Telehealth Consent

TELEHEALTH INFORMED CONSENT FORM

Direct Pay Virtual Clinic

PURPOSE OF THIS DOCUMENT

This Telehealth Informed Consent Form is provided to you in accordance with Minnesota law (Minn. Stat. § 147.37 and Minn. Stat. § 62A.671), the American Telemedicine Association guidelines, and applicable federal regulations. Informed consent for telehealth services is a legally required process that ensures you have the information necessary to make a voluntary, educated decision about participating in virtual healthcare services.

Please read this document in its entirety. You have the right to ask questions about any part of this document before consenting. By proceeding with your telehealth appointment, you affirm that you have read, understood, and voluntarily consent to the terms described herein.

This form does not replace or supersede any separate informed consent forms that may be required for specific treatments, procedures, or medications, which will be obtained separately as clinically appropriate.

SECTION 1: WHAT IS TELEHEALTH?

Telehealth (also referred to as telemedicine) is the delivery of healthcare services through electronic communications technology, including two-way audio-visual platforms, digital data transmission, and secure messaging. At Direct Pay Virtual Clinic, telehealth services are delivered via a secure, HIPAA-compliant video conferencing platform in real time (synchronous telehealth).

Telehealth services at Direct Pay Virtual Clinic are provided by a licensed Advanced Practice Registered Nurse with Family Nurse Practitioner (FNP) certification, licensed by the Minnesota Board of Nursing pursuant to Minn. Stat. Ch. 148. All telehealth services are provided within the scope of practice authorized under Minnesota law.

Telehealth is an established, clinically validated modality of healthcare delivery for a wide range of conditions and has been recognized by the Minnesota Legislature (Minn. Stat. § 62A.671) and federal health agencies as equivalent to in-person care for appropriate clinical scenarios.

SECTION 2: BENEFITS OF TELEHEALTH

The use of telehealth technology in the delivery of healthcare services offers the following potential benefits:

•       Improved access to healthcare, particularly for patients with limited mobility, transportation barriers, or time constraints

•       Elimination of exposure to other patients in waiting room settings, reducing transmission of communicable illness

•       Convenience of receiving care from your home, workplace, or other private location

•       Reduced time away from work or caregiving responsibilities

•       Rapid access to clinical evaluation for acute symptoms without the need to travel

•       Continuity of care for established conditions through follow-up consultations

•       Reduced overall cost of care in certain circumstances

SECTION 3: LIMITATIONS AND MATERIAL RISKS OF TELEHEALTH

You have the right to be informed of the known limitations and potential risks associated with telehealth services. By consenting to telehealth, you acknowledge your awareness of the following:

3.1 Physical Examination Limitations

A telehealth consultation does not permit the Provider to conduct a physical examination in the traditional sense. The Provider will rely on visual observation via video, your self-reported history, any vital signs you are able to take at home, and any prior medical records you provide. This limitation may affect the Provider's ability to detect certain physical findings that would only be apparent during an in-person examination. As a result, the Provider may determine that an in-person visit is necessary for certain conditions.

3.2 Diagnostic Limitations

Certain diagnostic procedures, including but not limited to auscultation of heart and lung sounds, palpation of the abdomen, neurological assessments, wound evaluations, and laboratory or imaging studies, cannot be performed via telehealth. In such cases, the Provider may order laboratory or imaging studies to be completed at a local facility, or may refer you to an in-person provider.

3.3 Technology Risks

The delivery of telehealth services depends on the proper functioning of electronic communications technology. The following technology-related risks exist:

•       Interruption, degradation, or failure of the internet connection, audio, or video feed may impair the quality of the consultation or prevent its completion

•       Electronic communications are subject to potential security breaches, including unauthorized interception, despite the use of encryption and other safeguards

•       Electronic data storage systems used to maintain your health records may be subject to technical failures or cybersecurity incidents

•       Device or software incompatibilities may affect the quality of the telehealth session

In the event of a significant technical failure during your consultation, your Provider will make reasonable efforts to reconnect or reschedule the appointment. In the event of a security breach affecting your protected health information, you will be notified in accordance with HIPAA Breach Notification requirements (45 C.F.R. §§ 164.400-414) and applicable Minnesota law.

