transmitted may be insufficient — for example, poor video or audio quality — leading to delays in evaluation.
• Technology failures may interrupt or delay care.
• Despite security measures, no electronic transmission can be guaranteed fully secure.
• Data from consumer wearables and self-reported inputs may be inaccurate or incomplete, and clinical decisions rely in part on what you report.
• Delays in evaluation or treatment could occur due to a technology or scheduling failure.

Your rights

• You may withdraw this consent at any time without affecting your right to future care or treatment.
• You may request an in-person referral, or decline telehealth and seek care elsewhere.
• You may ask that non-medical personnel be excluded from a telehealth encounter.
• Your PHI is protected as described in our Notice of Privacy Practices.
• You are entitled to a copy of the records of your telehealth encounters.

Recording

[CONFIRM: whether encounters are recorded, whether recordings are retained, and how consent is captured. Several states require all-party consent to record.] Encounters are not recorded without your explicit consent.

Licensure and location

Providers are licensed in the state where you are located at the time of the encounter. You must tell us your physical location at the start of each encounter. Services are available only in states where a suitably licensed provider is available. [CONFIRM active state list and how location is verified.]

Prescriptions

A provider may prescribe when clinically appropriate, in accordance with applicable law and professional standards. No prescription is guaranteed. Certain medications cannot be prescribed by telehealth, and some require an in-person evaluation or additional testing. Providers exercise independent clinical judgment and may decline to prescribe or may recommend in-person care instead.

Fees

Fees for consultations and programs are disclosed before you are charged. [CONFIRM: whether any services are billed to insurance, and the good-faith-estimate obligations under the No Surprises Act for self-pay patients.]

Acknowledgement

By proceeding with a telehealth encounter, you confirm that you have read and understood this Consent, that you have had the opportunity to ask questions, and that you consent to receive care by telehealth from Omni Health System providers.