Telehealth Consent Form

Last Updated: November 21, 2025 • Applies to care delivered within the United States (all 50 states + DC) under the reorganized Texas Medical Board rules (Ch. 169/175).

OUR HEALTHCARE PROVIDERS DO NOT ADDRESS MEDICAL EMERGENCIES. IF YOU BELIEVE YOU ARE HAVING A MEDICAL EMERGENCY, YOU SHOULD DIAL 911 OR GO TO THE NEAREST EMERGENCY ROOM.

INTRODUCTION

Telehealth is a mode of delivering health care services via communication technologies to facilitate diagnosis, consultation, treatment, education, care management, and self-management of a patient's health care.

You are reviewing and acknowledging this Telehealth Consent Form because you are seeking healthcare services (the "Services") from OpenLoop Healthcare Partners PC and its affiliated entities (OpenLoop Healthcare Partners California, PC, OpenLoop Healthcare Partners Colorado, PC, OpenLoop Healthcare Partners New Jersey Professional Corporation, OpenLoop Healthcare Partners, Wisconsin, S.C., OpenLoop Healthcare Partners Puerto Rico, P.C., Rezilient OLH, PA, Reliant MD Medical Associates PLLC) (collectively, the "Practice") utilizing telehealth technologies facilitated through the My Healthy Doc website, iOS mobile app, web mobile app, or any partner platform, mobile app, or web mobile technologies (collectively, the "Platform"). This Telehealth Consent Form supplements but does not modify or supersede any Terms of Use, Privacy Policy, or Notice of Privacy Practices of OpenLoop Healthcare Partners PC, OpenLoop Health Inc., or other healthcare providers offering services via the Platform.

Geographic Scope: These services are provided only to patients who are physically located in the United States (all 50 states and the District of Columbia) at the time of the telehealth encounter. We do not deliver care, fulfill prescriptions, or ship medications outside the United States.

By clicking "I consent to telehealth" you indicate that you have reviewed this Telehealth Consent Form or had it explained to you, that you understand the risks and limitations of using telehealth technologies, that you have been given the opportunity to ask questions and that such questions have been answered to your satisfaction, and that you consent to receiving the Services from licensed health care providers employed by or contracted with Practice ("Providers") who are located at sites remote from you.

TEXAS RESIDENTS - IMPORTANT NOTICES

NOTICE CONCERNING COMPLAINTS (Texas Residents)

English: Complaints about physicians, as well as other licensees and registrants of the Texas Medical Board, including physician assistants, acupuncturists, and surgical assistants may be reported for investigation at the following address:

Texas Medical Board

Attention: Investigations

333 Guadalupe, Tower 3, Suite 610

P.O. Box 2018, MC-263

Austin, Texas 78768-2018

Phone: 1-800-201-9353

Website: www.tmb.state.tx.us

Español: Las quejas sobre médicos, así como sobre otros profesionales acreditados e inscritos del Consejo Médico de Texas, incluyendo asistentes de médicos, practicantes de acupuntura y asistentes de cirugía, se pueden presentar en la siguiente dirección para ser investigadas:

Texas Medical Board

Attention: Investigations

333 Guadalupe, Tower 3, Suite 610

P.O. Box 2018, MC-263

Austin, Texas 78768-2018

Teléfono: 1-800-201-9353

Sitio web: www.tmb.state.tx.us

This notice is provided in compliance with Texas Occupations Code Chapter 175 (effective as of regulatory updates post-January 2025).

Standard of Care

Texas Law (Occupations Code §111.003): The same standard of care that applies to in-person health care services also applies to telehealth services.

This means that your provider must deliver the same quality of care, diagnostic accuracy, and treatment recommendations through telehealth as they would during an in-person visit.

If your provider determines that they cannot meet the appropriate standard of care for your particular health concern via telehealth, they have the professional discretion and obligation to decline the telehealth visit and recommend that you seek in-person care instead.

Your Rights:

  • You have the right to the same quality of care as in-person services
  • Your provider will inform you if telehealth is not appropriate for your condition
  • You may request an in-person visit at any time

Practitioner-Patient Relationship

Establishment of Care: Texas law permits the establishment of a valid practitioner-patient relationship through telehealth services without a prior in-person visit.

