Telehealth Informed Consent

Date of Last Revision: May 21, 2025

This “Telehealth Informed Consent” informs you about the treatment methods, benefits, risks, and limitations of using a virtual care platform.Telehealth involves the use of secure electronic communications, information technology, or other means to enable a healthcare provider and a patient at different locations to communicate and share individual patient health information for the purpose of rendering clinical care.

Services Provided:

Telehealth services offered by Emerald Medical Practice P.C. (AZ), Emerald Medical Practice P.C (CA), Emerald Medical Practice P.A. (KS), Centennial Medical Practice P.C. (ID), and Ruby Medical Practice P.C. (NJ) (collectively, “Emerald”) and Emerald’s providers (our “Providers” or your “Provider”) may include a consultation, diagnosis, treatment recommendation, prescription, lab order, and/or referral to in-person care, as determined clinically appropriate (the “Services”).

Path Healthcare Systems Corp. does not provide the Services.It performs administrative, payment and other supportive activities for the Group and Providers.

Electronic Transmissions

The types of electronic transmissions that may occur using the telehealth platform include, but are not limited to:

• Appointment scheduling;
• Completion, exchange, and review of clinical intake forms and other clinically relevant information (for example: health records; images; output data from medical devices; sound and video files; diagnostic and/or lab test results) between you and your Provider via:
• asynchronous communications;
• two-way interactive audio in combination with store-and-forward communications; and/or
• two-way interactive audio and video interaction;
• Treatment recommendations by your Provider based upon such review and exchange of clinical information;
• Delivery of a consultation report with a diagnosis, treatment and/or prescription recommendations, as deemed clinically relevant;
• Prescription refill reminders (if applicable); and/or
• Other electronic transmissions for the purpose of rendering clinical care to you.

Expected Benefits:

• Improved access to care by enabling you to remain in your preferred location while your Provider consults with you.Our telehealth services are available Monday to Friday, 7am – 7pm Mountain Time (except federal Holidays).
• Convenient access to follow-up care.If you need to receive non-emergent follow-up care relating to your treatment, please contact your Provider.
• More efficient care evaluation and management.

Service Limitations:

• The primary difference between telehealth and direct in-person service delivery is the inability to have direct, physical contact with you. Accordingly, some clinical needs may not be appropriate for a telehealth visit and your Provider will make that determination.
• Our providers do not address medical emergencies. If you believe you ARE experiencing a medical emergency, You should CALL 911 AND/OR GO TO THE EMERGENCy MEDIcAL FACILITY. IN AN EMERGENCY, please do not attempt to contact PATH HEALTHCARE SYSTEMS CORP., GROUP, or your Provider.After receiving emergency treatment, you should FOLLOW THE INSTRUCTIONS OF YOUR EMERGENCY CARE PROVIDER FOR FOLLOW-UP CARE.
• Our Providers are in addition to, and not a replacement for, your local primary care provider.Responsibility for your overall care should remain with your local care provider, if you have one, and we strongly encourage you to locate one if you do not.

Your Privacy Rights:

Your privacy is important to us and we endeavor to protect your personal information. The electronic communication systems we use will incorporate network and software security protocols to protect the confidentiality of your personal information and Protected Health Information.

Possible Risks:

• Delays in evaluation and treatment could occur due to deficiencies or failures of the equipment and technologies, or Provider availability.
• In the event of an inability to communicate as a result of a technological or equipment failure, please contact the Group at (801) 255-6051.
• In rare events, your Provider may determine that the transmitted information is of inadequate quality, thus necessitating a rescheduled telehealth consult or an in-person meeting with your local provider.
• In very rare events, security protocols could fail, causing a breach of privacy of personal information.

Patient Acknowledgments:

I further acknowledge and understand the following:

1. Prior to the telehealth visit, I have been given an opportunity to select a provider as appropriate, including a review of the provider’s credentials, or I have elected to visit with the next available provider from Group, and have been given my Provider’s credentials.
2. I understand that I may be asked to provide my identification and confirm my physical location prior to or during the telehealth visit.
3. If I am experiencing a medical emergency, I will be directed to call 911 or go to an emergency medical facility for care.My Provider is not able to connect me directly to any local emergency services.
4. I may elect to seek services from a group with in-person clinics as an alternative to receiving telehealth services from Group.
5. I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time without affecting my right to future care or treatment.
6. Federal and state law requires health care providers to protect the privacy and the security of health information.I am entitled to all confidentiality protections under applicable federal and state laws.I understand all electronic communications and medical reports resulting from the telehealth visit are part of my medical record.I understand the same confidentiality protections that apply to my other medical care also apply to the telehealth services.
7. Group will take steps to make sure that my health information is not seen by anyone who should not see it. Telehealth may involve electronic communication of my personal health information to other health practitioners who may be located in other areas, including out of state. I consent to Group using and disclosing my health information for purposes of my treatment (e.g., prescription information) and care coordination, to receive reimbursement for the services provided to me, and for Group’s health care operations.
8. Dissemination of any patient-identifiable images or information from the telehealth visit to researchers or other educational entities will not occur without my consent unless authorized by state or federal law.
9. There is a risk of technical failures during the telehealth visit beyond the control of Group.
10. In choosing to participate in a telehealth visit, I understand that some parts of the Services, if offered, involving tests (e.g., labs or bloodwork) may be conducted at another location such as a testing facility, at the direction of my Provider.
11. Persons may be present during the telehealth visit other than my Provider who will be participating in, observing, or listening to my consultation with my Provider (e.g., in order to operate the telehealth technologies). If another person is present during the telehealth visit, I will be informed of the individual’s presence and his/her role.
12. My Provider will explain my diagnosis and its evidentiary basis, and the risks and benefits of various treatment options.
13. I understand that by creating a treatment plan for me, my Provider has reviewed my medical history and clinical information and, in my Provider’s professional assessment, has made the determination that the provider is able to meet the same standard of care as if the medcial services were provided in-person when using the selected telehealth technologies, including but not limited to, asynchronous store-and-forward technology.
14. I have the right to request a copy of my medical records.I can request to obtain or send a copy of my medical records to my primary care provider or other designated health care provider by contacting Group at: 50 W Broadway Ste 333, PMB 518579, Salt Lake City, Utah 84101 or by email at privacy@generalmedicine.co.A copy will be provided to me at reasonable cost of preparation, shipping and delivery.
    
15. It is necessary to provide my Provider with a complete, accurate, and current medical history.I understand that I can log into my account profile at any time to access, update or review my health information.
16. There is no guarantee that I will be issued a prescription and that the decision of whether a prescription is appropriate will be made in the professional judgement of my Provider.If my Provider issues a prescription, I have the right to select the pharmacy of my choice.
17. There is no guarantee that I will be treated by a Group provider. My Provider reserves the right to deny care for potential misuse of the Services or for any other reason if, in the professional judgment of my Provider, the provision of the Services is not medically or ethically appropriate.

Medical Board Complaints: If at any time you wish to file a complaint with the state’s Medical Board, you can do so by following the procedures outlined here.

I understand that the above methods of unencrypted communication will be used to communicate with me about medical services, for my own convenience, and I accept all risks associated with them (including, without limitation, risks of improper exposure of my medical information). I have read the Terms of Service, Privacy Notice and HIPAA Notice of Privacy Practices.