INFORMED CONSENT FOR TELEHEALTH SERVICES
Defined terms herein have the same meaning as set forth in our Terms and Conditions unless otherwise expressly stated, and this Informed Consent is deemed incorporated therein.
Please read this Informed Consent for Telehealth Services (“Consent”) carefully before receiving telehealth services. This document explains how telehealth services work, the risks and benefits of telehealth care, your rights as a patient, and the responsibilities of both you and the healthcare Providers.
By electronically signing, clicking “I Agree,” scheduling a telehealth appointment, or participating in a telehealth encounter, you acknowledge that you have read, understand, and agree to the terms below.
1. WHO IS PROVIDING YOUR CARE
Administrative and Technology Services
Administrative, scheduling, technology, payment processing, customer support, marketing, and other nonclinical management services are provided by Kal Health, LLC (the “MSO”).
The MSO is a management services organization and does not practice medicine, provide medical care, make clinical decisions, control clinical judgment, or interfere with the independent professional judgment of licensed healthcare Providers.
Clinical and Medical Services
Medical services are independently provided by Maiden Lane Medical PLLC (the “Practice”) and its affiliated licensed healthcare professionals (the “Providers”).
A provider-patient relationship is established only when a Provider agrees to evaluate, diagnose, treat, advise or otherwise provide clinical services to you.
All Providers delivering care through telehealth are licensed or otherwise authorized to practice in the state where you are physically located at the time services are rendered.
2. WHAT TELEHEALTH IS
Telehealth involves the use of electronic communications, video technology, audio technology, remote monitoring tools, and information technology to provide healthcare services when you and your Provider are not physically located in the same place.
Telehealth services may include, when clinically appropriate:
Real-time audio and video visits
Audio-only visits
Secure patient portal messaging
Electronic questionnaires and intake forms
Remote review of medical records, laboratory results, imaging, photographs, or patient-submitted information
Follow-up care coordination and treatment planning
Telehealth services may occur in real time (“synchronous”) or through delayed review of information you submit (“asynchronous” or “store-and-forward”).
You understand that asynchronous communications may not be reviewed immediately and should never be used for emergencies or urgent medical concerns.
Telehealth is not a substitute for emergency care or comprehensive in-person medical evaluation when clinically indicated.
3. SCOPE OF TELEMEDICINE SERVICES
The Practice is a women’s health practice. Telehealth services may include, but are not limited to:
- Contraceptive counseling and prescribing
- Birth control pill, patch, ring, and injection management
- Long-acting reversible contraception (LARC) counseling and referral for in-person placement
- Emergency contraception counseling and prescribing
- Menstrual disorder evaluation and management
- Abnormal uterine bleeding evaluation
- Menopausal hormone therapy management
- Polycystic Ovary Syndrome (PCOS) evaluation and management
- Thyroid disorder evaluation and management
- Cortisol and adrenal disorder screening
- Weight management counseling and medication management
- Review and coordination of laboratory testing
- Preventive health counseling
- Urinary tract infection evaluation and treatment
- Referral coordination for imaging, specialists, or in-person care
Limitations of Telemedicine Services
Certain services require in-person care and cannot safely or appropriately be performed through telehealth, including but not limited to:
- Pelvic examinations
- Pap smears and cervical cancer screening
- Breast examinations
- IUD insertion or removal
- Contraceptive implant insertion or removal
- Endometrial biopsy and other gynecologic procedures
- Evaluation of severe pelvic pain
- Evaluation of suspected ectopic pregnancy
- Medical emergencies or unstable conditions
If in-person evaluation or emergency care is medically necessary, your Provider may direct you to visit an emergency department, urgent care center, specialist, or local healthcare provider.
Pregnancy management and obstetric care are not provided through this telehealth platform unless specifically stated otherwise by the Practice. If you become pregnant, your Provider will assist with referral to an appropriate obstetric care provider.
4. PATIENT RESPONSIBILITIES
- By participating in telehealth services, you acknowledge and agree that:
- You are physically located in the state you disclose at the time of the encounter.
- You will notify the Practice immediately if your physical location changes during the visit.
