Telehealth Informed Consent

Parties and Entity Roles

For purposes of this Telehealth Informed Consent, Contracted Clinicians PC is the professional clinical entity responsible for furnishing or arranging the professional telehealth services described in this consent, including provider-patient consultations, diagnoses, treatment recommendations, prescriptions when clinically appropriate, and referrals to in-person care when clinically appropriate.

National Provider Services LLC serves as the management services organization and business associate support entity for Contracted Clinicians PC. In that role, National Provider Services LLC may provide non-clinical administrative, payment, technology, operational, patient-support, and related business-associate services in support of the telehealth services.

Contracted Clinicians PC and its engaged licensed clinicians are responsible for clinical decision-making and the professional practice of medicine or other licensed healthcare services, as applicable. National Provider Services LLC does not itself provide professional medical diagnosis, treatment, prescribing, or clinical decision-making services.

For ease of reference, Contracted Clinicians PC, its engaged clinicians, and National Provider Services LLC may be referred to collectively in this consent as the “Group,” “we,” “us,” or “our,” as applicable to their respective roles.

Telehealth Services Overview

Telehealth involves the use of electronic communications, information technology, or other means to allow a healthcare provider and a patient in different locations to communicate and share patient health information for purposes of rendering clinical care.

The telehealth services covered by this consent may include a patient consultation, diagnosis, treatment recommendation, prescription, and/or referral to in-person care, as determined clinically appropriate by the treating provider. The provider will be licensed in the state where the patient is located at the time of consultation or will otherwise meet an applicable professional licensure exception under state law. The provider-patient relationship will be established in accordance with the laws and rules applicable in the relevant state.

Electronic transmissions used in connection with telehealth may include appointment scheduling; completion, exchange, and review of medical intake forms and clinically relevant information; asynchronous communications; two-way interactive audio communications combined with store-and-forward communications; two-way interactive audio-video communications; treatment recommendations based on exchanged clinical information; delivery of consultation reports with diagnosis, treatment, or prescription recommendations when clinically relevant; prescription refill reminders when applicable; and other electronic transmissions for purposes of rendering clinical care.

Clinically relevant information exchanged through telehealth may include health records, images, output data from medical devices, sound or video files, diagnostic information, and laboratory test results. The availability and scope of any particular telehealth service will depend on the patient’s clinical circumstances, the provider’s professional judgment, and applicable legal and professional requirements.

Expected Benefits and Service Limitations

Telehealth may improve access to care by allowing the patient to remain in the patient’s preferred location while consulting with the treating provider. Telehealth may also provide convenient access to follow-up care and may support more efficient care evaluation and management.

The primary difference between telehealth and direct in-person care is that the provider does not have direct physical contact with the patient. As a result, some clinical needs may not be appropriate for telehealth evaluation or treatment. The treating provider will determine whether telehealth is clinically appropriate for the patient’s circumstances.

Telehealth services are not a substitute for all forms of in-person medical care. Contracted Clinicians PC does not operate in-person clinic locations for patient care through this consent, and telehealth services furnished under this consent are intended to supplement, not replace, the patient’s relationship with a local primary care provider or other treating clinician. If nonemergent follow-up care related to telehealth treatment is needed, the patient may contact the provider through the secure messaging service or other designated platform functionality.

Possible Risks of Telehealth

Telehealth involves risks associated with the use of electronic communications, remote clinical evaluation, and technology-dependent care delivery. Delays in evaluation or treatment may occur because of equipment deficiencies, technology failures, or provider availability.

If the patient and provider are unable to communicate because of a technological or equipment failure, the patient should use the support contact designated by Contracted Clinicians PC or National Provider Services LLC at support@leyahealth.com.

In some circumstances, the provider may determine that transmitted information is inadequate in quality or completeness for clinical evaluation. That determination may require a rescheduled telehealth consultation or referral for in-person evaluation with a local primary care provider or other appropriate clinician.

Although privacy and security safeguards may be used in connection with telehealth services, security protocols can fail in rare events, potentially resulting in a breach of privacy involving personal medical information. Telehealth therefore may involve confidentiality risks that differ from, or are additional to, risks associated with in-person care.

Patient Acknowledgments and Consents

By proceeding with telehealth services, the patient acknowledges and agrees that, before the telehealth visit, the patient may be given an opportunity to select a provider, as appropriate, including an opportunity to review the provider’s credentials, or may elect to receive services from the next available provider affiliated with Contracted Clinicians PC.

The patient understands that Contracted Clinicians PC providers do not address medical emergencies through the telehealth services covered by this consent. If the patient is experiencing a medical emergency, the patient should call 9-1-1 and/or go to the nearest emergency room. The patient further understands that the provider may not be able to connect the patient directly to local emergency services.

The patient acknowledges that telehealth is voluntary and that the patient may seek care from a medical group or provider with in-person clinical locations as an alternative to receiving telehealth services. The patient may withhold or withdraw consent to the use of telehealth in the course of care at any time without affecting the patient’s right to future care or treatment.

