TELEHEALTH INFORMED CONSENT
Generic template - replace every bracketed field before publication
IMPORTANT: This document is a general business template and is not legal advice. Telehealth consent requirements vary by state, profession, treatment type, modality, prescribing practice, record-sharing rules, communications methods, and whether care is synchronous or asynchronous. Have qualified healthcare counsel review the final version before use.
This Telehealth Informed Consent (the “Consent”) explains how healthcare services may be delivered through Voyocare and the risks, benefits, limitations, alternatives, and patient rights associated with receiving care through telehealth. By accepting this Consent and proceeding with a telehealth evaluation, you acknowledge that you have read and understood the information below and voluntarily consent to receive healthcare services through telehealth.
1. What Telehealth Is
- Telehealth is the delivery of healthcare services using electronic information and communication technologies when the patient and healthcare professional are in different physical locations.
- A telehealth encounter may include online intake forms, secure messaging, telephone or video communications, review of photographs or documents, review of laboratory information, electronic prescribing, follow-up care, and other electronic communications permitted by applicable law.
- The exact telehealth modality used may depend on your location, the nature of your condition, applicable law, and the clinical judgment of your healthcare professional.
2. Parties Involved in Your Care
- PYLOT LLC provides non-clinical administrative, technology, coordination, payment, support, or related services.
- Medical services are provided by PYLOT LCC and individually licensed healthcare professionals engaged by or affiliated with that entity (each, a “Provider”).
- The platform or management company does not control the independent medical judgment of a Provider and is not a substitute for the clinician-patient relationship.
- Prescriptions, when issued, may be dispensed by independently licensed pharmacies, including Voyocare or another pharmacy selected or permitted under applicable law.
- Your Provider must be appropriately licensed or otherwise authorized to provide care in the jurisdiction where you are physically located at the time of the telehealth encounter.
3. Electronic Communications and Technologies Used
- Telehealth care may involve account creation, identity verification, appointment scheduling, intake questionnaires, medical-history collection, secure messages, telephone calls, video sessions, uploads of images or documents, laboratory information, prescription communications, refill reminders, follow-up prompts, and related communications
- The platform may use synchronous communications, such as live video or audio, asynchronous communications, such as secure messaging or store-and-forward review, or a combination of methods.
- Your Provider may determine that a different communication method or an in-person examination is required before making a clinical decision.
4. Expected Benefits of Telehealth
- Improved access to healthcare services without requiring travel to a traditional clinical location.
- Convenient communication with healthcare professionals and care teams.
- Faster collection and review of health information for conditions appropriate for telehealth.
- Greater flexibility for follow-up care, treatment monitoring, and administrative coordination.
- Potentially improved privacy and convenience for sensitive health concerns.
5. Potential Risks and Limitations
- Limited physical examination: A Provider may be unable to perform hands-on examination, palpation,
auscultation, or other physical assessment that would be possible during an in-person visit. - Incomplete information: Clinical decisions may depend on information you provide. Inaccurate, incomplete, withheld, or misleading information can increase the risk of incorrect diagnosis, inappropriate treatment, medication interactions, or other harm.
- Need for additional testing: Your Provider may require laboratory testing, imaging, vital signs, records from another clinician, or an in-person examination before making a diagnosis or prescribing treatment.
- Technology failure: Internet outages, device failure, software errors, or connection problems may interrupt or delay care.
- Data quality: Poor-quality photographs, audio, video, or uploaded records may limit a Provider's ability to evaluate you.
- Privacy and security: Reasonable safeguards may be used, but no electronic communication system is
completely immune from unauthorized access, interception, misrouting, or technical failure. - Delays: Telehealth may not be appropriate for urgent or rapidly changing symptoms. Delays in reviewing asynchronous submissions can occur.
- Referral to in-person care: A Provider may stop or decline a telehealth evaluation if the Provider determines thatan in-person visit or different level of care is medically appropriate.
6. Medication and Prescription Safety
- There is no guarantee that a Provider will prescribe medication.
- A prescription may be issued only when a Provider determines, in that Provider's independent clinical judgment, that treatment is appropriate and legally permitted.
- You must disclose all medications, supplements, allergies, medical conditions, prior adverse reactions, pregnancy status where relevant, and other information that could affect treatment safety.
- Your Provider may decline, discontinue, modify, or delay treatment based on safety concerns, contraindications, drug interactions, laboratory findings, new health information, or changes in applicable law.
- Insert treatment-specific contraindications or safety language here when appropriate: [TREATMENT SPECIFIC SAFETY DISCLOSURE].
7. Patient Responsibilities and Acknowledgments
- I will provide truthful, complete, and current health information and will not intentionally omit information relevant to my care.
- I understand that the safety and effectiveness of telehealth care may depend on the accuracy of the information I provide.
- I understand that my Provider may recommend or require in-person care and that I may choose to obtain care from another healthcare professional.
- I understand that telehealth is an alternative to, and not necessarily a replacement for, in-person care.
- I understand that I may decline telehealth and seek care from a healthcare professional with in-person availability.
- I understand that I may withdraw my consent to telehealth, subject to applicable law and the limitations described below.
- I understand that records of my telehealth evaluation may become part of my medical record.
- I understand that my health information may be shared with healthcare professionals, pharmacies, laboratories, or other entities involved in my care where permitted by law.
8. Privacy and Confidentiality
- Federal and state laws may protect the confidentiality, security, use, and disclosure of your health information.
- Where applicable, you may receive a separate Notice of Privacy Practices from the healthcare entity maintaining your medical record.
