Consent to Telehealth

Telehealth Informed Consent (One-Time Purchase Program)

Acceptance of Terms
By clicking “I Agree,” checking the acceptance box, or otherwise indicating acceptance, you acknowledge that you have read, understood, and agree to be bound by this Telehealth Informed Consent (“Consent”). If you do not agree, do not proceed with your purchase. A copy of this Consent will be included in your medical record and is available upon request at [email protected].

Medical Emergencies
If you are experiencing a medical emergency, call 9-1-1 immediately. Do not attempt to contact Zealthy, Inc. or your Provider for emergency care.

Purpose
This Consent informs you (“patient,” “you,” or “your”) about telehealth, including its methods, risks, and limitations, and obtains your informed consent to receive a medical evaluation via telehealth from physicians or other licensed healthcare providers (“Providers”) for the purpose of determining whether a prescription medication you purchased through Zealthy, Inc. is appropriate.

Zealthy, Inc. operates technology platforms to connect you with Providers but does not itself provide medical care.

What is Telehealth
Telehealth is the delivery of healthcare using electronic communications when the patient and Provider are not in the same physical location. This may include:

• Transmission of medical records, images, or health data;
• Audio, video, or text-based interactions;
• Use of questionnaires, forms, or photographs to aid in evaluation.

Telehealth may be used for diagnosis, treatment, or follow-up related to your purchase. You understand that telehealth has limitations compared to in-person care, such as lack of physical examination, potential technical failures, or missed nonverbal cues. You may withdraw your consent at any time, though this may end the Provider’s ability to prescribe medication.

Benefits and Risks
Expected benefits include improved access to care, evaluation from your chosen location, and efficient prescription review. Risks include technical failures, incomplete or inaccurate information, limited examination ability, or regulatory limits on prescribing.

Scope of Care
Providers engaged through Zealthy for this one-time encounter may conduct a consultation, make a treatment decision, and, if clinically appropriate, issue a prescription. This encounter does not replace primary or emergency care and does not establish an ongoing provider-patient relationship beyond the scope of this purchase. You should maintain or establish care with a local primary care provider for your overall health needs.

Privacy and Security
All telehealth encounters comply with HIPAA and applicable privacy laws. Your personal and health information will not be disclosed without your consent except as permitted by law.

Prescriptions
If a Provider determines medication is clinically appropriate, a prescription may be issued. You are responsible for any associated costs not included in your purchase.

Patient Acknowledgments
By consenting, you agree that:

• You understand the risks and benefits of telehealth.
• You consent to receiving your evaluation via telehealth.
• You understand that this encounter is limited to the product you purchased and does not create an ongoing medical relationship.
• You have provided accurate and complete medical history.
• You accept that outcomes are not guaranteed.

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If you have concerns about a Provider, contact your state’s Medical Board (list available at AAFP Legal Requirements).

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State-Specific Consents

The following consents apply to users accessing the Service for the purposes of participating in a telehealth consultation as required by the states listed below: 