The patient understands that federal and state law require healthcare providers to protect the privacy and security of health information and that the patient is entitled to confidentiality protections under applicable federal and state laws. The patient also understands that medical reports resulting from a telehealth visit are part of the patient’s medical record.

The patient acknowledges that telehealth may involve electronic communication of personal health information to other healthcare practitioners who may be located in other areas, including outside the patient’s state. Patient-identifiable images or information from a telehealth visit will not be disseminated to researchers or educational entities without the patient’s affirmative consent.

The patient understands that certain parts of the services, including laboratory testing, bloodwork, or other tests, may be conducted at another location, such as a testing facility or the patient’s home, when directed by the provider or otherwise clinically appropriate.

The patient understands that persons other than the treating provider may be present during a telehealth visit to operate telehealth technologies. If another person is present, the patient will be informed of that person’s presence and role, and the patient may request omission of personally sensitive details, ask non-medical personnel to leave the consultation, or terminate the consultation.

The patient understands that the provider will explain the patient’s diagnosis, the evidentiary basis for that diagnosis, and the risks and benefits of available treatment options. The patient has the right to request a copy of the patient’s medical records and may request that records be provided to the patient’s primary care provider or another designated healthcare provider by contacting support@leyahealth.com.

The patient understands that there is no guarantee that a prescription will be issued. Any prescribing decision will be made in the professional judgment of the treating provider. If a prescription is issued, the patient has the right to select the pharmacy of the patient’s choice.

The patient understands that there is no guarantee that the patient will be treated by a Contracted Clinicians PC provider. A provider may deny care for potential misuse of the services or for any other reason if, in the provider’s professional judgment, furnishing the services is not medically or ethically appropriate.

Communications, Messaging, and Consent to Electronic Contact

The patient agrees to receive invitations, notifications, reminders, service-related messages, and other communications from Contracted Clinicians PC, its providers, National Provider Services LLC, and their authorized affiliates, agents, contractors, or service providers through the applicable website, mobile application, patient portal, or other telehealth platform, and by email, text message, fax, telephone, or other contact method provided by the patient.

The patient authorizes communications to be made using an automatic telephone dialing system and/or an artificial or prerecorded voice message system, including automated calls, automated text messages, and similar electronic communications directed to the telephone number, email address, or other contact information provided by the patient. The patient is responsible for promptly notifying Contracted Clinicians PC or National Provider Services LLC of any change to the patient’s mobile telephone number, email address, mailing address, or other contact information.

The patient understands that automated messages, texts, emails, and other communications may include, without limitation, invitations or instructions to access or use the applicable telehealth platform, patient portal, or mobile application. The patient may receive multiple messages per day and is responsible for any message, data, or other carrier charges imposed by the patient’s mobile carrier or communications provider.

Consent to receive automated messages, emails, and text messages is optional and is not a condition of receiving treatment or using the telehealth platform. The patient may opt out of automated messages at any time by contacting support@leyahealth.com or by replying “STOP” to an automated text message, if that functionality is available for the message received. Opting out of certain communications may affect the timeliness or availability of administrative, scheduling, reminder, or platform-related messages, but it does not by itself withdraw the patient’s telehealth consent unless the patient separately withdraws that consent.

Privacy, Security, and Confidentiality Disclosures

The patient understands that telehealth may involve the electronic communication of the patient’s personal health information to providers, healthcare practitioners, administrative support personnel, and other authorized service providers involved in the telehealth services, including individuals or entities located outside the patient’s state.

Contracted Clinicians PC and National Provider Services LLC will use physical, technical, and administrative safeguards designed to protect the privacy and security of personal information and health information in connection with telehealth services. The patient understands, however, that communications by email, text message, or other unsecured channels may not be encrypted and may be intercepted or read by persons other than the intended recipient.

The patient may request not to communicate with Contracted Clinicians PC or National Provider Services LLC by unsecured email or text message by contacting support@leyahealth.com.

Medical reports and other documentation generated from telehealth visits are part of the patient’s medical record. Patient-identifiable images or information from a telehealth visit will not be disclosed to researchers or educational entities without the patient’s affirmative consent. Confidentiality protections remain subject to applicable federal and state law, authorized disclosures, and the operational limitations of electronic communications.

Open Payments and External Transparency Notice

The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. The federal Physician Payments Sunshine Act requires certain information about payments or other transfers of value over ten dollars from manufacturers of drugs, medical devices, and biologics to physicians and teaching hospitals to be made publicly available. Patients may review the federal Open Payments database at openpaymentsdata.cms.gov.

State-Specific Consents and Disclosures

The following state-specific consents and disclosures apply to patients accessing telehealth services through Contracted Clinicians PC and supported by National Provider Services LLC, as required by the state in which the patient is located at the time services are received.

Alaska.

The patient understands that the patient's primary care provider may obtain a copy of the patient's records of the telehealth encounter. The patient may register a formal complaint about a provider through the applicable medical board website.

Connecticut.

The patient understands that the patient's primary care provider may obtain a copy of the patient's records of the telehealth encounter.

