Patient Consent Telemedicine Services

This Patient Consent to Telemedicine Care (“Consent”) is entered into by and between StayWell Health, PC, a California professional corporation (“Practice”), and the undersigned patient (“Patient”).

Purpose of Consent.

This Consent authorizes Practice and its contracted physicians, physician groups, and allied health providers (collectively, “Providers”) to deliver urgent-care telemedicine services to Patient during the term of this Consent.

Telemedicine involves the delivery of healthcare using interactive audio-visual technology, audio-only communications, and secure asynchronous intake tools, where the Patient and Provider are not in the same physical location.

Scope of Services. 

• Covered Services: Urgent-care telehealth for non-emergent conditions (e.g., minor infections, rashes, medication refills, simple injuries).

• Excluded Services: Emergency care, inpatient care, chronic disease management, surgery, behavioral health, reproductive/fertility services, pediatrics under 18, and any care outside urgent telehealth scope.

• Controlled Substances: Providers will not prescribe controlled substances under any circumstances.

• Medication & Pharmacy Costs: Patient is responsible for all medication and pharmacy costs.

Patient Responsibilities.

• Emergency Protocol: If Patient experiences an emergency or life-threatening symptoms, Patient agrees to call 911 immediately. Providers may terminate any telehealth session that appears emergent.

• Accurate Information: Patient must provide true and complete information, including name, date of birth, residential or property address, and confirmation of short-term rental booking.

• Location Disclosure: Patient must truthfully attest to their physical location at the time of each telehealth encounter. Care is only provided where the Provider is licensed.

• Technology: Patient must use their own device, internet, or phone connection. Technical failures may disrupt services, and Practice is not responsible for connectivity issues.

Provider Status and Liability.

• All Providers are independent contractors (1099), not employees of Practice.

• Providers are solely responsible for the professional judgment, diagnosis, and treatment they render.

• Patient acknowledges that Practice is not responsible or liable for the medical decisions, acts, or omissions of Providers.

• Each Provider maintains their own malpractice insurance consistent with applicable state minimums.

Confidentiality and Privacy.

Practice complies with all applicable federal and state privacy laws, including HIPAA. Separate HIPAA Privacy Notice will be provided. Visits are not recorded by either party. Artificial intelligence–assisted scribing technology may be used for medical record documentation; Patients may opt out by notifying Provider.

Communications.

Telehealth visits will occur via secure video or audio platforms only. Text messaging, unsecured email, or social media are not permitted for medical communications.

Financial Responsibility.

Patient owes no fees directly to Practice for covered visits; services are provided as part of arrangements between Practice and the property manager or property owner. If a property manager or property owner fails to remain current on payments, Patient’s access to services may be suspended or terminated.

Duration of Consent.

This Consent remains valid for one year from the date signed, unless revoked sooner in writing by Patient. Consent automatically renews if Patient uses services after expiration.

Acknowledgments.

By clicking the box, you acknowledge:

1. Telehealth is not the same as an in-person examination.

2. No guarantee of diagnosis, treatment, or outcome is made.

3. Providers may determine telehealth is insufficient and recommend in-person care.

4. Patient has the right to withdraw consent at any time, though withdrawal does not affect prior care delivered.

5. Patient has read this Consent, understands it, and agrees to be bound by its terms.

6. That you have read and understood this Agreement;

7. Understand that StayWell Health PC is not responsible for medical care;

8. Voluntarily assume all risks associated with telehealth;

9. Agree to indemnify and release StayWell Health PC from any and all liability;

10. Consent to binding arbitration under California law.

Interpreter Attestation (if applicable)

If Patient requires an interpreter, either Patient’s chosen interpreter or a Provider-arranged interpreter must acknowledged in documentation and signed by interpreter when required.

State-Specific Addenda (Summary of Key Requirements)

Alabama: Verbal consent required at initiation of telehealth visit.
Alaska: Provider must disclose their credentials at start of visit.
Arizona: Patient consent must be documented in the medical record.
Arkansas: Written or verbal patient consent required and maintained.
California: Verbal consent required at initiation; notice of telehealth bill of rights provided.
Colorado: Patient must be informed of potential limitations of telehealth.
Connecticut: Written consent required for minors; telehealth consent must be documented.
Delaware: Patient must provide informed consent prior to first telehealth encounter.
District of Columbia: Patient informed of Provider credentials and technology limitations.
Florida: Providers must document consent in patient’s record.
Georgia: Providers must disclose credentials and limitations of telehealth.
Hawaii: Patient must be informed of Provider’s licensure status.
Idaho: Patient must be advised of risks and limitations of telehealth.
Illinois: Providers must obtain and document informed consent in medical record.
Indiana: Patient must consent prior to first telehealth encounter.
Iowa: Providers must disclose identity and credentials.
Kansas: Patient informed of Provider location and licensure.
Kentucky: Patient consent required for use of telehealth; must be documented.
Louisiana: Written or verbal consent required; documentation required.
Maine: Provider must disclose limitations of telehealth.
Maryland: Patient consent must be documented in the record.
Massachusetts: Verbal or written consent required prior to telehealth services.
Michigan: Consent must be obtained and documented annually.
Minnesota: Providers must disclose potential technology risks.
Mississippi: Consent required prior to telehealth services.
Missouri: Patient must acknowledge telehealth limitations.
Montana: Written or verbal consent required; must be documented.
Nebraska: Consent required for telehealth services; must be documented.
Nevada: Providers must disclose identity, credentials, and location.
New Hampshire: Patient must consent prior to telehealth encounter.
New Jersey: Providers must disclose limitations of telehealth and record consent.
New Mexico: Consent required prior to telehealth services.
New York: Patient consent must be documented in record.
North Carolina: Consent must be obtained prior to telehealth.
North Dakota: Providers must disclose credentials and limitations.
Ohio: Patient consent must be documented in record.
Oklahoma: Written or verbal consent required and documented.
Oregon: Patient must consent prior to telehealth services.
Pennsylvania: Providers must disclose credentials and risks of telehealth.
Rhode Island: Consent required and documented annually.
South Carolina: Patient must be advised of telehealth limitations.
South Dakota: Consent required prior to telehealth services.
Tennessee: Consent must be documented in record.
Texas: Written or verbal consent required; documentation mandatory.
Utah: Consent required and documented prior to telehealth services.
Vermont: Consent required prior to telehealth encounter.
Virginia: Providers must disclose limitations of telehealth.
Washington: Written or verbal consent required and documented.
West Virginia: Patient consent required prior to telehealth.
Wisconsin: Providers must obtain and record consent.
Wyoming: Consent required prior to telehealth encounter.