3.4 Information Transmission Risks

Your protected health information (PHI) will be transmitted electronically in the course of your telehealth visit and related care. While Direct Pay Virtual Clinic uses HIPAA-compliant, encrypted platforms and maintains appropriate administrative, physical, and technical safeguards as required by 45 C.F.R. §§ 164.312, no electronic transmission system can be guaranteed to be 100% secure. You have the right to withhold consent to the electronic transmission of your health information; however, doing so will prevent the provision of telehealth services.

3.5 Clinical Appropriateness

Not all medical conditions are appropriate for telehealth evaluation and treatment. Your Provider will exercise clinical judgment to determine whether telehealth is an appropriate modality for your specific concern. If the Provider determines that your condition requires in-person evaluation, you will be informed and provided with appropriate referrals or recommendations.

3.6 Medication Risks

Prescriptions issued via telehealth carry the same risks as those issued in person, including but not limited to adverse drug reactions, drug interactions, and contraindications. It is your responsibility to disclose all current medications, supplements, and allergies to your Provider. The Provider will not prescribe controlled substances via telehealth.

SECTION 4: YOUR RIGHTS AS A TELEHEALTH PATIENT

As a patient receiving telehealth services from Direct Pay Virtual Clinic, you have the following rights, which are protected under Minnesota law (Minn. Stat. § 144.651 - Minnesota Patients' Bill of Rights) and applicable federal law:

•       The right to receive, upon request, a written summary of the information provided in this consent form

•       The right to ask questions about the telehealth process, the technology being used, and the qualifications of your Provider at any time

•       The right to withdraw your consent to telehealth at any time, either before or during a consultation, without penalty and without affecting your right to receive future care; withdrawal of consent must be communicated to the Clinic in writing

•       The right to request an in-person evaluation if you believe telehealth is not adequately addressing your needs

•       The right to access, inspect, copy, and amend your health records as provided under HIPAA (45 C.F.R. §§ 164.524, 164.526) and Minn. Stat. § 144.293

•       The right to receive a copy of this consent form for your records

•       The right to be treated with dignity, respect, and without discrimination in accordance with applicable law

•       The right to privacy and confidentiality of your health information as provided by HIPAA, the Minnesota Health Records Act, and the Minnesota Consumer Data Privacy Act

•       The right to know the identity, qualifications, and license status of the Provider delivering your care

•       The right to participate in decisions about your care, including the right to refuse any recommended treatment

•       The right to file a complaint regarding your care with the Minnesota Board of Nursing (www.nursingboard.state.mn.us) or the U.S. Department of Health and Human Services Office for Civil Rights (www.hhs.gov/ocr) without retaliation

SECTION 5: PRIVACY, CONFIDENTIALITY, AND RECORDING

5.1 Privacy Protections

Your telehealth session and all health information exchanged during your consultation are protected by HIPAA (45 C.F.R. Parts 160 and 164), the Minnesota Health Records Act (Minn. Stat. Ch. 144), and the Minnesota Consumer Data Privacy Act. Direct Pay Virtual Clinic uses a HIPAA-compliant telehealth platform subject to a Business Associate Agreement as required by 45 C.F.R. § 164.308(b).

All electronic communications are encrypted using industry-standard encryption protocols. Health information is stored in a secure, encrypted electronic health record system with access limited to authorized clinical personnel on a need-to-know basis.

5.2 Recording Policy

Telehealth sessions will NOT be audio or video recorded without your express prior written consent. If you wish to record the session for personal use, you must obtain the prior written consent of the Provider before doing so. Unauthorized recording of telehealth sessions may violate Minnesota's two-party consent law (Minn. Stat. § 626A.02) and is strictly prohibited.

5.3 Patient Environment

You are responsible for ensuring the privacy of your own environment during your telehealth visit. The Clinic recommends that you conduct your appointment in a private location where others cannot overhear your conversation. The Clinic is not responsible for breaches of privacy resulting from your failure to ensure a private environment on your end of the consultation.

5.4 Third Parties

If you wish to have a family member, caregiver, interpreter, or other third party present during your telehealth visit, you must inform your Provider at the beginning of the session. The presence of third parties may affect the scope of information discussed. Minors under 18 years of age receiving telehealth services must be accompanied by a parent or legal guardian unless otherwise permitted by Minnesota law (e.g., regarding minors' rights to consent to certain health services under Minn. Stat. § 144.341 et seq.).