When you engage in a telehealth consultation with one of our providers, a professional practitioner-patient relationship is established, just as it would be during an in-person visit.

What This Means:

  • Your provider has the same professional obligations to you as in an in-person setting
  • The same standard of care applies to telehealth as to in-person visits
  • Your provider must maintain appropriate medical records
  • You have the same rights and protections as with in-person care

Your Choice: While telehealth is a convenient and effective way to receive care, you always have the right to request an in-person visit if you prefer. Your provider may also recommend an in-person visit if it is medically necessary for your specific condition.

If you have questions about whether telehealth is appropriate for your particular health concern, please discuss this with your provider at the beginning of your consultation.

TREATMENT-SPECIFIC CONSENT

By clicking "I consent to telehealth", you understand and agree to the following:

I understand that Practice offers telehealth visits, which are conducted through videoconferencing, telephonic, and asynchronous technology and my Provider will not be present in the room with me.

I am consenting to Practice importing and accessing my medical records and medical list including prescription records.

To protect the confidentiality of my health information, I agree to undertake my telehealth visit in a private location, and I understand that my Provider will similarly be in a private location. If any other individuals are present (i.e., for technological or translation assistance), I will be informed of the individual's presence and such individual's role, and I will be given the opportunity to consent to such individual's presence.

I understand that in some cases, my Provider might be a nurse practitioner or a physician assistant and not a physician.

I understand that I could seek an in-office visit rather than obtain care from a Provider, and I am choosing to participate in a telehealth visit with a Provider. I further understand that my Provider may not have access to a complete copy of my medical records and will not have the ability to perform an in-person examination, which could result in negative health outcomes from the recommended treatment (e.g., adverse drug interactions or allergic reactions). I further understand that while using telehealth technologies may benefit me, no such benefits or specific results are guaranteed and my condition may not improve.

I agree that any information I provide as part of any telehealth visit is accurate, true, and complete.

I understand that my Provider may determine that a telehealth visit is not appropriate for me due to my particular health concern or for other reasons related to my health status. In such a case: (i) I will receive an alert notifying me that I will be unable to use the Services for the particular issue I submitted; (ii) my request for a telehealth visit will not be submitted to my Provider; (iii) my Provider will not receive any of the information that I submitted; and (iv) I will need to seek any needed care in another way.

I understand that participating in a telehealth visit is not a guarantee that I will be given a prescription, and that the decision as to whether a prescription is appropriate for my condition will be made in the professional judgment of my Provider.

I understand that while the Platform may make available access to certain pharmacy or diagnostic lab services, I may request to use any pharmacy or lab of my preference.

I understand that I am responsible for payment of any amounts due and owing resulting from my telehealth visit.

I understand that Providers do not address medical emergencies via the Platform. I understand that the responsibility of my Provider may be to direct me to emergency medical services, such as an emergency room.

I (we) the parent(s) or legal guardian of a minor, do hereby authorize consent to any medical order, laboratory order, medical diagnosis, or treatment and that I (we) have legal authority to consent to such treatment or order.

TELEHEALTH SERVICES DISCLOSURES

Audio-Only Telehealth Services (Telephone Consultations)

Texas House Bill 1700 (Effective September 1, 2025): We may provide telehealth services via audio-only telephone consultations when clinically appropriate.

Important Limitations: Audio-only consultations may have limitations compared to video consultations or in-person visits. Without visual examination, certain conditions may be more difficult to diagnose or assess.

Your provider will determine whether an audio-only consultation is appropriate for your specific health concern based on the applicable standard of care. If visual examination is necessary, your provider will recommend a video visit or in-person appointment instead.

Verbal Consent for Audio-Only Services:

If you choose to proceed with an audio-only telehealth consultation, your provider will obtain and document your verbal consent at the beginning of the call. This consent confirms that you understand the limitations of audio-only care and agree to proceed.

You may request a video visit or in-person appointment at any time if you prefer.

Technical Issues and Platform Limitations

I understand that telehealth services rely on technology, and technical issues may occur that could affect my consultation, including but not limited to:

  • Internet connectivity issues or network interruptions
  • Software malfunctions or platform errors
  • Power outages affecting either party
  • Audio or video quality degradation
  • Platform service disruptions or maintenance
  • Device compatibility issues

I understand that the Practice and the Platform provider will make commercially reasonable efforts to minimize technical disruptions and maintain service quality.

