Telehealth Consent Form | Brello Health

TELEHEALTH &
CONSENT

Telegra MD, LLC

This page outlines the terms and conditions under which telehealth services will be provided by Telegra MD, LLC through Brello, LLC’s online platform (collectively, the “Practice”). Telehealth is the delivery of healthcare services when the healthcare provider and the patient (“Patient”) are not in the same physical location and communicate through the use of technology. Telehealth services may include consultations, follow-ups, and other medical services delivered via electronic means. Electronically transmitted information may be used for diagnosis, treatment, follow-up, prescribing, or education, and may include medical records, medical images, interactive audio, video and/or data communications, and output data from medical devices, sound, and video files.

The Patient is hereby advised that the care provided by Practice is not a replacement for an in-person relationship with a primary care provider. If the Patient does not have a primary care provider, they are advised to seek care of one.

The Patient understands the following with respect to telehealth offered by the Practice and any of its providers:

Choice of Telehealth. The Patient has elected to have a telehealth visit instead of an-office visit. The Patient agrees that the Practice will determine whether the Patient’s condition is appropriate for telehealth and acknowledges that the Practice may recommend an in-person visit in lieu of, or in addition to, the telehealth visit.
Provider Credentials. The Patient has had an opportunity to review the Practice’s and the providers’ credentials and has selected their preferred provider.
Potential Risks. The Patient acknowledges that there are potential risks associated with the use of telehealth, including, but not limited to: (a) the information transmitted may be less comprehensive than that available during an in-person visit, which may affect the accuracy of diagnosis or medical decision-making; (b) delays in medical evaluation or treatment could occur due to deficiencies or failures of the telehealth equipment; (c) security protocols could fail, causing a breach of privacy; and/or (d) miscommunication may occur due to technology issues, and certain diagnostic tests may not be possible to perform remotely.
Protected Health Information (“PHI”). The Patient understands that telehealth often involves electronic transmission of the Patient’s PHI. The Patient’s PHI includes, but is not limited to, the Patient’s individually identifiable health information; medical history; diagnoses; and communications to and from the Patient’s other health care provider(s). The Patient understands that PHI may be lost due to technical failures, cyber intrusion, or other issues disrupting the Patient’s telehealth visit or causing delays in response from the Practice or Provider. The Patient assumes these risks and holds the Practice and its Providers harmless from any claims arising out of the use of telehealth to conduct the visit. The Patient understands that PHI obtained during the telehealth visit will not be disclosed to others without the Patient’s consent unless permitted by applicable law and in accordance with the Practice’s Notice of Privacy Practices.
Communication with Primary Care Physician. The Patient has the right to request that we submit information about their treatment with the Practice and provider to their primary care physician. If the Patient makes such a request and consents to the disclosure of PHI, the Practice will send the Patient’s medical record and/or a report containing an explanation of the Patient’s treatment, to the Patient’s primary care physician within seventy-two (72) hours of the consultation with the provider.
Emergency Situations. The Patient acknowledges and understands that the telehealth visit is not intended for emergency situations. In the event of a clinical emergency, the Patient must dial 911 immediately. The Patient agrees that: (a) by utilizing the telehealth service, the provider encounter is not a replacement for their existing relationship with their primary physician or other primary healthcare provider; (b) they will contact their primary physician or other primary healthcare provider immediately should their condition change or any symptom worse; and (c) if emergency care is required, they will contact local emergency services immediately.
Right to Withdraw Consent. The Patient has the right to withhold or withdraw consent for telehealth at any time without affecting their right to future care, treatment, benefits, or programs for which they are otherwise entitled. The Patient understands that if others are present at their location during the telehealth visit, the confidentiality of the telehealth visit may be compromised.
Understanding of Alternatives. The Patient understands the alternatives to telehealth, such as an in-person encounter, as they have been explained, and in choosing to participate in a telehealth visit, understands that some parts of the exam may require in-person physical testing to be performed at the direction of the Practice providers.
Payment Terms. THE PATIENT UNDERSTANDS THAT THEY WILL BE RESPONSIBLE FOR PAYMENT. THE PRACTICE DOES NOT ACCEPT INSURANCE. ALL OUT OF POCKET EXPENSES ASSOCIATED WITH THE TELEHEALTH VISIT ARE DUE PRIOR TO THE TELEHEALTH VISIT.
Location Compliance. The Patient understands that they must be physically located in his or her home state (i.e., the state associated with the patient’s primary residence in their Brello profile) during his or her telehealth consultation(s), and represents that they will be located in such state during the entirety of each telehealth visit. The Patient understands that if they are not physically located in their home state at the time of the scheduled telehealth visit, the Practice may decline to treat them via telehealth.
Prescribing Medication. The Patient understands that the Practice’s healthcare professionals may exercise their professional judgement to prescribe medication specifically to treat the Patient’s diagnosed condition, but there is no guarantee that the Patient will be prescribed a medication. If a medication is prescribed, the Patient has the ability to request that their medication be filled at a pharmacy of their choice.
Acknowledgement of Risks and Questions. The Patient has been advised of all potential risks, consequences, and benefits of telehealth, including risks related to the security of electronic communications. The Patient has been afforded the opportunity to ask questions about the information presented within this Telehealth Consent document. All of the Patient’s questions have been answered, and they understand the information contained herein.

By entering my name below, I acknowledge that I have read and understand the terms of this Telehealth Consent Form, and I agree to receive services from the Practice via telehealth. I represent and warrant that I am authorized to provide this consent.

I can contact the Practice at info@brellohealth.com for a copy of this Telehealth Consent document or to withdraw my consent as applicable.