Telehealth Consent

IF YOU BELIEVE YOU ARE EXPERIENCING A MEDICAL EMERGENCY, YOU SHOULD DIAL 9-1-1 AND/OR GO TO THE NEAREST EMERGENCY ROOM AND SHOULD NOT PROCEED WITH SERVICES MADE AVAILABLE THROUGH THIS PLATFORM.

IF YOU ARE CONTEMPLATING SUICIDE, CONTACT 9-1-1 OR THE NATIONAL SUICIDE PREVENTION LINE AT 9-8-8.

You are receiving and acknowledging this Telehealth Consent because you are seeking certain services from clinicians affiliated with PWNHealth, LLC, PWN Remote Care Services, P.A., or its related professional entities that comprise the PWN provider organization (collectively, “Providers”) utilizing telehealth technologies facilitated by Everly Health, Inc. and its affiliates (“Everly”) who make available directly or in coordination with third-parties the website, mobile application, and any other related telehealth technologies and/or software (collectively, the “Platform”). This Telehealth Consent does not modify or supersede any Terms of Service, Privacy Notice, or Notice of Privacy Practices of Everly or the Providers, rather it supplements these terms and documents, and any capitalized terms utilized in this Telehealth Consent but not otherwise defined herein shall have the meaning set forth for such term in the Terms of Service, Privacy Notice, or Notice of Privacy Practices. Providers and Everly require that you read and fully understand this Telehealth Consent before you may use the Platform.

By creating an account, starting a telehealth consultation, clicking “I consent to telehealth,” checking a related box to signify your acceptance, or using any other acceptance protocol presented through the Platform, you indicate that you have reviewed the risks as described herein of receiving services utilizing telehealth technologies and consent to receiving the services. A record of this Telehealth Consent is maintained in the files and records of the applicable Provider delivering your services, and your on-going participation in services provided by Everly or Providers using telehealth technologies serves as an on-going acknowledgement of your acceptance of this Telehealth Consent and updates at such time as the representations you provide herein.

What is Telehealth?

Telehealth (or telemedicine, often these terms are used interchangeably) involves the delivery of health and wellness services using electronic communications, information technology, or other means between a licensed, certified, or registered health care professional at one location and a patient in another location and may or may not involve a clinical matter or the practice of medicine. Telehealth may be used for diagnosis, treatment, follow-up, and/or patient education. Telehealth services may involve various modalities, including asynchronous interactions, real-time video and audio encounters, and interactive audio with store and forward. This “Telehealth Consent” informs the patient (“patient,” “you,” or “your”) concerning the treatment methods, risks, and limitations of utilizing telehealth to meet your health and wellness needs.

What are the Possible Benefits of Telehealth?

It can be easier and more efficient for you to access health and wellness services. You can obtain health and wellness services at times that are convenient for you without the necessity of an in-office appointment.

What are the Possible Risks of Telehealth?

Information transmitted to your Provider may not be sufficient to allow for appropriate health or wellness services to meet your particular need. Some clinical needs may not be appropriate for a telehealth visit and your Provider will make that determination. Limitations inherent in the use of the Platform may affect your Provider’s ability to provide health care services to you, and in some cases, an in-person physical examination, test, or other procedure not available on the Platform might provide information important or relevant with respect to your health care services. In some cases, the quality of the information you submit to your Provider (including any photograph(s) and other data you upload) may affect the quality of the health care services that your Provider is able to deliver through the Platform.

The technology necessary to interact with your Provider may fail and delay your services. If a technical failure prevents you from communicating with your Provider, you should call the following number: Phone: +1 (888) 362-4321, Monday-Friday, 9:00 a.m. to 5:30 p.m. ET; Email: [email protected]. As all data exchanged is in a digital format, a data breach enables increased access to your health data. In rare events, a lack of access to complete medical records and/or the quality of transmitted data could result in adverse drug interactions, allergic reactions, and/or other clinical judgment errors.

You may stop or decline any on-going services provided by a Provider using the Platform at any time, although you acknowledge that Providers have no obligation for your on-going care or selection of separate services in such circumstances.

Patient Acknowledgments:

By accepting this Telehealth Consent, you acknowledge that you understand and voluntarily consent to the following:

  • I am at least 18 years of age and am consenting on my own behalf; or I am the parent or legal guardian of a minor receiving services and have legal authority to consent on their behalf.

  • I have reviewed this Telehealth Consent carefully, and understand there are risks, limitations, and benefits of utilizing telehealth.

  • I understand and acknowledge that I must be located in a state in which my Provider is licensed and qualified to provide the telehealth services.

  • I understand that the electronic nature of the telehealth services means that there is a greater risk to the privacy of my health information.

  • In some cases, my Provider may be a nurse practitioner or physician assistant and not a physician.

  • I understand that persons may be present during the telehealth visit other than my Provider in order to operate the Platform, including, and upon request, for language translation assistance. If another person is present during the telehealth visit, I will be informed of the individual's presence and his/her role.