Either my provider or I may discontinue a telehealth appointment if technical issues prevent adequate communication for safe and effective care.

IMPORTANT - Your Legal Rights Are Protected:

This acknowledgment of technical limitations does NOT waive your rights in cases of medical malpractice, negligence, or violations of the applicable standard of care.

You retain all legal rights to pursue remedies for any harm caused by substandard medical care, regardless of whether technical issues were present.

If a technical failure prevents completion of your consultation, we will make reasonable efforts to reschedule or complete your care through alternative means.

When Telehealth May Not Be Appropriate

While telehealth is effective for many health concerns, certain conditions and symptoms require in-person evaluation and treatment. Your provider will inform you if an in-person visit is necessary for your safety and appropriate care.

SEEK IMMEDIATE IN-PERSON OR EMERGENCY CARE FOR:

  • Chest pain or pressure (possible heart attack)
  • Difficulty breathing or shortness of breath
  • Severe bleeding that won't stop
  • Signs of stroke: facial drooping, arm weakness, speech difficulty
  • Severe allergic reactions (difficulty breathing, swelling of face/throat)
  • Loss of consciousness or altered mental status
  • Severe abdominal pain
  • Major injuries or trauma
  • Suicidal thoughts or plans to harm yourself or others
  • Poisoning or overdose

IF YOU ARE EXPERIENCING A MEDICAL EMERGENCY, CALL 911 OR GO TO THE NEAREST EMERGENCY ROOM.

Conditions That Often Require In-Person Evaluation:

Physical Examination Requirements:

  • Suspicious skin lesions or moles requiring visual inspection
  • Abdominal pain requiring palpation or examination
  • Musculoskeletal injuries requiring physical manipulation or range-of-motion testing
  • Ear infections requiring otoscopic examination
  • Eye injuries or sudden vision changes
  • Suspected fractures or dislocations

Diagnostic Testing Requirements:

  • Conditions requiring immediate laboratory work (blood tests, urinalysis)
  • Situations requiring imaging studies (X-rays, ultrasound, CT, MRI)
  • Conditions requiring specialized diagnostic equipment
  • Pregnancy confirmation and prenatal care initiation

Procedural Interventions:

  • Wound care requiring sutures or staples
  • Foreign body removal
  • Abscess drainage
  • Joint aspiration or injection
  • Any procedure requiring sterile technique

Complex or Unstable Conditions:

  • Uncontrolled diabetes with high or low blood sugar symptoms
  • Uncontrolled high blood pressure with symptoms
  • Severe asthma exacerbation
  • Dehydration requiring IV fluids
  • Complex medication management requiring close monitoring

Provider Discretion and Communication:

Your provider is trained to identify when telehealth is not appropriate for your condition. If during your consultation your provider determines that you need in-person care, they will:

  • Clearly explain why in-person care is needed
  • Provide specific recommendations for where to seek care (primary care, urgent care, emergency room)
  • Offer guidance on timing (immediate, same-day, or within a few days)
  • Document the recommendation in your medical record
  • Coordinate with your local providers when appropriate

Your safety is our highest priority. We will always recommend the most appropriate level of care for your specific situation, even if it means directing you to in-person services.

PRIVACY AND DATA PROTECTION

Protected Health Information (PHI) Authorization

Section 1: Treatment, Payment, and Healthcare Operations (No Additional Authorization Required)

Under HIPAA, we may use and disclose your protected health information for the following purposes without requiring your separate authorization:

  • Treatment: Providing, coordinating, or managing your healthcare
  • Payment: Billing and collecting payment for services provided
  • Healthcare Operations: Quality improvement, training, and business operations

This includes sharing information with:

  • Your primary care physician (with your consent as indicated separately)
  • Specialists or consulting providers
  • Pharmacies for prescription fulfillment
  • Laboratories for diagnostic testing
  • Insurance companies for claims processing

Section 2: Marketing, Research, and Other Purposes (Separate Authorization Required)

We will NOT use or disclose your protected health information for the following purposes without obtaining your separate written authorization:

  • Marketing communications or promotional materials
  • Research studies or clinical trials
  • Sale of your health information to third parties
  • Most psychotherapy notes (if applicable)
  • Any other purpose not permitted by HIPAA without authorization

If we wish to use your information for any of these purposes, we will provide you with a separate authorization form that clearly describes the specific use and your right to decline.