SECTION 6: TECHNICAL REQUIREMENTS

To participate in a telehealth visit with Direct Pay Virtual Clinic, you must have access to the following:

•       A smartphone, tablet, or computer with a functioning forward-facing camera and microphone

•       A stable internet connection with sufficient bandwidth to support live video conferencing (minimum recommended: 1.5 Mbps upload and download)

•       A private location where you can speak freely and without interruption

•       The ability to access the telehealth platform link provided by the Clinic (compatible browser or app may be required)

•       Any home monitoring equipment requested by your Provider (e.g., blood pressure cuff, thermometer, pulse oximeter), if applicable

If you experience technical difficulties prior to or during your appointment, please contact the Clinic immediately. Technical difficulties that prevent the completion of a consultation may be rescheduled at no additional charge, subject to the Clinic's cancellation policy.

SECTION 7: GEOGRAPHIC AND LICENSURE REQUIREMENTS

Telehealth services provided by Direct Pay Virtual Clinic are available only to patients who are physically located within the State of Minnesota at the time the services are rendered. This requirement is necessary because our Provider is licensed in Minnesota and provides care under Minnesota law. If you access telehealth services while located outside Minnesota, your care may not comply with applicable licensure laws, and the Clinic shall have no liability for services rendered under such circumstances.

If you relocate to another state permanently or are temporarily residing or traveling outside Minnesota, please contact the Clinic before scheduling an appointment so we can advise you on your options.

SECTION 8: EMERGENCY PROTOCOL

Medical emergencies include, but are not limited to: chest pain, difficulty breathing, stroke symptoms, uncontrolled bleeding, loss of consciousness, severe allergic reaction, suicidal ideation with intent or plan, or any other condition posing an immediate threat to life or limb.

If your Provider identifies signs of a medical emergency during a telehealth consultation, they will advise you to call 911 immediately and may, at their clinical discretion, contact emergency services on your behalf. By consenting to telehealth, you acknowledge that the Clinic's ability to respond to an in-person emergency on your behalf is limited by the virtual nature of the service.

If you are experiencing thoughts of suicide or self-harm, please contact the 988 Suicide and Crisis Lifeline by calling or texting 988, or go to your nearest emergency room.

SECTION 9: AFTER YOUR VISIT

Following your telehealth consultation, the Clinic will provide you with:

•       A clinical summary or after-visit notes accessible through the patient portal or by request

•       Any prescriptions transmitted electronically to your selected pharmacy, as applicable

•       Orders for laboratory or imaging studies, as applicable, with instructions on where to have these completed

•       Referrals to specialists or in-person providers, as clinically appropriate

•       Instructions for follow-up care and return precautions (symptoms that should prompt you to seek further care)

You are responsible for following up on all orders, referrals, and care recommendations provided. If you have questions after your visit, please contact the Clinic through the patient portal or the contact information on our Website.

SECTION 10: CONSENT STATEMENT

By proceeding with your telehealth appointment at Direct Pay Virtual Clinic, you affirm that:

•       You are 18 years of age or older, or are the parent or legal guardian of the minor patient receiving services

•       You have read this entire Telehealth Informed Consent Form and have had the opportunity to ask questions

•       You understand the nature, benefits, and material risks and limitations of telehealth services as described in this document

•       You voluntarily and knowingly consent to receiving healthcare services via telehealth

•       You understand that your protected health information will be transmitted electronically as part of your care

•       You understand and agree to the recording policy described in Section 5.2

•       You confirm that you are physically located within the State of Minnesota at the time of your telehealth visit

•       You understand that you may withdraw this consent at any time in writing

•       You understand that telehealth is not an emergency service and that 911 should be called in an emergency

•       You have been informed of your rights as a telehealth patient as described in Section 4

 

Patient Full Name (Print Clearly): ________________________________   Date of Birth: ________________

Patient Signature: __________________________________________   Date: ________________

If signing on behalf of a minor or incapacitated patient:

Guardian/Legal Representative Name (Print): ________________________________

Signature: __________________________________________   Relationship to Patient: ________________   Date: ________

Legal Authority (e.g., parent, legal guardian, power of attorney): ________________________________