Telehealth Consent & Patient Rights

Last updated: January 2025

Informed Consent for Telehealth Services

By using Fifty 410's telehealth services, you acknowledge that you have read, understand, and agree to the following terms regarding the delivery of healthcare services via telemedicine technology.

Nature of Telehealth Services

Telehealth involves the use of electronic communications to enable healthcare providers at different locations to share individual patient medical information for the purpose of improving patient care. This may include:

• Consultation with your healthcare provider via secure messaging or video
• Review of your medical history and current health information
• Remote prescribing of medications when clinically appropriate
• Electronic transmission of prescriptions to pharmacies
• Ongoing monitoring and follow-up care

Benefits of Telehealth

• Improved access to healthcare by enabling patients to receive care remotely
• More efficient medical evaluation and management
• Obtaining expertise of a specialist without traveling
• Reduced exposure to infectious diseases
• Convenience and reduced time away from work or family

Risks of Telehealth

As with any medical service, there are potential risks associated with telehealth:

• Information transmitted may not be sufficient for appropriate medical decision-making
• Delays in evaluation or treatment could occur due to technology failures
• Security protocols could fail, causing a breach of privacy
• Lack of access to complete medical records may result in adverse interactions or allergic reactions
• The provider may determine that the presenting condition is not appropriate for telehealth services

Your Rights as a Patient

You have the right to:

• Withhold or withdraw consent to telehealth services at any time
• Request an in-person consultation at any time
• Access your medical records in accordance with applicable laws
• Expect that all communications will be confidential
• Know the identity and qualifications of all providers involved in your care
• Receive information about the diagnosis, proposed treatment, and alternatives
• Refuse any recommended treatment

Your Responsibilities

As a patient using telehealth services, you agree to:

• Provide accurate and complete health information
• Inform your provider of all medications you are currently taking
• Follow the treatment plan as prescribed
• Contact us if you experience adverse effects or your condition worsens
• Seek emergency care when appropriate (telehealth is not for emergencies)

Emergency Services Notice

Telehealth services are NOT appropriate for medical emergencies.

If you are experiencing a medical emergency, call 911 immediately or go to your nearest emergency room. Emergency conditions include but are not limited to:

• Chest pain or difficulty breathing
• Severe allergic reactions
• Stroke symptoms (sudden numbness, confusion, trouble speaking)
• Severe abdominal pain
• Thoughts of self-harm or suicide

State-Specific Telehealth Notices

The following notices are provided in compliance with individual state telehealth regulations. Please review the notice applicable to your state of residence.

Texas

Telehealth services provided to Texas residents comply with the Texas Medical Board rules for telemedicine (22 TAC §174). You have the right to:

• Receive a list of all healthcare providers involved in your telehealth encounter
• Access your medical records
• File a complaint with the Texas Medical Board

To file a complaint: Texas Medical Board, P.O. Box 2018, Austin, TX 78768-2018, Phone: (512) 305-7010, or online at www.tmb.state.tx.us

California

California residents receiving telehealth services are protected under the Telehealth Advancement Act of 2011 (Business and Professions Code §2290.5) and subsequent amendments. You have the right to:

• Verbal and written informed consent prior to telehealth services
• Request an in-person consultation at any time
• All rights afforded under CCPA regarding your personal information

To file a complaint: Medical Board of California, 2005 Evergreen Street, Suite 1200, Sacramento, CA 95815, Phone: (800) 633-2322

New York

New York residents are protected under New York Public Health Law Article 29-G and Education Law §6530. Telehealth services in New York require:

• Informed consent obtained prior to service delivery
• Compliance with all applicable professional licensing standards
• Protection of patient confidentiality in accordance with HIPAA and state law

To file a complaint: New York State Department of Health, Complaint Unit, 161 Delaware Avenue, Delmar, NY 12054-1393, Phone: (800) 663-6114

Florida

Florida telehealth services are governed by Florida Statutes §456.47. Florida patients have the right to:

• Be informed of the provider's license type and state of licensure
• Request in-person services at any time
• Have telehealth services held to the same standard of care as in-person services

To file a complaint: Florida Department of Health, 4052 Bald Cypress Way, Bin C-75, Tallahassee, FL 32399-3265, Phone: (850) 245-4339

Illinois

Illinois telehealth services comply with 225 ILCS 60/49.5 (Telehealth Act). Illinois patients are entitled to:

• The same standard of care as in-person services
• Know the identity and credentials of healthcare providers
• Privacy protections under state and federal law

Pennsylvania

Pennsylvania telehealth services are provided in accordance with 63 P.S. §422.51. Patients have the right to:

• Informed consent before receiving telehealth services
• Request in-person evaluation at any time
• Receive care that meets the same standards as in-person care

Ohio

Ohio telehealth services comply with Ohio Revised Code §4743.09. Ohio patients are entitled to:

• Information about the limitations of telehealth
• Documentation of all telehealth encounters in medical records
• The same standard of care as in-person consultations

Georgia

Georgia telehealth services are governed by O.C.G.A. §33-24-56.4. Patients have the right to:

• Informed consent prior to telehealth services
• Know if other individuals are present during the telehealth encounter
• Receive documentation of the encounter

Arizona

Arizona telehealth services comply with A.R.S. §36-3602. Arizona patients are entitled to:

• Know the provider's name, credentials, and contact information
• Documentation of services in their medical record
• Emergency referral protocols when appropriate

All Other States

For residents of states not specifically listed above, Fifty 410 telehealth services comply with all applicable state and federal telehealth regulations, including:

• Provider licensure requirements in your state of residence
• Informed consent requirements
• HIPAA privacy and security standards
• Prescribing regulations under the Ryan Haight Act

If you have questions about telehealth regulations in your state, please contact us at [email protected].

Privacy and Security

Fifty 410 is committed to protecting your health information in accordance with the Health Insurance Portability and Accountability Act (HIPAA) and applicable state privacy laws.

• All telehealth communications are encrypted using industry-standard protocols
• Your medical information is stored securely and accessed only by authorized personnel
• We do not sell or share your personal health information with third parties for marketing
• You may request a copy of our Notice of Privacy Practices at any time

For more information about how we protect your data, please review our Privacy Policy.

Healthcare Provider Information

All Fifty 410 healthcare providers are:

• Licensed providers (MD, DO, NP, or PA)
• Licensed in the state where you are located at the time of service
• Trained in providing telehealth services
• Subject to ongoing quality assurance and peer review

You have the right to request the name, license number, and credentials of your healthcare provider at any time.

Your Consent

By using Fifty 410's telehealth services, you confirm that:

• You have read and understand this Telehealth Consent document
• You understand the risks and benefits of telehealth services
• You consent to receive healthcare services via telehealth technology
• You understand you may withdraw consent at any time
• You have had the opportunity to ask questions about telehealth services

Questions or Concerns

If you have questions about this consent form, your telehealth services, or your rights as a patient, please contact us:

• Email: [email protected]
• Phone: Available upon request via email

For concerns about the quality of care you received, you may also contact your state medical board using the information provided in the state-specific notices above.