Your Rights Regarding PHI Authorization

  • Right to Revoke: You may revoke any authorization in writing at any time by contacting our Privacy Officer at:
    Privacy Officer
    OpenLoop Healthcare Partners PC
    317 6th Ave, Ste. 400
    Des Moines, IA 50309
    Email: support@myhealthydoc.com
  • Effect of Revocation: Your revocation will not apply to actions already taken based on your authorization prior to our receipt of your written notice.
  • Right to Inspect: You may inspect or obtain a copy of the protected health information that would be used or disclosed under any authorization.
  • No Retaliation: Refusing to sign an authorization (for marketing, research, etc.) will not affect your ability to receive treatment, payment, or enrollment in health plans, except in specific circumstances such as research-related treatment.

Note: If the person or entity receiving your health information is not covered by HIPAA (such as certain employers, schools, or legal entities), that information may be re-disclosed and no longer protected under HIPAA regulations.

Business Associates and Third-Party Service Providers

In order to provide you with telehealth services, we work with various third-party service providers known as "Business Associates" under HIPAA. These entities may have access to your protected health information solely for the purpose of performing services on our behalf.

Types of Business Associates may include:

  • Electronic Health Record (EHR) Vendors: Companies that host and maintain our medical records systems
  • Telehealth Platform Providers: Technology companies that operate the video/audio consultation software
  • Billing and Payment Processors: Services that process insurance claims and payment transactions
  • Pharmacy Partners: Pharmacies that receive and fulfill prescriptions
  • Laboratory Services: Labs that process diagnostic tests
  • Medical Transcription Services: Companies that transcribe medical notes and documentation
  • Cloud Storage Providers: Secure hosting services for medical data
  • IT and Security Services: Companies that maintain and protect our technology infrastructure

Your Privacy Protection:

All Business Associates are required by federal law to:

  • Sign legally binding agreements (Business Associate Agreements) committing them to protect your information
  • Use your information only for the specific services they provide to us
  • Implement appropriate security measures to safeguard your data
  • Report any data breaches or security incidents
  • Comply with all HIPAA Privacy and Security Rules

Transparency: A complete list of our current Business Associates is available upon request. To obtain this list, please contact our Privacy Officer at:

Privacy Officer
OpenLoop Healthcare Partners PC
317 6th Ave, Ste. 400
Des Moines, IA 50309
Email: support@myhealthydoc.com
Phone: (840) 465-2530

We carefully vet all Business Associates and only work with reputable companies that demonstrate strong privacy and security practices.

Data Breach Notification

We take the security of your protected health information very seriously and employ robust safeguards to prevent unauthorized access, use, or disclosure. However, in the unlikely event of a data breach, you have the right to be notified.

Federal HIPAA Requirements:

Under the HIPAA Breach Notification Rule, we are required to notify you without unreasonable delay and in no case later than 60 days following discovery of a breach of your unsecured protected health information.

Texas State Law:

The Texas Identity Theft Enforcement and Protection Act provides additional protections. Texas law requires notification of security breaches involving sensitive personal information and imposes specific requirements on businesses to protect consumer data.

What Happens If a Breach Occurs:

  • Immediate Investigation: We will promptly investigate the incident to determine the scope and impact of the breach.
  • Notification to You: We will notify you by mail or email (as permitted by law) with details about:
    • What information was involved
    • What happened and when
    • Steps we are taking to address the breach
    • Steps you can take to protect yourself
    • Contact information for questions
  • Notification to Authorities: We will notify the U.S. Department of Health and Human Services and, if required, other regulatory authorities including the Texas Attorney General.
  • Remediation: We will take immediate action to mitigate any harm and prevent future breaches, which may include:
    • Enhancing security measures
    • Offering credit monitoring services (if applicable)
    • Providing identity theft protection resources
    • Working with law enforcement if criminal activity is suspected

How to Report a Suspected Breach:

If you believe your health information has been compromised or used inappropriately, please contact us immediately:

Privacy Officer
Email: support@myhealthydoc.com
Phone: (840) 465-2530
Mail: 317 6th Ave, Ste. 400, Des Moines, IA 50309

We maintain comprehensive incident response procedures and regularly test our security measures to minimize the risk of data breaches.

