Telehealth & SMS Communication Consent Form

1. Definition of Telehealth

Telehealth is the delivery of healthcare services when the patient and healthcare provider are not in the same physical location. Telehealth may use video conferencing, telephone calls, secure messaging, and other forms of electronic communication.

Telehealth services may include:

• Clinical evaluation and diagnosis
• Therapy and treatment
• Follow-up care
• Patient education
• Review and transmission of medical records, images, test results, or information from medical devices

Providers may include primary care practitioners, specialists, or subspecialists who are appropriately licensed to provide care in Connecticut.

2. Scope and Limitations of Telehealth Services

I understand that telehealth may not replicate every aspect of an in-person visit. Possible limitations include:

• Some clinical information may be unavailable remotely.
• Technical problems, including poor audio or video quality and internet disruptions, may interfere with care.
• The provider’s ability to perform a physical examination is limited.
• An in-person visit, testing, or referral may be required.
• Certain nonverbal cues may be more difficult to observe remotely.
• Telehealth may not be appropriate for every medical condition.
• Telehealth is not intended to replace emergency care or an urgent in-person medical evaluation.

3. Patient Responsibilities

As a telehealth patient, I agree to:

1. Provide accurate and current personal, medical, insurance, contact, and location information.
2. Be physically located in Connecticut at the time of my telehealth appointment, unless otherwise authorized by the provider and permitted by applicable law.
3. Provide my current physical location at the beginning of each telehealth visit.
4. Use technology that supports reasonably reliable audio and video communication when video is required.
5. Participate from a location that provides reasonable privacy.
6. Take reasonable steps to prevent unauthorized individuals from hearing or viewing the telehealth session.
7. Notify the provider immediately of technical problems or interruptions.
8. Inform the provider about all medications, supplements, allergies, medical conditions, and relevant changes in my health.
9. Follow the provider’s instructions, including recommendations for testing, follow-up care, referrals, or in-person evaluation.
10. Inform the provider if another person is present during the telehealth session.

4. Provider Responsibilities

Beyond Health, LLC and its providers agree to:

• Conduct telehealth services according to applicable professional standards and Connecticut law.
• Protect patient information in accordance with HIPAA and other applicable federal and state privacy laws.
• Use appropriate safeguards to protect electronically transmitted information.
• Explain relevant telehealth risks, benefits, limitations, and reasonable alternatives.
• Provide instructions for follow-up care or in-person evaluation when clinically appropriate.
• Stop or reschedule a telehealth visit if technical limitations prevent an adequate evaluation.

5. Privacy and Confidentiality

I understand and acknowledge that:

• Telehealth communications and records will be handled in accordance with HIPAA and other applicable privacy laws.
• Personally identifiable information, images, and medical information will not be disclosed without authorization except as permitted or required by law.
• In certain circumstances, including a declared public health emergency, alternative communication technology may be used after the risks and limitations have been explained and I have consented to its use.
• Email may be used for administrative communications, but standard email may not be completely secure or confidential.
• Neither the patient nor the provider may record a telehealth session without the prior knowledge and explicit consent of all participants.
• Despite reasonable safeguards, electronic communications may involve privacy and security risks.

6. Video and Audio Conduct

I agree that:

• I will not record, photograph, stream, copy, or otherwise capture any part of a telehealth session without prior written authorization.
• The provider will access the audio and video connection only as necessary to conduct the telehealth visit.
• Additional individuals may participate in the session only after their identity and role have been disclosed and my consent has been obtained, except when otherwise permitted or required by law.
• I will notify the provider if another person enters the room or can hear or observe the session.

7. Technology Risks

I understand that telehealth involves potential technology and security risks, including:

• Internet outages or disruptions
• Software or equipment failures
• Poor audio or video quality
• Delays or interruptions in care
• Unauthorized access or disclosure
• Hacking, malware, or data breaches
• Miscommunication caused by technical limitations
• Other currently unknown risks associated with electronic healthcare delivery

I understand that Beyond Health, LLC cannot guarantee that every electronic communication or telehealth connection will be completely secure or uninterrupted.

8. Emergency Protocol

I understand and agree that:

• Telehealth providers cannot provide hands-on emergency care.
• I will provide my current physical address or location at the beginning of each telehealth visit.
• If I am experiencing a medical emergency, I must call 911 or go to the nearest emergency department.
• I will not use text messaging, email, secure messaging, voicemail, or telehealth scheduling tools to report an emergency.
• The provider may contact emergency services or another appropriate person if the provider reasonably believes that immediate assistance is necessary.
• Beyond Health, LLC may assist in directing me to emergency care but cannot physically intervene through telehealth.