Florida.

The patient may review Florida patient-rights information through the Florida Agency for Health Care Administration and may review Florida weight-loss consumer-rights information through the applicable Florida resource.

Iowa, Idaho, Indiana, Kentucky, Rhode Island.

The patient may register a formal complaint about a provider through the applicable state medical board website.

Kansas.

If the patient has a primary care provider or other treating physician, the person providing telemedicine services must send a report to that provider describing the treatment and services rendered during the telemedicine encounter within three days after the patient gives consent for the report to be sent.

Maine.

The patient may register a formal complaint about a provider through the applicable medical board website or the Maine Board of Osteopathic Licensure website.

New Hampshire and Ohio.

The patient understands that the patient's primary care provider or treating provider may obtain a copy of the patient's records of the telehealth encounter.

Oklahoma.

The patient may register a formal complaint about a provider through the applicable medical board website or the Oklahoma Board of Osteopathic Examiners website.

South Carolina.

The patient understands that medical records may be distributed only with the patient's consent and in accordance with applicable laws and regulations to other treating healthcare practitioners.

Texas.

With the patient's consent, the patient's medical records may be sent to the patient's primary care physician within 72 hours after receiving services. Complaints about physicians and other Texas Medical Board licensees or registrants may be reported to the Texas Medical Board using the complaint information required by Texas notice language.

Vermont.

The patient has 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. Receiving telemedicine services through the telehealth platform does not preclude the patient from receiving real-time telemedicine or face-to-face services with the distant provider at a future date. The patient may register a formal complaint about a provider through the Vermont Board of Medical Practice website or the Vermont Board of Osteopathic Examiners website.

Arbitration; Delegation; Class-Action Waiver

Any controversy, dispute, or claim arising out of or relating to the Services, this Telehealth Informed Consent, any related terms or contract, the relationship between the patient/customer and Contracted Clinicians PC, National Provider Services LLC, or their respective providers, affiliates, agents, contractors, successors, or assigns, or any alleged breach, termination, enforcement, interpretation, or validity of any of the foregoing, shall be resolved by final and binding arbitration administered in accordance with the rules of net-ARB.com, except to the extent those rules conflict with this section.

The parties expressly agree that the arbitrator, and not any court or judge, shall have exclusive authority to resolve any dispute concerning arbitrability, including any dispute regarding the existence, formation, interpretation, scope, validity, enforceability, unconscionability, revocability, or applicability of this arbitration agreement, this delegation clause, the class-action waiver, or any portion of this Telehealth Informed Consent relevant to arbitrability, except to the extent non-waivable applicable law requires a court to decide a particular issue.

The patient/customer and the Group agree that all claims must be brought and resolved only on an individual basis. No claim may be brought, maintained, heard, arbitrated, or resolved as a class action, collective action, consolidated action, representative action, mass action, private-attorney-general action, or other proceeding in which a party acts or seeks to act in a representative capacity, except to the extent such waiver is prohibited by non-waivable applicable law.

The arbitrator shall have no authority to conduct any class, collective, consolidated, representative, mass, or private-attorney-general arbitration, and shall have no authority to join or consolidate claims of more than one patient/customer, unless all parties expressly agree in a signed writing after the dispute arises.

The arbitrator may award any individual relief available under applicable law. Nothing in this arbitration agreement limits any non-waivable statutory right or remedy that would otherwise be available to a party on an individual basis.

The costs of arbitration shall be initially borne by the patient/customer and later apportioned by the arbitrator, except that no cost-allocation provision shall apply to the extent it would render this arbitration agreement unenforceable or prevent the vindication of non-waivable rights. If required by applicable law or by the arbitration forum’s rules, the Group will pay or advance arbitration fees or costs to the extent necessary to preserve enforceability.

The arbitrator’s award shall be final and binding, except for any judicial review available under applicable non-waivable law. Judgment on the arbitrator’s award may be entered in any court of competent jurisdiction.

If any portion of this arbitration agreement is found unenforceable, that portion shall be severed to the maximum extent permitted by law, and the remaining portions shall remain enforceable, except that if the class-action waiver is finally determined to be unenforceable as to a claim that may not proceed individually, this arbitration agreement shall not apply to that claim unless the parties agree otherwise in writing.

Acknowledgment and Consent to Proceed

By checking the acknowledgment box, clicking “I agree,” accessing or using the website or platform, submitting intake information, scheduling a consultation, receiving Services, or otherwise becoming a patient, the patient acknowledges that the patient has read, understands, and agrees to this Telehealth Informed Consent, including the Arbitration Agreement, Delegation Clause, Class-Action Waiver, communications consent, privacy disclosures, and all other conditions stated herein.

The patient consents to receive telehealth services from Contracted Clinicians PC and its providers, with administrative and business-associate support from National Provider Services LLC, subject to the terms of this consent.

The patient understands that acceptance of this consent is required before the patient receives telehealth services or sees a clinician through the applicable telehealth platform and that the patient may withdraw telehealth consent as described above.