Informed Consent

TELEHEALTH INFORMED CONSENT

DO NOT USE THIS SERVICE IF YOU MAY BE EXPERIENCING A MEDICAL EMERGENCY. In an emergent situation, you can: (i) call 911; (ii) go to the nearest emergency room; (iii) contact your local crisis center; (iv) if applicable, call 988 the National Suicide Prevention Lifeline; or (v) if applicable, contact the Crisis Text Line (text “GO” to 741-741).

We are pleased you have chosen Baylor Scott and White Health, its affiliate provider and medical groups (“Provider Group”) for your telehealth needs.

This document is intended to inform you of what you can expect of your clinician in terms of his or her credentials and in connection with your treatment via telehealth.

After you have carefully read this document and had an opportunity to have your questions answered, certain state laws mandate that you must sign and date it before commencing services.

YOUR TELEHEALTH PROVIDER’S CREDENTIALS.

You understand that if you have an appointment for a telehealth visit, your provider’s credentials will be made available to you before your appointment.

For on-demand urgent care visits, the provider’s credentials are available upon request.

If you have any questions about these credentials, please direct them to your telehealth provider. For those states that require it, you can find an explanation of the levels of regulation applicable to telehealth providers in the STATE DISCLOSURES section of this consent.

MEDICATION HISTORY CONSENT .

I consent to my medication history being obtained for clinician use in my diagnosis and treatment.

The medication history obtained may include history of healthcare visits not related to this virtual visit.

The medication history will display a history of drugs and medications that have been retrieved unless prohibited by federal, state or local laws.

Certain information may not be available or accurate in this report, including items I have asked not to disclose due to patient privacy concerns, over-the-counter medications, low cost prescriptions, prescriptions paid for by me or non-participating sources or errors in insurance claims information. My provider may independently review my medication history.

IMPORTANT INFORMATION REGARDING YOUR TREATMENT BY TELEHEALTH HEALTH PROVIDERS, INCLUDING POTENTIAL RISKS AND BENEFITS.

VCMG offers treatment by various types of healthcare providers via telecommunications technology (also referred to as “telehealth”).

Our providers include physicians, nurses, and equivalent licensed professionals. The services provided may also include chart review, remote prescribing, appointment scheduling, refill reminders, health information sharing, and non-clinical services, such as patient education.

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.

There are various benefits associated with telehealth services, including improved access to care by enabling you to remain in your home while the provider consults with you, more efficient care evaluation and management, and obtaining expertise of a specialist as appropriate.

Possible risks include delays in evaluation and treatment could occur due to deficiencies or failures of the equipment and technologies, and in rare events, our provider may determine that the transmitted information is of inadequate quality, thus necessitating a rescheduled telehealth consult or a meeting with your local primary care doctor.

At times, your clinician may seek supervision or consultation with other affiliated or non-affiliated clinicians regarding your treatment, to enhance the services being provided to you given the multiple perspectives, experiences, and treatment philosophies.

All team members are ethically and legally bound to maintain your privacy and confidentiality in this scenario and none of your personal information will be shared or disclosed with any other individual outside Provider Group without your consent.

Exceptions to confidentiality do exist in certain situations, such as: threat of serious harm to self or others; reasonable suspicion of abuse or neglect of a child, or abuse, neglect, or exploitation of an incapacitated or dependent adult; court order and/or subpoena; permission from the client or guardian (i.e. voluntary release signed by the client or guardian); during supervisory consultations; diagnosis and dates of service shared with an insurance company to collect payments; information released as outlined in VCMG’s Notice of Privacy Practices and Privacy Policy; and as otherwise required by law.

All disclosures will be made only to the extent permitted by law.

Please visit the Terms of Use accessible https://evisit.baylorscottandwhite.com/terms_of_service before commencing services with us.

If you are located in the state of Florida or New York and are seeking treatment for medical weight loss, you can visit and view your respective Patient Weight-loss Bill of Rights: OR .

UNDERSTANDING WEIGHT LOSS MEDICATIONS: BENEFITS & RISKS

If you are considering the use of weight-loss medications, you need to consider the benefits and risks, including those set forth below. Prescriptions are subject to provider judgment, and some medications may not be FDA-approved for weight loss in all contexts.

BENEFITS:

• These medications can help you feel less hungry, making it easier to eat fewer calories.
• When used in conjunction with healthy eating and regular physical activity, they can support weight loss.
• Some medications may also help with blood sugar levels or heart health.

