Telehealth Consent

ReMDi Health-Telehealth

Authorization to Use and Disclose Medical Information & Consent to Telehealth

IMPORTANT NOTICE

BY CLICKING “I AGREE,” CHECKING A RELATED BOX, OR OTHERWISE AFFIRMATIVELY ACCEPTING THIS CONSENT, YOU ACKNOWLEDGE THAT YOU HAVE READ, UNDERSTOOD, AND AGREE TO BE BOUND BY THIS TELEHEALTH CONSENT.

IF YOU DO NOT AGREE, DO NOT CREATE AN ACCOUNT OR USE THE SERVICES.

IF YOU ARE EXPERIENCING A LIFE-THREATENING EMERGENCY OR ARE CONTEMPLATING SELF-HARM, CALL 911 IMMEDIATELY OR CONTACT THE 988 SUICIDE & CRISIS LIFELINE BY DIALING 988.

1. Purpose of This Consent

The purpose of this Authorization and Telehealth Consent (“Consent”) is to inform you about the use of telehealthand to obtain your informed consent to receive healthcare services via telehealth from independent licensed healthcare providers affiliated with ReMDi Health (“Providers”).

This Consent applies to healthcare services provided through ReMDi Health–supported platforms, which may include third-party technology platforms such as DrWell (the “Platform”).

The terms “you” and “your” refer to the individual using the Services.

2. What Is Telehealth

Telehealth is the delivery of healthcare services using electronic communications, information technology, or other digital means between a patient and a Provider who are not in the same physical location. Telehealth services may include, but are not limited to:

Audio and/or video consultations
Secure messaging or email communications
Review of medical history, images, or health information
Follow-up care, education, and care coordination
Review of diagnostic data or laboratory results

You understand that in-person care may be an alternative, and you may discuss alternatives with your Provider at any time.

3. Our Role and Provider Responsibility

ReMDi Health provides technology, administrative, and care-coordination support and does not practice medicine. All medical care is provided solely by independent licensed Providers, including physicians and nurse practitioners, who:

Exercise independent medical judgment
Are solely responsible for diagnosis, treatment, and prescriptions
Determine whether telehealth is appropriate for your condition

Use of the Platform does not create a provider–patient relationship with ReMDi Health or the technology vendor.

4. Anticipated Benefits of Telehealth

Potential benefits of telehealth include:

Improved access to care
Convenience and scheduling flexibility
Reduced travel and wait times
Continuity of care and follow-up

However, no specific medical outcome or result is guaranteed.

5. Potential Risks of Telehealth

You understand that telehealth involves certain risks, including but not limited to:

Technical failures, delays, or interruptions
Incomplete information due to lack of physical examination
Limitations in diagnosing certain conditions remotely
Delays in care if urgent or emergent conditions are not identified
Privacy or security risks associated with electronic communications
Potential need to seek in-person or emergency care

Your Provider may determine that telehealth is not appropriate for your condition.

5. New York Telehealth Disclosures

If you are located in New York State at the time of care:

Telehealth services may be provided by NY-licensed clinicians
Telehealth has limitations compared to in-person care
Your clinician may require labs, imaging, or refer you out for in-person evaluation
Prescriptions are issued only if medically appropriate and lawful
You must provide your current physical location before each visit
Telehealth is not for emergencies

By scheduling or participating in telehealth services, you provide informed consent to receive care via telehealth in New York.

6. Emergency & Urgent Care

Telehealth is not appropriate for emergencies.

If you experience a medical emergency or urgent symptoms, call 911 or seek care at an emergency facility immediately.

Providers may not respond instantly to messages sent through the Platform.

7. Data Privacy & Authorization to Use Medical Information

You authorize ReMDi Health and your Providers to use and disclose your medical information as permitted by law for purposes of:

Treatment
Care coordination
Payment and billing
Healthcare operations
Legal or regulatory obligations

Electronic communications (including email or messaging) may contain protected health information. While safeguards are used, absolute security cannot be guaranteed. Your Provider’s Notice of Privacy Practices governs how your information is handled.

8. Laboratory Testing & Diagnostic Services

Your Provider may order laboratory testing, including at-home or third-party lab services. You understand that:

Labs are operated by independent third parties
Results may be false-positive, false-negative, or inconclusive
ReMDi Health and Providers cannot guarantee test accuracy
Test limitations may impact diagnosis or treatment decisions

9. Open Payments (Sunshine Act) Notice

The federal Physician Payments Sunshine Act requires certain financial relationships between healthcare providers and manufacturers to be publicly disclosed.

For informational purposes, you may review the CMS Open Payments database at:
👉 https://openpaymentsdata.cms.gov

10. Your Acknowledgments and Consent

By accepting this Consent, you acknowledge and agree that:

You consent to receiving healthcare services via telehealth
Your Provider may be a nurse practitioner or physician
Telehealth technology may evolve and may not be error-free
Certain conditions may not be appropriate for telehealth
You may need in-person or emergency care
You have the right to ask questions and discuss alternatives
You may withdraw consent to telehealth at any time by written notice to your Provider, understanding that in-person care is not offered through ReMDi Health
Withdrawal will not affect prior care already provided
You will provide accurate, complete health information
You are financially responsible for services rendered and will not submit claims to government payors unless expressly permitted

11. Licensing & Patient Rights

Providers are licensed in the states in which they practice, including California and New York, as applicable.

California Notice

Physicians and nurse practitioners are regulated by the Medical Board of California.
License verification or complaints:
👉 www.mbc.ca.gov | 📞 (800) 633-2322

12. Voluntary Consent

By clicking “I AGREE,” you voluntarily consent to telehealth services and the use and disclosure of your medical information as described above.