TEXAS PATIENT RIGHTS AND PRIMARY CARE COORDINATION

Texas Patient Privacy Rights (Enhanced Protections)

Texas Medical Records Privacy Act (Health and Safety Code Chapter 181): If you are a Texas resident, you have additional privacy rights beyond federal HIPAA protections.

Enhanced Texas Privacy Rights Include:

  • Shorter Deadlines for Records Requests: We must provide you with copies of your medical records within 15 business days (compared to 30 days under HIPAA), with one 30-day extension permitted if needed.
  • Electronic Disclosure Notice: If we disclose your health information electronically, we must notify you of the disclosure under certain circumstances.
  • Marketing Restrictions: Stricter limitations on use of your health information for marketing purposes without your authorization.
  • Genetic Information Protection: Enhanced protections for genetic testing information and prohibition on certain uses by insurers and employers.
  • Mental Health Records: Additional protections for mental health and psychotherapy records beyond HIPAA requirements.
  • Right to Accounting: Right to receive an accounting of disclosures of your health information, with certain exceptions.

Your Rights Under Texas Law:

  • Access to Records: You have the right to inspect and obtain a copy of your health information within 15 business days of your request.
  • Request Amendments: You may request corrections or amendments to your health records if you believe they are inaccurate or incomplete.
  • Request Restrictions: You may request restrictions on certain uses and disclosures of your health information.
  • Confidential Communications: You may request to receive communications from us by alternative means or at alternative locations.
  • Notice of Privacy Practices: You have the right to receive a copy of our Notice of Privacy Practices.

How to File a Complaint:

If you believe your privacy rights have been violated, you have the right to file a complaint with:

1. Our Privacy Officer:

Privacy Officer
OpenLoop Healthcare Partners PC
317 6th Ave, Ste. 400
Des Moines, IA 50309
Email: support@myhealthydoc.com
Phone: (840) 465-2530

2. Texas Attorney General:

Office of the Attorney General
Health Information Privacy Unit
P.O. Box 12548
Austin, TX 78711-2548
Phone: (512) 463-2100
Website: www.texasattorneygeneral.gov

3. U.S. Department of Health and Human Services:

Office for Civil Rights (OCR)
U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Washington, D.C. 20201
Phone: 1-877-696-6775
Website: www.hhs.gov/ocr/privacy/hipaa/complaints/

You will NOT be retaliated against for filing a complaint.

These Texas-specific rights are in addition to your federal HIPAA rights and provide you with enhanced protections for your health information privacy.

Primary Care Physician Notification (Texas Requirement)

Under Texas law, if you have a primary care physician (PCP) or other treating physician, we MUST provide them with a summary of your telehealth consultation.

This summary will include an explanation of treatment provided, evaluation performed, analysis conducted, and diagnosis rendered during your telehealth visit.

Do you have a primary care physician or treating physician?

ADDITIONAL TREATMENT-SPECIFIC CONSENT (Teletherapy)

The following consent applies to patients accessing the Services to receive a telehealth consultation related to mental or behavioral health.

I acknowledge that I may be offered a telehealth consultation related to my mental or behavioral health as part of the Services. This type of telehealth consultation, known as "Teletherapy," involves the communication of my mental health information to my Provider. Teletherapy has the same purpose or intention as therapy sessions that are conducted in person. However, due to the nature of the technology used, I understand that Teletherapy may be experienced somewhat differently than face-to-face treatment sessions.

I understand that I have the following rights with respect to Teletherapy:

Patient's Rights, Risks, and Responsibilities:

I have the right to withhold or withdraw consent for my treatment at any time without affecting my right to future care or treatment.

The laws that protect the confidentiality of my medical information also apply to Teletherapy. As such, I understand that the information disclosed by me during the course of a Teletherapy session generally is confidential unless an exception to confidentiality applies (e.g., mandatory reporting of child, elder or vulnerable adult abuse; if my Provider believes I may be a danger to myself or others; or if I raise emotional or mental health as an issue in a legal proceeding).

In addition, I understand that Teletherapy services and care may not be as complete as face-to-face services. I also understand that if my Provider believes I would be better served by another form of therapeutic services (e.g., face-to-face services) I will be referred to a professional who can provide such services in my area.