RISKS:

• Like all medications, there can be side effects — common ones include nausea, upset stomach, or diarrhea.
• Rare but serious risks may include pancreatitis, gallbladder problems, or a possible increase in certain types of cancer.
• These medications will not work on their own — you still need to eat less and move more for them to help.
• They are not safe for people with or at risk for eating disorders like anorexia, bulimia, or body dysmorphia.

TREATMENT AND CONFIDENTIALITY OF MINORS .

In accordance with state laws, consent for treatment of a minor can only be authorized by a current legal guardian for the minor.

In the case of minors, as defined by state law, parents may request information about their child’s diagnosis or treatment.

While release of this information will be provided, it is best that the process be a collaborative one involving the minor, parent, and clinician in order to maintain the rapport established between the minor and clinician, since rapport is vital to treatment success. Certain state laws allow minors to consent for reproductive, behavioral health, or substance use treatment without parental involvement.

FEES AND BILLING ARRANGEMENTS / ASSIGNMENT OF BENEFITS.

You understand that you are required to pay all fees for your telehealth services.

If you believe any of the fees you have been charged are incorrect, you must immediately contact us in writing regarding the amount in question to be eligible to receive a refund.

You irrevocably waive your right to challenge the accuracy of any charge, or otherwise receive a refund, if you fail to notify us in writing within fifteen (15) calendar days after the charge, that you believe the charge is inaccurate (setting forth an explanation of why).

You authorize and assign to Provider Group and its providers the right to bill, submit claims, and receive payment directly from my health plan or other third-party payer for services provided.

This includes benefits under commercial plans and any Federal health care program as defined in 42 U.S.C. §1320a-7b(f)—including Medicare (traditional and Medicare Advantage), Medicaid (fee-for-service and managed care), TRICARE/CHAMPVA, and FEHB/VA—to the fullest extent permitted by applicable law, payer contracts, and plan terms.

I request that payment of authorized Medicare benefits be made on my behalf to VCMG and its providers for any covered services, and I authorize VCMG to submit claims, necessary disclosures of health information for payment and health care operations, and to act as my authorized representative for claim inquiries, appeals, and administrative reviews;

I further authorize endorsement/deposit of any checks issued in my name for such services.

By checking the box associated with “Accept”, you acknowledge that you understand and agree with the following:

• You hereby consent to receiving VCMG’s services via telehealth technologies.
• You understand that VCMG and its providers offer telehealth-based medical services, but that these services do not replace the relationship between you and your primary care doctor.
• You also understand it is up to the VCMG provider to determine whether or not your specific clinical needs are appropriate for a telehealth encounter.
• You understand that federal and state law requires health care providers to protect the privacy and the security of health information.
• You understand that VCMG will take steps to make sure that your health information is not seen by anyone who should not see it.
• You understand that telehealth may involve electronic communication of your personal medical information to other health practitioners who may be located in other areas, including out of state.
• You understand there is a risk of technical failures during the telehealth encounter beyond the control of VCMG.
• You agree to hold harmless VCMG for delays in evaluation or for information lost due to such technical failures.
• You understand that you have the right to withhold or withdraw your consent to the use of telehealth in the course of your care at any time, without affecting your right to future care or treatment.
• You understand that you may suspend or terminate use of the telehealth services at any time for any reason or for no reason.
• You understand that if you are experiencing a medical emergency, that you will be directed to dial 9-1-1 immediately and that the VCMG providers are not able to connect you directly to any local emergency services.
• You understand that you may expect the anticipated benefits from the use of telehealth in your care, but that no results can be guaranteed or assured.
• You understand that your healthcare information may be shared with other individuals for scheduling and billing purposes.
• Persons may be present during the consultation other than the VCMG provider in order to operate the telehealth technologies.
• You further understand that you will be informed of their presence in the consultation and thus will have the right to request the following: (a) omit specific details of your medical history/examination that are personally sensitive to you; (b) ask non-medical personnel to leave the telehealth examination; and/or (c) terminate the consultation at any time.
• You understand that there is no guarantee that you will be given a prescription as part of your telehealth consultation.
• You understand that if you participate in a consultation, that you have the right to request a copy of your medical records which will be provided to you at reasonable cost of preparation, shipping and delivery.
• You have read and you understand the disclosures set forth next to the state in which you are located at the time of the telehealth encounter, as set forth in this STATE DISCLOSURES section of this consent.

□ ACCEPT. By checking the box for this Informed Consent you hereby state that you have read, understood, and agree to the terms of this document.

STATE DISCLOSURES

Alaska: You understand your primary care provider may obtain a copy of your records of your telehealth encounter. (Alaska Stat. § 08.63.210(C)(2). Such disclosure occurs through a proper records request by the PCP or at the patient’s election to share.