- You will accurately identify yourself using requested identifying information.
- You are responsible for providing complete, accurate, and truthful medical history, medication information, allergy information, and any other information requested by your Provider.
- You understand that telehealth may not be appropriate for every medical condition.
- Your Provider may require laboratory testing, imaging, blood pressure readings, prior medical records, or in-person evaluation before diagnosis or treatment.
- Your Provider may decline to prescribe medications or continue treatment if clinically inappropriate or prohibited by law.
- Technical problems may interrupt or delay care.
- Participation in telehealth is voluntary, and you may withdraw consent at any time.
5. PRIVACY AND YOUR ENVIRONMENT
You are encouraged to participate in telehealth visits from a private location where your conversation cannot be overheard by others. This is especially important when discussing sensitive health topics such as sexual health, contraception, sexually transmitted infections, or personal safety concerns.
If you are unable to speak freely during an encounter, please let your Provider know. Your Provider may offer an alternative way to communicate (such as secure messaging) or may reschedule the visit to a time when you can speak privately.
If your Provider cannot ensure the privacy of sensitive health information during a telehealth visit, your Provider may recommend rescheduling or an in-person evaluation instead.
6. TECHNICAL DIFFICULTIES AND BACKUP PLAN
If the video or audio connection is lost during your visit:
Your Provider or a staff member will attempt to reconnect with you within 5 minutes.
If reconnection is not possible, the visit may be completed by telephone if clinically appropriate.
If the visit cannot be completed, it will be rescheduled at no additional charge.
Please have a working telephone number available during every telehealth visit in case a backup connection is needed.
7. BENEFITS OF TELEHEALTH
- Potential benefits of telehealth include:
- Improved access to medical care, especially for patients in underserved or rural areas
- Increased convenience and flexibility
- Reduced travel time and associated costs
- Improved continuity of care
- More timely follow-up and communication
- No specific clinical outcome or result is guaranteed.
8. RISKS AND LIMITATIONS OF TELEHEALTH
You understand that telehealth has risks and limitations, including but not limited to:
Your Provider cannot perform a physical examination during a telehealth visit, which may limit the ability to diagnose certain conditions.
There may be delays in evaluation or treatment compared to in-person care.
Technology failures, interruptions, or poor audio or video quality may affect the visit.
Medical records may not be readily available or then-currently reviewed by your Provider
Information may not be transmitted completely or accurately due to technical issues.
Despite reasonable security measures, electronic communications carry some risk of unauthorized access or data breach.
The inability to perform certain tests or assess vital signs in person may, in some cases, prevent your Provider from providing a diagnosis or identifying the need for emergency care.
Your Provider may determine that telehealth is not medically appropriate for your condition and may recommend in-person evaluation or emergency care.
10. PRESCRIBING
A telehealth visit does not guarantee that any medication will be prescribed or order issued.
All prescribing decisions are made solely at the clinical discretion of your Provider and in compliance with applicable federal and state law.
Controlled substances, if prescribed, will only be prescribed in compliance with applicable federal and state laws and professional standards.
Prescription Drug Monitoring Program (“PDMP”) databases may be reviewed where permitted or required by law.
Certain medications may require video visits, laboratory testing, identity verification, prior medical records, blood pressure verification, or in-person evaluation before they can be prescribed.
Pharmacy Choice
You have the right to obtain your prescription from any pharmacy of your choice. If you would like your prescription sent to a specific pharmacy, please inform your Provider or the Practice. If you do not specify a pharmacy, your prescription will be sent to the pharmacy on file in your account.
11. PRIVACY AND CONFIDENTIALITY
Telehealth services are provided using technology intended to protect the confidentiality and security of your health information in accordance with applicable laws, including HIPAA where applicable.
Despite reasonable safeguards, you understand that:
Electronic communications carry some risk of unauthorized access or disclosure.
Technical failures or data breaches may occur.
The Practice cannot guarantee uninterrupted or completely secure technology systems.
You should avoid using public or unsecured internet connections for telehealth visits when possible.
You may request copies of your medical records at any time in accordance with applicable state and federal law. Records will be retained for the period required by the laws of the state in which services were provided.