I understand that I may benefit from Teletherapy, but that results cannot be guaranteed or assured. I understand that there are potential risks and benefits associated with any form of counseling, and that despite my efforts and the efforts of my Provider, my condition may not improve, and in some cases may even get worse.

I accept that Teletherapy is not meant to cover emergency situations. If I am having suicidal thoughts or making plans to harm myself, I can call the National Suicide Prevention Lifeline at 1.800.273.TALK (8255) for free 24 hour hotline support. Patients who are actively at risk of harm to self or others are not suitable for Teletherapy services. If this is the case or becomes the case in future, my Provider will recommend more appropriate services.

I understand that dissemination of any personally identifiable images or information from the Teletherapy interaction to researchers or other entities shall not occur without my written consent.

I understand that my Provider may need to contact my emergency contact and/or the appropriate authorities in case of an emergency. I agree to inform my Provider of the address where I am located at the beginning of each session, and agree to provide the name of a contact person who my Provider may contact on my behalf in an emergency situation.

ADDITIONAL TREATMENT-SPECIFIC CONSENT (HIV Testing)

The following consent applies to patients accessing the Services to receive a telehealth consultation related to Human Immunodeficiency Virus ("HIV") testing.

HIV is the virus that causes acquired immunodeficiency syndrome ("AIDS") and can be transmitted through unprotected sex with someone who has HIV; contact with blood, including via contaminated hypodermic needles or blood transfusions; by HIV-infected pregnant women to their infants during pregnancy or delivery; or while breastfeeding.

HIV can be detected via an HIV antibody test. The HIV antibody test is a blood test that shows whether you have antibodies to the virus that causes AIDS. A sample of blood will be taken from your arm with a needle. If the first test shows that you have antibodies, a series of tests will then be done on the same blood sample to ensure the first test was correct. A positive result means that you have been exposed to the virus and are infected with HIV. It does not mean that you have AIDS or that you will become sick with AIDS in the future. While HIV can lead to AIDS, this test does not say whether you have AIDS. However, a positive result also means you could pass the virus to other people. There is treatment for HIV that can help you stay healthy. Individuals with HIV and/or AIDS can adopt safe practices to protect uninfected and infected people in their lives from becoming infected, or being infected themselves with different strains of HIV.

A negative test means you are unlikely to be infected with the virus. It takes time for the body to produce HIV antibodies. If you have been exposed to HIV recently, you will need to be retested in several months to be sure you're not infected. Your Provider will explain this to you.

Taking an HIV test is entirely voluntary. If you do not wish to take the test, you may decline and we will not perform the test. This test is not provided on an anonymous basis. Please seek an anonymous test site if you prefer for your HIV test information and results to remain anonymous. Anonymous testing sites are places where you can receive counseling and the HIV test without giving your name or address. You can find the nearest anonymous test site by contacting your local health department.

There are federal and state laws that protect the confidentiality of your HIV test results and related information. Please note, however, that we may disclose your results as required by law for reporting to appropriate public health authorities. There are federal and state laws that prohibit discrimination based on your HIV status and there may be services available to help with any such discrimination.

ADDITIONAL TREATMENT-SPECIFIC CONSENT (Genetic Testing)

The following consent applies to patients accessing the Services to receive a telehealth consultation related to genetic testing.

I acknowledge that I may be offered genetic testing as part of the Services. Testing for genetic conditions can be complex and the specifics of the test, including the methods for collecting a biologic specimen, will vary depending on the condition tested for. There are risks and benefits to genetic testing. If I am offered genetic testing as part of the Services, my Provider will explain the specifics of my particular test to me, and I will have the opportunity to obtain professional genetic counseling prior to completing the test to fully understand the risks and benefits.

CONSENT TO TEXT OR EMAIL USAGE FOR APPOINTMENT AND OTHER HEALTHCARE REMINDERS AND GENERAL INFORMATION

By clicking "I accept", I further authorize Practice to contact me by phone or SMS/text message at the telephone number I have provided, or to send emails at the email address I have provided, with appointment reminders and general health information. I understand that this request is to receive emails and/or text messages will apply to all future appointment reminders/feedback/health information unless I request a change in writing. I also acknowledge this means of communication is not considered secure for the transmission of private information.