Arizona: You understand that all medical records resulting from a telemedicine consultation are part of your medical record. (Ariz. Rev. Stat. Ann. § 36-3602(D)).

California: You understand that you have the right to withhold or withdraw your consent to the use of telehealth in the course of your care at any time, without affecting your right to future care or treatment, or, affecting your ability to access covered services from Medi-Cal in the future. You understand that you have the right to access Medi-Cal covered services through an in-person, face-to-face visit or through telehealth. You understand that Medi-Cal provides coverage for transportation services to in-person services when other resources have been reasonably exhausted. (Cal. Welf. & Inst. Code Ann. § 14132.725(d)).

Connecticut: You understand that your primary care provider may obtain a copy of your records of your telehealth encounter, and that you can revoke your consent at any time. (Conn. Gen. Stat. Ann. § 19a-906).

D.C.: You have been informed of alternate forms of communication between you and a physician for urgent matters. (D.C. Mun. Regs. tit. 17, § 4618.10). Relevant communications with the physician, including those done via electronic methods shall be documented and filed in your medical record. (D.C. Mun. Regs. tit. 17, § 4618.9).

Georgia: You have been given clear, appropriate, accurate instructions on follow-up in the event of needed emergent care related to the treatment. (Ga. Comp. R. & Regs. 360-3-.07(7)).

Idaho: You have been informed that if you want to register a formal complaint about a provider, you should visit the medical board’s website, here: https://dopl.idaho.gov/filing-a-complaint/ (Idaho Guidelines for Appropriate Regulation of Telemedicine). You further understand that your informed consent for the use of telehealth services shall be obtained by applicable law. Idaho Statutes 54-5708.

Indiana: If a prescription is issued to you, and subject to your consent the prescriber shall notify your primary care provider of any prescriptions the prescriber has issued for you if the primary care provider's contact information is provided by you. This requirement does not apply if: (A) The practitioner is using an electronic health record system that your primary care provider is authorized to access. (B) The practitioner has established an ongoing provider-patient relationship with the patient by providing care to the patient at least 2 consecutive times through the use of telehealth services. If the conditions of this clause are met, the practitioner shall maintain a medical record for you and shall notify your primary care provider of any issued prescriptions. Ind. Code Ann. 25-1-9.5-7.

If you are a Medicaid patient, you have the right to choose between an in-person visit or telehealth visit. Indiana Medicaid Manual: Telehealth and Virtual Services.

Iowa: To file a complaint, fill out the complaint form and email it to the medical board at ibmcomplaints@iowa.gov. Iowa Admin. Code 653-13.11(147,148,272C)(13.11(18)).

As appropriate your provider will identify the medical home or treating physician(s) for you, when available, where in-person services can be delivered in coordination with the telemedicine services. Your provider shall provide a copy of the medical record to your medical home or treating physician(s). Iowa Admin. Code 653-13.11(147,148,272C)(13.11(11))

Kansas: You understand that if you have a primary care provider or other treating physician, the person providing telemedicine services must send within three business days a report to such primary care or other treating physician of the treatment and services rendered to you during the telemedicine encounter. (Kan. Stat. Ann. § 40-2,212(2)(d)(2)(A).

Kentucky: You have been informed that if you want to register a formal complaint about a provider, you should visit the medical board’s website, here: https://kbml.ky.gov/board/Pages/default.aspx.

If requested by you, your physician must share the medical record with your primary care physician and other relevant members of your existing care team. Kentucky Board Opinion on the Use of Telemedicine Technologies (2014), as amended September 15, 2022.

Louisiana: You understand the role of other health care providers that may be present during the consultation other than the telehealth provider. (46 La. Admin. Code Pt XLV, § 7511).

Maine: You have been informed that if you want to register a formal complaint about a provider, you should visit the medical board’s website, here: https://www.maine.gov/md/complaint/file-complaint. (Code Me. R. tit. 02-373 Ch. 11, § 3.).

Nebraska: If you are a Medicaid recipient, you retain the option to refuse the telehealth consultation at any time without affecting your right to future care or treatment and without risking the loss or withdrawal of any program benefits to which the patient would otherwise be entitled. All existing confidentiality protections shall apply to the telehealth consultation. You shall have access to all medical information resulting from the telehealth consultation as provided by law for access to your medical records. Dissemination of any patient identifiable images or information from the telehealth consultation to researchers or other entities shall not occur without your written consent. You understand that you have the right to request an in-person consult immediately after the telehealth consult and you will be informed if such consult is not available. (Neb. Rev. Stat. Ann. § 71-8505; 471 Neb. Admin. Code § 1-006.05).

