Telehealth Consent Form

Telehealth is healthcare delivered using electronic communications when you and your healthcare professional are in different locations. It allows a licensed healthcare professional to evaluate, diagnose where appropriate, treat, and follow up with you remotely.

Telehealth may include:

• Live video visits
• Telephone or audio-only visits
• Secure messaging
• Electronic transmission of medical information
• Patient-submitted photographs or documents
• Other electronic communications used for healthcare

The specific technology used may vary depending on your clinical circumstances, availability, applicable law, and the healthcare professional involved in your care.

By completing the consent form at the end of this document, you are voluntarily agreeing to receive healthcare services through telehealth.

By providing consent, you acknowledge that you have been informed about the nature of telehealth, including its potential benefits, limitations, risks, and alternatives, and that you have had an opportunity to ask questions before proceeding.

Providing consent does not guarantee:

• A diagnosis
• A prescription
• A particular medication
• A particular treatment
• A referral
• A specific clinical outcome

A telehealth encounter generally follows these steps:

• You provide identifying and health information.
• You complete any required intake questions.
• You connect with a healthcare professional.
• The healthcare professional evaluates the information available through telehealth.
• The healthcare professional determines an appropriate clinical plan.
• The professional may prescribe, order testing, recommend follow-up, refer you, or recommend in-person care.
• The encounter is documented in your medical record as required.

Telehealth may offer benefits such as:

• Convenience
• Reduced travel
• Improved access to care
• Flexible access to healthcare professionals
• The ability to receive certain services remotely
• Potentially faster access to appropriate care

These benefits are potential benefits only. They are not guaranteed, and they may differ depending on your circumstances.

Telehealth has inherent clinical and technological limitations. These include, but are not limited to:

• A healthcare professional may not be able to perform a complete physical examination.
• Certain conditions require a hands-on examination.
• Some diagnostic information cannot be obtained remotely.
• Laboratory testing or imaging may be necessary.
• Audio or video quality may affect the encounter.
• Internet connectivity may fail or be interrupted.
• Device problems may interrupt communication.
• Information may be incomplete, delayed, or difficult to interpret remotely.
• Your healthcare professional may determine that telehealth is not appropriate for you.
• Your healthcare professional may recommend an in-person evaluation.
• Electronic communications involve privacy and security risks.
• Technical limitations may affect a professional's ability to assess you.

Reasonable safeguards are used, but telehealth cannot eliminate all clinical or technological risks.

Telehealth requires appropriate technology. You may need:

• A smartphone, tablet, or computer
• An internet or telecommunications connection
• A camera and microphone where video is required
• A compatible browser or application
• An appropriate environment for the visit

To support a safe and effective visit, you should:

• Use a private location when possible.
• Ensure adequate lighting and audio.
• Maintain a reliable connection.
• Provide accurate information.
• Notify your healthcare professional if technical issues affect communication.

If technical problems prevent an appropriate evaluation, your healthcare professional may end, reschedule, or change the modality of the encounter.

Lyla Health handles patient information in accordance with applicable law and its privacy documentation, which may include the Health Insurance Portability and Accountability Act (HIPAA) where applicable, and applicable federal and state privacy laws.

Despite reasonable administrative, physical, and technical safeguards, electronic communications involve inherent privacy and security risks. No method of electronic transmission or storage can be guaranteed to be completely secure, and absolute privacy or security cannot be promised.

Information generated during a telehealth encounter may become part of your medical record. This may include:

• Clinical notes
• Patient history
• Reported symptoms
• Diagnoses
• Treatment recommendations
• Prescriptions
• Patient-submitted documents or images
• Relevant communications

Medical records are maintained, used, and disclosed according to applicable law and Lyla Health's privacy practices.

Healthcare professionals generally must be authorized to provide healthcare services in the jurisdiction where you are physically located at the time of your telehealth encounter.

You agree to provide accurate information about the state or jurisdiction in which you are physically located when receiving telehealth services and to notify your healthcare professional if your location changes during an encounter.

Availability of telehealth services depends on applicable law, healthcare professional licensure, and clinical appropriateness, and may vary by jurisdiction and over time.

Your healthcare professional will use independent clinical judgment to determine whether telehealth is appropriate for your circumstances.

Your healthcare professional may recommend:

• An in-person examination
• Urgent care
• Emergency care
• Laboratory testing
• Imaging
• Specialist evaluation
• Other diagnostic services
• Additional follow-up

Lyla Health does not guarantee any particular diagnosis, treatment, prescription, medication, referral, or clinical outcome.

Telehealth is one way to receive care. Alternatives may include:

• In-person primary care
• Urgent care
• Emergency care
• Specialist care
• Diagnostic testing
• Other appropriate healthcare services

You may choose an alternative to telehealth where such care is available and appropriate for your needs.

Telehealth consent does not guarantee that you will receive a prescription, medication, diagnosis, treatment, referral, or other clinical service.

Prescribing and treatment decisions are based on:

• Clinical judgment
• Patient-specific information
• Applicable federal law
• Applicable state law
• Applicable clinical standards

Certain medications or treatments may require an in-person evaluation or may not be appropriate through telehealth.

As a patient receiving telehealth services, you agree to:

• Provide accurate and complete health information.
• Provide your accurate current physical location.
• Provide accurate medication and allergy information.
• Provide relevant medical history.
• Follow reasonable clinical instructions.
• Use the telehealth technology appropriately.
• Notify your healthcare professional about technical problems.
• Participate in the encounter from an appropriate location.
• Seek emergency care when necessary.
• Not use telehealth services for emergencies.

Your consent to telehealth is voluntary. You may withdraw your consent to receive telehealth services at any time, subject to applicable law and clinical or administrative requirements.

Withdrawing consent may mean that:

• The telehealth encounter cannot proceed.
• An alternative modality may be recommended.
• An in-person appointment may be recommended.

Additional requirements may apply when:

• The patient is a minor.
• A parent or legal guardian provides consent.
• An authorized representative is acting on behalf of the patient.
• Applicable state law imposes additional requirements.

Additional requirements may apply based on the patient's age, jurisdiction, and circumstances.

Please note the following regarding cost:

• Telehealth services may involve fees.
• Insurance coverage for telehealth varies.
• Copayments, deductibles, coinsurance, and other patient responsibility may apply.
• Telehealth consent does not guarantee insurance coverage.
• Self-pay patients may be responsible for disclosed charges.
• No-shows are charged $89. If you fail to cancel your appointment 24 hours prior to your visit, you will be charged a fee of $89 in the event of a no-show.

For details, review Lyla Health's billing and payment information.

If you have questions about telehealth, this consent, privacy, or your care, please contact Lyla Health before proceeding with your telehealth visit.

Patient Support

support@lylahealth.com

Privacy Questions

privacy@lylahealth.com

Phone

(844) 915-8900