Telehealth Consent Form

This Consent covers: Consent to Telehealth, Treatment-Specific Consent, Consent to Text or Email Communication, Authorization to Use and Disclose Medical Information, and Assignment of Benefits. By proceeding with Prometheuz services you acknowledge that you have read, accepted, and agreed to be bound by this Consent.

Consent to Telehealth

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 healthcare. The purpose of this Consent is to provide you with information about telehealth and to obtain your informed consent to the use of telehealth in the delivery of healthcare and/or mental health services to you by physicians, physician assistants, nurse practitioners, and/or mental health professionals (“Providers”) using the online platforms owned and operated by OpenLoop and/or its affiliates and/or subsidiaries (the “Service”).

You are reviewing and acknowledging this Telehealth Consent Form because you are seeking Services from OpenLoop Healthcare Partners, PC and its affiliated entities (including but not limited to OpenLoop Healthcare Partners California, PC; OpenLoop Healthcare Partners Colorado, PC; OpenLoop Healthcare Partners New Jersey Professional Corporation; and OpenLoop Healthcare Partners, Wisconsin, S.C.) (collectively, the “Practice”) utilizing telehealth technologies facilitated through the OpenLoop Health Inc. platform or any partner platform (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. If you would like to speak to the privacy team, please call 1 (844) 819-7956 or email [email protected].

Treatment-Specific Consent

By proceeding, you understand and agree to the following:

1. Telehealth visits are conducted through videoconferencing, telephonic, and asynchronous technology; my Provider will not be present in the room with me.
2. I am consenting to Practice importing and accessing my medical records and medication list, including prescription records.
3. I agree to undertake my telehealth visit in a private location. My Provider will similarly be in a private location. If any other individuals are present, I will be informed of their presence and role and given the opportunity to consent.
4. I understand there are potential risks to the use of telehealth technology, including but not limited to interruptions, delays, unauthorized access, technical difficulties, data processing errors, AI misinterpretation, recording failures, and ambient listening inaccuracies. Either my Provider or I can discontinue the telehealth appointment if technical connections are not adequate. I AGREE TO HOLD HARMLESS PRACTICE AND ITS MANAGEMENT COMPANY, OPENLOOP HEALTH, INC., TOGETHER WITH THEIR EMPLOYEES, CONTRACTORS, AGENTS, DIRECTORS, MEMBERS, MANAGERS, SHAREHOLDERS, OFFICERS, REPRESENTATIVES, ASSIGNS, PREDECESSORS, AND SUCCESSORS, FOR DELAYS IN EVALUATION OR FOR INFORMATION LOST DUE TO SUCH TECHNICAL FAILURES OR FOR ANY ISSUES ARISING FROM THE USE OF AI TECHNOLOGIES, RECORDINGS, OR AMBIENT LISTENING SYSTEMS.
5. My telehealth visit may involve the use of artificial intelligence (AI) technologies for purposes including transcription, analysis of medical information, clinical decision support, and quality assurance. I have the right to request information about what AI technologies are being used and how my information is being processed.
6. My Provider may use AI tools to assist with analyzing medical data, supporting clinical decision-making, generating summaries, or recommending potential diagnoses or treatment options. AI tools are intended to support, not replace, the professional judgment of my Provider.
7. My telehealth visit may be recorded (audio and/or video) for purposes including quality assurance, provider training, clinical documentation, and care coordination. I will be notified at the beginning of any session that is being recorded.
8. Ambient listening technologies may be used during my telehealth visit. I can request that ambient listening be disabled during portions of my visit by notifying my Provider.
9. In some cases, my Provider might be a nurse practitioner or a physician assistant and not a physician.
10. I could seek an in-office visit rather than obtain care from a Provider, and I am choosing to participate in a telehealth visit. My Provider may not have access to a complete copy of my medical records and will not be able to perform an in-person examination, which could result in negative health outcomes. No specific results are guaranteed, and my condition may not improve.
11. Certain technology may be used while still in a beta testing and development phase and may contain bugs or other errors that could limit functionality or impact the quality, accuracy, and/or effectiveness of the medical care or other services received.
12. The delivery of healthcare services via telehealth is an evolving field. No potential benefits or specific results can be guaranteed, including any laboratory testing results or related diagnosis or treatment. My condition may not be cured or improved, and in some cases may get worse.
13. Any information I provide as part of any telehealth visit is accurate, true, and complete.
14. My Provider may determine that a telehealth visit is not appropriate for my particular health concern, in which case I will be notified and will need to seek care in another way.
15. Participating in a telehealth visit is not a guarantee that I will be given a prescription. The decision as to whether a prescription is appropriate will be made in the professional judgment of my Provider.
16. 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.
17. I am responsible for payment of any amounts due and owing resulting from my telehealth visit.
18. Providers do not address medical emergencies via the Platform. My Provider may direct me to emergency medical services, such as an emergency room.
19. I (or a parent/legal guardian of a minor) authorize consent to any medical order, laboratory order, medical diagnosis, or treatment.
20. I agree that OpenLoop Health, Inc. is a third-party beneficiary of this Telehealth Consent Form and has the right to enforce it.
21. I give permission to Providers to use and disclose my protected health information including my entire medical record for the purpose of telehealth treatment. I may revoke this authorization in writing at any time by contacting: Privacy Officer, 317 6th Ave. Ste. 400, Des Moines, IA 50309, or emailing [email protected].

Additional Consent: Compounded Medications

The following applies to patients who receive a prescription for compounded medications:

1. I understand that the FDA does not approve nor review compounded products for safety, effectiveness, or quality.
2. Compounding pharmacies must adhere to strict quality control standards and are licensed pharmacies subject to state and federal regulations.

Additional Consent: Teletherapy

The following applies to patients accessing mental or behavioral health services. I acknowledge that Teletherapy has the same purpose or intention as therapy sessions conducted in person, but due to the nature of the technology used, it may be experienced somewhat differently. I have the right to withhold or withdraw consent for my treatment at any time. The laws that protect the confidentiality of my medical information also apply to Teletherapy.

Teletherapy is not meant to cover emergency situations. If you are having suicidal thoughts or making plans to harm yourself, call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255) for free 24-hour hotline support.

Laboratory Products and Services

Certain healthcare services may require that you complete an at-home diagnostic test provided by third-party laboratories. Neither OpenLoop Health, Inc. nor your Provider(s) can guarantee the accuracy or reliability of these tests. These laboratory tests can provide false negative, false positive, or inconclusive results that could impact your Provider’s ability to correctly diagnose or treat your medical conditions.

Authorization to Bill Insurance and Assignment of Benefits

I authorize OpenLoop Healthcare Partners, PC and its affiliated entities to bill my insurance company directly and authorize any third-party payer to make payment directly to Practice. I understand that I am financially responsible for any balance. Services provided by outside companies (i.e., lab, pathology, radiology) are billed separately by those companies.

Consent to Text or Email Communication

I authorize Practice to contact me via phone call, SMS/text message, or email for the purposes of appointment reminders, patient feedback requests, and general health and wellness information. These communications may be generated in part by automated systems or artificial intelligence (AI). Standard messaging and data rates may apply. This authorization will remain in effect for future communications unless revoked in writing.

This consent form is provided by OpenLoop Healthcare Partners, PC — the licensed medical practice partner supporting Prometheuz’s telehealth services. For questions about this consent, contact [email protected] or call 1 (844) 819-7956.