Additional information regarding privacy practices is available in the Practice’s Notice of Privacy Practices and our Privacy Policy.
12. RECORDINGS
Telehealth encounters will not be recorded by the Practice or by your Provider without your explicit permission, except as otherwise permitted or required by law. If recording is requested by either party, separate consent will be obtained.
You agree that you will not record any telehealth encounter (audio, video, or otherwise) without the prior written consent of your Provider and the Practice. Unauthorized recording may result in termination of the telehealth visit and may violate applicable state and federal law.
13. LANGUAGE AND ACCESSIBILITY
Interpreter services are available upon request for patients with limited English proficiency. You may request interpreter services at the time of scheduling or at any point during the encounter.
If you need accommodations related to hearing, vision, or other accessibility needs, please notify the Practice before your visit so that appropriate arrangements can be made.
14. RIGHT TO WITHDRAW CONSENT
You may withdraw consent to telehealth services at any time by notifying the Practice.
Withdrawal of consent will not affect treatment or services already provided but may limit the Practice’s ability to continue providing care remotely.
The Practice and Providers also reserve the right to discontinue telehealth services when clinically, operationally, or legally appropriate.
15. EMERGENCY SERVICES DISCLAIMER
TELEHEALTH SERVICES ARE NOT EMERGENCY SERVICES.
If you are experiencing a medical emergency:
Call 911 immediately; or
Go to the nearest emergency department.
If you or someone you know is experiencing a mental health crisis or suicidal thoughts:
Call 911; or
Call or text the 988 Suicide and Crisis Lifeline by dialing 988.
Do not use portal messages, electronic communications, or telehealth systems for emergencies or crisis situations. Providers may not be able to respond immediately to electronic communications.
16. REPRODUCTIVE HEALTH SERVICES AND STATE LAW
The availability and scope of reproductive healthcare services delivered through telehealth may vary depending on the laws of the state in which you are physically located. Certain services may not be available in all states.
If a requested service cannot be provided in your state, your Provider will inform you and, when possible, assist with identifying alternative resources.
17. GOVERNING LAW
This Consent is governed by the laws of the state in which you are physically located at the time telehealth services are rendered.
18. STATE-SPECIFIC DISCLOSURES
The following disclosures apply depending on your physical location at the time services are provided. If your state is not specifically listed below, the general terms of this Consent apply, and telehealth services are provided in compliance with all applicable laws and regulations of your state. You may contact your state medical board for additional information regarding telehealth rights and complaint procedures.
ALABAMA
Telehealth services are voluntary, and you may request in-person care when available and clinically appropriate.
ALASKA
You may request that a copy of your telehealth encounter summary be sent to your primary care provider.
ARIZONA
Provider licensure may be verified through the Arizona Medical Board.
ARKANSAS
Telehealth services are subject to Arkansas laws and professional standards governing remote medical care.
CALIFORNIA
Medical doctors are licensed and regulated by the Medical Board of California.
Complaints may be directed to:
Medical Board of California
1-800-633-2322
Information about payments made to physicians by pharmaceutical and medical device companies is available at:
https://openpaymentsdata.cms.gov
COLORADO
Complaints may be submitted to the Colorado Medical Board.
CONNECTICUT
You have the right to confidentiality and continuity of care in accordance with Connecticut law.
DELAWARE
You may request a full fee schedule prior to receiving services.
FLORIDA
Out-of-state telehealth providers must register with the Florida Board of Medicine to provide telehealth services to patients located in Florida, where applicable.
GEORGIA
Your identity and physical location will be verified prior to the encounter, and your consent will be documented in your medical record.
HAWAII
Telehealth services are voluntary and subject to applicable Hawaii law.
IDAHO
Electronic communications may be affected by temporary technical failures or transmission interruptions.
ILLINOIS
You acknowledge that you have been informed of your Provider’s identity, credentials, and licensure and understand the limitations of telehealth services.
INDIANA
Controlled substances will only be prescribed in compliance with Indiana telehealth laws.
IOWA
Telehealth services are subject to the same professional standards as in-person medical care.