  • I understand that information I provide as part of any telehealth offering is viewed as accurate, true, and complete. I understand that I can contact Provider by phone at +1 (888) 362-4321, Monday-Friday, 9:00 a.m. to 5:30 p.m. ET; or by email at [email protected] to access, amend, or review my health information.

  • I understand that there is no guarantee that I will be given treatment, including a prescription and that the decision of whether a treatment or prescription is appropriate will be made in the professional judgment of my Provider. I understand that while the use of telehealth may provide benefits to me, no such benefits or specific results can be guaranteed and my condition may not improve.

  • I understand that there is a risk of technical failures during the telehealth encounter beyond the control of Everly and my Provider(s). I AGREE TO HOLD HARMLESS EVERLY, PROVIDERS, AND EMPLOYEES, CONTRACTORS, AGENTS, DIRECTORS, MEMBERS, MANAGERS, SHAREHOLDERS, OFFICERS, REPRESENTATIVES, ASSIGNS, PARENTS, PREDECESSORS, AND SUCCESSORS OF EACH SUCH PARTIES FOR DELAYS IN EVALUATION OR FOR INFORMATION LOST DUE TO SUCH TECHNICAL FAILURES.

  • I understand that the Platform makes available a specific set of services and I may need to seek other resources for my other health needs. There is no guarantee that I will be treated by a Provider. My Provider reserves the right to deny care for any reason if, in the professional judgment of my Provider, the provision of the services, including when provided via telehealth, is not medically or ethically appropriate. I understand that the Providers, and not Everly, are responsible for the quality and appropriateness of the care they render to me and make all decisions regarding clinical care in their independent discretion without the influence of Everly.

  • I understand that by using the Platform I am not always speaking or messaging with my Provider in real-time, and there may be a delay before my messages or information is reviewed.

  • I understand that I have the opportunity to discuss the use of telehealth, including the health care services, with my Provider(s), including the benefits and risks of such use and the alternatives to the use of telehealth. I have the right to withdraw my consent to the use of telehealth in the course of my care, without prejudice to any future care or treatment and without risking the loss or withdrawal of any health benefits to which I am entitled, but I understand that the Providers who provide health care services via the Platform do not offer in-person treatment.

  • I understand that I have access to my medical record pertaining to the health care services of Providers utilizing the Platform in accordance with applicable laws and regulations and that my primary care provider, or other treating provider, may obtain copies of my health and wellness information with my consent.

  • I understand that while the Platform may make available access to pharmacy services that are coordinated with the health care services, I am able to request any pharmacy of my preference.

  • I understand that my clinical information may be shared with contractors and/or affiliates for scheduling and billing purposes related to the services made available through the Platform.

  • I will not record the telehealth consultation without my Provider's prior express consent.

  • I understand that I may obtain a copy of my telehealth treatment records and request that they are shared with my primary care provider or other treating physician by contacting Provider at by phone at +1 (888) 362-4321, Monday-Friday, 9:00 a.m. to 5:30 p.m. ET; or by email at [email protected].

State-Specific Disclosures (as applicable): The following disclosures apply to users accessing the Platform for the purposes of participating in a telehealth visit as required by the states listed below:

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, here: https://medicalboard.iowa.gov/consumers/filing-complaint.

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, here: https://kbml.ky.gov/grievances/Pages/default.aspx.

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, here: https://www.maine.gov/md/discipline/file-complaint.html.

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, here: https://www.oregon.gov/omb/investigations/pages/how-to-file-a-complaint.aspx.

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, here: https://health.ri.gov/complaints/.

Texas: I have been informed of the following notice:

NOTICE CONCERNING COMPLAINTS- 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, Assistance in filing a complaint is available by calling the following telephone number: 1-800-201-9353, For more information, please visit our website at www.tmb.state.tx.us.

AVISO SOBRE LAS QUEJAS- Las quejas sobre médicos, asi como sobre otros profesionales acreditados e inscritos del Consejo Médico de Tejas, incluyendo asistentes de médicos, practicantes de acupuntura y asistentes de cirugia, 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, Si necesita ayuda para presentar una queja, llame al: 1-800-201-9353, Para obtener más información, visite nuestro sitio web en www.tmb.state.tx.us

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, here: http://www.healthvermont.gov/health-professionals-systems/board-medical-practice/file-complaint; or Board of Osteopathic Examiners can be found at: https://www.sec.state.vt.us/professional-regulation/file-a-complaint-employer-mandatory-reporting.aspx.

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, here: http://wyomedboard.wyo.gov/consumers/file-a-complaint.

Consent to Text or Email Usage for Appointment Reminders and Other Healthcare Reminders: I consent to receive communications from Providers at my phone number-including via automated or non-automated SMS communications (including text messages), an automatic telephone dialing system, or artificial or prerecorded voice or email to receive appointment reminders, test kit information, general health reminders, and other health-related communications. You may reply STOP to end. Message frequency varies. Carrier message and data rates may apply. I understand that this request to receive communications 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.