• Alaska: I understand my primary care provider may obtain a copy of my records of my telehealth encounter. (AK Stat. 08.64.364).
• Arizona: I understand I am entitled to all existing confidentiality protections pursuant to A.R.S. § 12-2292. I also understand all medical reports resulting from the telemedicine consultation are part of my medical record as defined in A.R.S. § 12-2291. I also understand dissemination of any images or information identifiable to me for research or educational purposes shall not occur without my consent, unless authorized by state or federal law. (A.R.S. § 36-3602).
• California: Physicians and midwives and other practitioners are licensed and regulated by the Medical Board of California. To confirm a license or file a complaint, go to www.mbc.ca.gov or call (800) 633-2322.
• Connecticut: I understand that my primary care provider may obtain a copy of my records of my telehealth encounter. (C.G.S.A. § 19a-906).
• D.C.: I have been informed of alternate forms of communication between me and a physician for urgent matters. (17 DCMR § 4618.10).
• Idaho: I acknowledge that my identity has been verified, and I have been informed about my Provider’s credentials. I understand the security measures in place to protect my health information and have been informed about the possibility of information loss due to technical failures.
• Kentucky: If I am a Medicaid recipient, I recognize I have the option to refuse the telehealth consultation at any time without affecting the right to future care or treatment and without risking the loss or withdrawal of a Medicaid benefit to which I am entitled. I understand that I have the right to be informed of any party who will be present at the site during the telehealth consult and I have the right to exclude anyone from being present. I also understand that I have the right to object to the videotaping of the telehealth consultation. (KY Admin. Regs. Tit. 907, 3:170).
• Louisiana: I understand the role of other health care providers that may be present during the consultation other than the Telehealth Group provider. I further understand that I may decline to receive medical services via telemedicine and may withdraw from such care at any time. (46 La. Admin. Code Pt XLV, § 7511). 
• Maryland: I understand that dissemination of image or information identifiable to me shall not be disseminated to other entities without my consent, unless there is an emergency preventing the practitioner from obtaining such consent. (Code of MD Reg. 10.09.49.09). Regarding audiologists, speech language pathologists, and hearing aid dispensers, I recognize the inability to have direct, physical contact with the patient is a primary deference between telehealth and direct in-person service delivery. The knowledge, experiences, and qualifications of the consultant providing data and information to the provider of the telehealth services need not be completely known to, and understood by the provider. The quality of transmitted data may affect the quality of services provided by the provider. Changes in the environment and test conditions could be impossible to make during delivery of telehealth services. Telehealth services may not be provided by correspondence only. (Code of MD Reg. 10.41.06.04). 
• Nebraska: If I am a Medicaid recipient, I retain the option to refuse the telehealth consultation at any time without affecting my 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. I shall have access to all medical information resulting from the telehealth consultation as provided by law for access to my medical records. Dissemination of any patient identifiable images or information from the telehealth consultation to researchers or other entities shall not occur without my written consent. I understand that I have the right to request an in-person consult immediately after the telehealth consult and I will be informed if such consult is not available. (NE Revised Stat.71-8505; NE Admin. Code Tit. 471, Ch. 1). 
• Nevada: I consent to the forwarding of my medical records to my primary care provider or other designated healthcare providers. 
• New Hampshire: I understand that the Telehealth Group provider may forward my medical records to my primary care or treating provider. (N.H. Rev. Stat. §329:1-d). 
• New Jersey: I understand I have the right to request a copy of my medical information and I understand my medical information may be forwarded directly to my primary care provider or health care provider of record, or upon my request, to other health care providers. (NJ Rev. Stat. §45:1-62). 
• Ohio: I agree to hold harmless Zealthy, Inc., the Group and my Provider for any delays or disruptions in service due to technical failures. 
• Pennsylvania: I understand that I may be asked to confirm my consent to behavioral health or tele-psych services. 
• Rhode Island: If I use email or text-based technology to communicate with my Telehealth Group provider, then I understand the types of transmissions that will be permitted and the circumstances when alternate forms of communication or office visits should be utilized. I have also discussed security measures, such as encryption of data, password-protected screen savers and ata files, or utilization of other reliable authentication techniques, as well as potential risks to privacy. I acknowledge that my failure to comply with this agreement may result in the Telehealth Group provider terminating the email relationship. (Rhode Island Medical Board Guidelines). 
• South Carolina: I understand my medical records may be distributed in accordance with applicable law and regulation to other treating health care practitioners. (S.C. Code 1976 §40-47-37). 
• Tennessee: I understand that I may request an in-person assessment before receiving a telehealth assessment if I am a Medicaid recipient. 
• Texas: I acknowledge that for telehealth services in Texas, consent must be obtained prior to each encounter or annually. I have been informed about any additional fees associated with telehealth services and agree to pay them as part of the service cost. 
• Vermont: 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 tele-dermatology or tele-ophthalmology services via Telehealth Group 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). If receiving audio-only services, I understand the availability of alternative delivery methods and the insurance implications. 
• Wisconsin: I confirm that my identity and my Provider’s credentials have been verified, the technology used has been explained, and that telehealth is appropriate for my care, with security measures in place. 

Compliance with State Laws

This Telehealth Informed Consent is designed to comply with the laws and regulations of all 50 states regarding telehealth. If you reside in a state with specific requirements not listed above, please inform your provider, and additional consents may be obtained as necessary. 

By clicking “I Agree,” checking the agreement box or a related box to signify my acceptance, using other acceptance protocol presented through the Website, App or Service, or otherwise indicating acceptance, I, _______________________________,  acknowledge that I have read, understand and agree to this Consent and consent to receive telehealth. 

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I acknowledge and understand that I will digitally receive a copy of this Consent (you have the ability to print, PDF, copy/pase, or screenshot a copy of this Consent). 

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THIS FORM MUST BE PLACED IN THE MEDICAL RECORD. A COPY OF THIS DOCUMENT CAN BE ACCESSED BY EMAILING [email protected] OR BY ACCESSING THE CONSENT HERE.