KANSAS
You may request in-person follow-up care when clinically appropriate.
KENTUCKY
Telehealth encounters are subject to Kentucky laws governing remote healthcare services.
LOUISIANA
Telehealth services are voluntary, and you may discontinue participation at any time.
MAINE
You have the right to receive information regarding available follow-up care and referrals.
MARYLAND
You may request access to your medical records in accordance with Maryland law.
MASSACHUSETTS
You acknowledge that telehealth is voluntary and that you may request in-person services where available and medically appropriate.
MICHIGAN
Telehealth services are provided in accordance with Michigan professional practice standards.
MINNESOTA
You may request information regarding the credentials and licensure of your Provider.
MISSISSIPPI
Controlled substances will only be prescribed in compliance with Mississippi law.
MISSOURI
Telehealth services are subject to applicable Missouri laws governing remote care and prescribing.
MONTANA
You may request information regarding telehealth alternatives and in-person treatment options.
NEBRASKA
Telehealth services are voluntary and may be discontinued by either party when appropriate.
NEVADA
Your Provider may recommend in-person evaluation if telehealth is not medically appropriate for your condition.
NEW HAMPSHIRE
You may request copies of your medical records in accordance with applicable law.
NEW JERSEY
You have the right to request in-person care instead of telehealth services when available.
NEW MEXICO
Telehealth services are subject to New Mexico laws governing patient privacy and professional practice.
NEW YORK
Complaints regarding physicians may be directed to:
Office of Professional Medical Conduct
1-800-663-6114
You may request that encounter information be shared with your primary care provider. You have the right to receive a copy of your medical records in accordance with New York law.
NORTH CAROLINA
You understand that telehealth is optional and that in-person care may be available.
NORTH DAKOTA
Telehealth services are provided in accordance with North Dakota professional standards.
OHIO
Providers comply with Ohio telehealth and prescribing requirements. Complaints may be directed to the State Medical Board of Ohio.
OKLAHOMA
Telehealth services are subject to Oklahoma laws governing healthcare delivery and prescribing.
OREGON
Interpreter services are available upon request.
PENNSYLVANIA
Complaints may be submitted to the Pennsylvania State Board of Medicine.
RHODE ISLAND
You may request information regarding alternatives to telehealth services.
SOUTH CAROLINA
Telehealth services are subject to South Carolina laws governing remote medical care.
SOUTH DAKOTA
Telehealth services may be discontinued if clinically inappropriate or unsafe.
TENNESSEE
Controlled substances will only be prescribed in accordance with Tennessee law.
TEXAS
NOTICE CONCERNING COMPLAINTS:
Texas Medical Board
P.O. Box 2018
Austin, TX 78768
1-800-201-9353
Texas law may require identity verification prior to telehealth services. Telehealth services are provided using a HIPAA-compliant platform.
UTAH
Telehealth services are voluntary and subject to applicable Utah law.
VERMONT
You may request information regarding telehealth privacy protections and alternatives.
VIRGINIA
Telehealth services are subject to Virginia laws governing professional healthcare practice.
WASHINGTON
You understand that telehealth is optional and that you may request in-person services where available.
WEST VIRGINIA
Telehealth services are subject to applicable West Virginia professional standards.
WISCONSIN
You may request information regarding follow-up care and referrals.
WYOMING
Telehealth services are voluntary and may not be appropriate for all medical conditions.
PATIENT ACKNOWLEDGMENT AND AGREEMENT
By agreeing below, I acknowledge that:
I have read and understand this Informed Consent for Telehealth Services.
I have had the opportunity to ask questions and receive answers regarding telehealth services.
I understand the risks, benefits, limitations, and alternatives to telehealth care.
I understand that telehealth is voluntary and that I may withdraw consent at any time.
I understand that details of my medical history may not be available to the telehealth Provider and there will be a lack of in-person physical examination or available test results, and I understand the limitations of care, diagnosis and treatment this could cause.
I acknowledge that I should not use telehealth for or during an emergency.
I agree that no guarantees or assurances have been made about the results of this service.
I consent to receive telehealth services from the Practice and its affiliated licensed Providers.