ADDITIONAL STATE-SPECIFIC DISCLOSURES

The following consents apply to patients accessing the Services for the purposes of participating in a telehealth visit within the states listed below, as required by state law:

Alaska: I understand that my primary care provider may obtain a copy of my records of my telehealth encounter.

California Patients: The Open Payments database is a federal tool used to search payments made by drug and device companies to physician and teaching hospitals. It can be found at https://openpaymentsdata.cms.gov.

For informational purposes only, a link to the federal Centers for Medicare and Medicaid Services (CMS) Open Payments web page is provided above. The federal Physician Payments Sunshine Act requires that detailed information about payment and other payments of value worth over ten dollars ($10) from manufacturers of drugs, medical devices, and biologics to physicians and teaching hospitals be made available to the public.

Treatment Records: I understand that If I live in one of the following states, my primary care provider or other treating physician may obtain a copy of my telehealth treatment records with my consent, and Practice may securely send a copy of my telehealth treatment records to my primary care provider or other treating physician. If I need help sending my telehealth treatment records to my primary care provider I can contact call 1-855-597-1248 If I would like Practice to do so, I can contact call 1-855-597-1248 and provide information necessary for Practice to securely send my records.

Connecticut: I understand that my primary care provider may obtain a copy of my records of my telehealth encounter.

Kansas: I understand that if I have a primary care provider or other treating physician, the person providing telemedicine services must send a report to such primary care or other treating physician of the treatment and services rendered to me during the telemedicine encounter within three days of me providing consent to the person providing telemedicine services to send such report.

New Hampshire: I understand that my primary care provider or treating provider may obtain a copy of my records of my telehealth encounter.

New Jersey: I understand I have the right to request a copy of my medical information, and I understand my medical information may be forwarded directly to my primary care provider or health care provider of record, or upon my request, to other health care providers.

Ohio: I understand that my primary care provider may obtain a copy of my records of my telehealth encounter.

South Carolina: I understand that my medical records may be distributed only with my consent and in accordance with applicable laws and regulations to other treating health care practitioners.

Texas: See the "Texas Patient Rights and Primary Care Coordination" section above for complete Texas-specific requirements regarding medical record transmission to your primary care physician.

Billing:

Patients residing in New Jersey, New York, and Rhode Island have the right under each states respective billing laws to request an itemized price list for laboratory results.

Formal Complaints:

California: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board's website at www.mbc.ca.gov, or the physician assistant board's website at www.pab.ca.gov.

Georgia: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board's website at gcmb.georgia.gov.

Idaho: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board's website at boardofmedicine.idaho.gov.

Indiana: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board's website at www.in.gov/pla/professions/indiana-medical-licensing-board/.

Iowa: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board's website at medicalboard.iowa.gov.

Kentucky: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board's website at kbml.ky.gov.

Maine: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board's website at www.maine.gov/md.

New York: I have been informed that to get information regarding your rights and how to report professional misconduct, I should visit www.health.ny.gov/professionals/doctors/conduct/.

Oklahoma: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board's website at okmedicalboard.org; or, the Oklahoma Board of Osteopathic Examiners' website at www.okosteo.org.

Oregon: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board's website at www.oregon.gov/omb.

Rhode Island: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board's website at health.ri.gov/licenses/detail.php?id=229.

Texas: See the prominent "Notice Concerning Complaints" for Texas residents at the top of this consent form for complete bilingual information about filing complaints with the Texas Medical Board.

Vermont: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board's website at www.healthvermont.gov/health-professionals-systems/health-care-providers/medical-practice-board; or, the Vermont Board of Osteopathic Examiners' website at www.healthvermont.gov/health-professionals-systems/health-care-providers/osteopathic-physicians.

Wyoming: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board's website at wyomedicinelaw.wyo.gov.

CONTACT INFORMATION

For questions about this consent or telehealth services:

Email: support@myhealthydoc.com

Phone: (840) 465-2530

Support Hours: Monday-Friday, 9 AM - 5 PM PST

Mailing Address:
OpenLoop Healthcare Partners PC
317 6th Ave. Ste. 400
Des Moines, IA 50309

Last Updated: January 2025

This comprehensive consent form is presented for your acceptance before beginning any telehealth consultation and ensures full compliance with telehealth regulations and HIPAA requirements.