New Hampshire: You understand that the telehealth provider may forward your medical records to your primary care or treating provider. (N.H. Rev. Stat. § 329:1-d).

New Jersey: You understand that you have the right to request a copy of your medical information and you understand your medical information may be forwarded directly to your primary care provider or health care provider of record, or upon your request, to other health care providers. If you do not have a primary care provider or other health care provider of record, the health care provider engaging in telemedicine or telehealth may advise you to contact a primary care provider, and, upon request by you, may assist you with locating a primary care provider or other in-person medical assistance that, to the extent possible, located within reasonable proximity to you. N.J. Rev. Stat. Ann. § 45:1-62.

Ohio: You understand that the telehealth provider may forward your medical records to your primary care or treating provider. Ohio Admin. Code 4731-37-01(C)(4).

Oregon: If you have a concern or complaint about the providers providing care to you, you may contact a board agency to assist you. You understand that the provider may ask if you need more detail. ORS 17-52-677.07. See also Or. Medical Board, Statement of Philosophy: Telemedicine (Oct 2, 2020)

Complaints may be filed with:

Oregon Medical Board
1500 SW 1st Ave., Suite 620
Portland, OR 97201-5847
Complaint Resource Staff: 971-673-2702 | complaintresource@omb.oregon.gov

Rhode Island: If you use e-mail or text-based technology to communicate with your provider, then you understand the types of transmissions that will be permitted and the circumstances when alternate forms of communication or office visits should be utilized. You have also discussed security measures, such as encryption of data, password protected screen savers and data files, or utilization of other reliable authentication techniques, as well as potential risks to privacy. You acknowledge that your failure to comply with this agreement may result in the telehealth provider terminating the relationship. (Rhode Island Medical Board Guidelines).

South Carolina: You understand your medical records may be distributed in accordance with applicable law and regulation to other treating health care practitioners. You understand the value of having a primary care medical home and, if requested, we can provide assistance in identifying available options for a primary care medical home. S.C. Code Ann. § 40-47-37.

You also understand that if you are a Medicaid beneficiary, you can withdraw your consent at any time. South Carolina Health and Human Svcs. Dept. Physicians Provider Manual, p. 35 (Feb. 2024)

South Dakota: You have received disclosures regarding the delivery models and treatment methods or limitations. You have discussed with the telehealth provider the diagnosis and its evidentiary basis, and the risks and benefits of various treatment options. (S.D. Codified Laws § 34-52-3).

Tennessee: You understand that you may request an in-person assessment before receiving a telehealth assessment if you are a Medicaid recipient. (TN Dept. of Mental Health and Substance Abuse Services. Office of Crisis Services Telecommunications Guidelines, p. 8, (2012) (Accessed Jan. 2024)).

Texas: You understand that your medical records may be sent to your primary care physician within 72 hours. Tex. Occ. Code Ann. § 111.005. You have 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 our website at 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

Utah: You are able to a (i) access, supplement, and amend your patient-provided personal health information; (ii) contact your provider for subsequent care; (iii) obtain upon request an electronic or hard copy of your medical record documenting the telemedicine services, including the informed consent provided; and (iv) request a transfer to another provider of your medical record documenting the telemedicine services. Utah Admin. Code r. 156-1-602.

Virginia: You acknowledge that you have received details on security measures taken with the use of telemedicine services, such as encrypting date of service, password protected screen savers, encrypting data files, or utilizing other reliable authentication techniques, as well as potential risks to privacy notwithstanding such measures; You agree to hold harmless [PC] for information lost due to technical failures; and you provide your express consent to forward patient-identifiable information to a third party. (Virginia Board of Medicine Guidance Document 85-12).

Vermont: You understand that you 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. You understand that receiving telehealth services via store-and-forward technologies by [PC] does not preclude you from receiving real-time telemedicine or face-to-face services with the distant provider at a future date. (Vt. Stat. Ann. § 9361).

You have been informed that if you want to register a formal complaint about a provider, you should visit the medical board’s website, here: http://www.healthvermont.gov/health-professionals-systems/board-medical-practice/file-complaint; Board of Osteopathic Examiners can be found at: https://sos.vermont.gov/opr/complaints-conduct-discipline/#emr (Vt. Board of Medical Practice, Policy on the Appropriate Use of Telemedicine Technologies in the Practice of Medicine (March 1, 2023).