9. Payment and Billing for Telehealth Services

Telehealth services are subject to the same payment policies as in-person services.

Co-Pay Requirement

• A co-pay may be required for each telehealth visit and is due at the time of service.
• When applicable, the co-pay may be charged automatically to the credit or debit card I have on file with Beyond Health, LLC.

Card-on-File Policy

• Patients receiving telehealth services must provide a valid credit or debit card to be maintained securely on file.
• The card may be used to process co-pays and patient-responsible balances after insurance adjudication, subject to the applicable financial policy.
• If I wish to use a different card for a specific visit, I must contact the office at least 24 hours before my scheduled appointment and provide the updated payment information.

Insurance and Patient Responsibility

• Telehealth services will be submitted to insurance in the same manner as applicable in-person services.
• I am responsible for co-pays, deductibles, co-insurance, non-covered services, and other patient-responsible balances determined by my insurance plan.
• My card on file may be used to collect a patient-responsible balance after my insurance company has processed the claim, in accordance with the applicable financial policy.

Payment Confirmation

• I will receive a receipt for amounts charged.
• Billing questions should be directed to Beyond Health, LLC at 203-408-2420.

10. Clinical Limitations and Follow-Up Care

I understand that:

• Telehealth may be inadequate for certain conditions, symptoms, examinations, or procedures.
• The provider may discontinue the telehealth evaluation and require an in-person visit when telehealth is not clinically appropriate.
• The provider may recommend laboratory testing, diagnostic imaging, specialist care, urgent care, or emergency evaluation.
• My treatment outcome may be affected if I do not follow provider instructions or if technical limitations prevent a complete evaluation.
• Participation in telehealth does not guarantee a diagnosis, prescription, treatment, or particular medical outcome.

11. Telehealth Consent and Patient Rights

By signing this Agreement, I acknowledge that:

1. I have received information about telehealth and its potential risks, benefits, alternatives, and limitations.
2. I have had an opportunity to ask questions and receive answers.
3. I may refuse telehealth services or withdraw my telehealth consent at any time.
4. Refusing or withdrawing consent will not prevent me from seeking future care, although alternative arrangements may be required.
5. Telehealth is not a replacement for emergency medical services.
6. I consent to receive telehealth services from providers who are appropriately licensed to provide care in Connecticut.
7. My personal and medical information may be transmitted electronically for purposes related to my care.
8. I accept the risks reasonably associated with the electronic transmission of information.
9. I may request an in-person visit when appropriate and available.
10. I understand that the provider may determine that an in-person evaluation is medically necessary.

12. Electronic Communications and SMS/Text Messaging Consent

Beyond Health, LLC may communicate with patients through telephone calls, email, secure messaging, and text messaging for general support, appointment-related information, occasional notifications, and other practice information.

Optional SMS/Text Messaging Consent

Upon acknowledging and signing this form, I consent to receive text messages (SMS) from Beyond Health, LLC for general support, appointment-related communications, occasional notifications, and practice information. Message frequency may vary. Message and data rates may apply. I understand that I may reply STOP at any time to opt out of further text messages. I may reply HELP for assistance or call Beyond Health, LLC at 203-408-2420. Please review the Beyond Health, LLC Privacy Policy at: www.beyondhealthct.com/privacy-policy.

I understand that:

• Consent to receive text messages is voluntary.
• Consent to receive text messages is not a condition of receiving medical care or services from Beyond Health, LLC.
• Standard text messages may not be encrypted or completely secure.
• Text messaging should not be used to communicate urgent or emergency medical concerns.
• Text messages may not be monitored continuously.
• For a medical emergency, I must call 911 or go to the nearest emergency department.
• I may withdraw my SMS consent at any time by replying STOP.
• Opting out of text messages will not prevent Beyond Health, LLC from contacting me through other permitted methods when necessary for treatment, payment, healthcare operations, or as otherwise allowed by law.

13. Accessibility and Language Assistance

If I need this form in another language or require an accommodation because of a disability, I will notify Beyond Health, LLC before signing whenever possible.

Acknowledgment and Consent

By signing below, I acknowledge that:

• I have read and understand this Telehealth and Communication Consent Form.
• I have had an opportunity to ask questions.
• My questions have been answered to my satisfaction.
• I voluntarily consent to receiving telehealth services from Beyond Health, LLC.
• My signature constitutes an electronic signature under applicable law.
• My selection regarding SMS/text messaging is documented separately in Section 12.
• I understand that I may withdraw my optional SMS consent at any time by replying STOP.