- Your information may be transmitted electronically among healthcare professionals, pharmacies, laboratories, technology providers, and other parties involved in delivering or supporting your care.
- Personally identifiable information or images will not be used for unrelated research, education, publicity, or marketing without separate consent where required by law.
- Insert the applicable privacy and medical-record notice links here: [PRIVACY POLICY URL] and [NOTICE OF PRIVACY PRACTICES URL].
9. Individuals Present During a Telehealth Encounter
- A healthcare professional may be assisted by clinical or technical personnel during a telehealth encounter.
- You may be informed of the identity and role of any other person participating in or observing the encounter where required by law.
- You may ask non-essential personnel to leave, request additional privacy, or end the telehealth encounter at any time.
- You should participate from a private location whenever possible and take reasonable steps to protect the confidentiality of your communications.
10. Records and Information Sharing
- Telehealth records may include intake responses, messages, notes, prescriptions, laboratory information, images, documents, and records of communications.
- You may request access to your medical records as permitted by applicable law.
- Insert records-request instructions here: [RECORDS REQUEST METHOD / EMAIL / PORTAL].
- Where required or requested with your consent, records from a telehealth encounter may be shared with your primary care physician or another treating healthcare professional.
11. Laboratories and Other Ancillary Services
- Your Provider may recommend or require laboratory testing, diagnostic testing, blood draws, imaging, or other services that occur outside the telehealth platform.
- Such services may be provided by independent laboratories, testing centers, imaging facilities, home-testing companies, or other third parties.
- Separate charges, terms, privacy practices, and scheduling requirements may apply.
12. Communications Related to Your Care
- You may receive appointment notices, intake reminders, refill reminders, safety messages, clinician
communications, order updates, and other care-related communications by secure message, email, telephone, or text message where permitted. - Unencrypted email and text messages may not be fully secure.
- Marketing or promotional communications should be governed by separate consent where required by law.
- Insert communications preference or opt-out instructions here: [COMMUNICATIONS CONTACT / SETTINGS].
13. Not for Emergencies
- The telehealth platform does not provide emergency medical services.
- If you are experiencing severe chest pain, difficulty breathing, signs of stroke, severe allergic reaction, uncontrolled bleeding, loss of consciousness, severe injury, suicidal thoughts, imminent danger, or any condition you believe may be life-threatening, call 911 or your local emergency number or go to the nearest emergency department.
- Do not rely on asynchronous messaging, email, text message, or routine telehealth review for emergency or urgent medical conditions.
14. Maintaining Local and Ongoing Medical Care
- Telehealth may be appropriate for certain conditions but does not replace all forms of healthcare.
- You are encouraged to maintain an ongoing relationship with a local primary care professional and other appropriate specialists.
- Your Provider may recommend that you follow up with a local healthcare professional for examination, monitoring, laboratory work, diagnostic testing, or continuity of care.
15. Financial and Pharmacy Considerations
- Telehealth consent is separate from any consent to recurring billing, membership fees, medication charges, laboratory charges, pharmacy fulfillment, or subscription terms.
- Withdrawal of telehealth consent does not automatically cancel orders, shipments, pharmacy processing, memberships, subscriptions, or charges already incurred.
- Billing, cancellation, refund, and fulfillment matters should be governed by separate applicable terms and policies: [PAYMENT TERMS URL], [REFUND POLICY URL], and [SUBSCRIPTION TERMS URL].
16. Federal Open Payments Disclosure
- Federal law may require drug, device, biological, and medical-supply manufacturers and certain other entities to report specified payments or transfers of value made to physicians or teaching hospitals.
- Where applicable, reported information may be publicly available through the federal Open Payments database administered by the Centers for Medicare & Medicaid Services.
- The existence of a reported payment does not by itself establish improper conduct or a conflict of interest.
17. Withdrawal of Consent
- You may withdraw your consent to receive future care through telehealth by notifying your Provider or using the contact method designated by the platform.
- Insert withdrawal instructions here: [WITHDRAWAL METHOD / SUPPORT EMAIL / PORTAL].
- Withdrawal does not affect the validity of care already provided, records already created, prescriptions already issued, or disclosures already made in reliance on your consent.
- Withdrawal of telehealth consent may prevent completion of treatment that cannot reasonably be delivered through another permitted method.
18. State-Specific Telehealth Disclosures
- Telehealth consent requirements vary by state and may include special rules concerning modality, patient identity, provider identity, records sharing, primary care notifications, consent documentation, complaint notices, prescribing, and withdrawal rights.
- The business should maintain a current state-law matrix and present supplemental language based on the patient's physical location at the time of care.
- Insert or link jurisdiction-specific disclosures here: [STATE-SPECIFIC TELEHEALTH DISCLOSURES].
19. Provider Complaints and Licensing Boards
- Patients may have the right to file complaints about licensed healthcare professionals with the professional licensing board or regulatory authority in the state where care was provided.
- Where a state requires specific complaint language, addresses, telephone numbers, or bilingual notices, those disclosures should be presented exactly as required.
- Insert applicable complaint resources here: [STATE BOARD COMPLAINT DISCLOSURES].
20. No Guarantee of Treatment or Results
- Telehealth access does not guarantee that you will qualify for treatment, receive a diagnosis, obtain a prescription,
receive a refill, or achieve any particular health outcome. - A Provider may decline treatment or recommend an alternative based on medical history, clinical judgment,
applicable law, or patient safety. - Individual results vary.
21. Consent to Telehealth
- By checking the applicable acceptance box, signing electronically, or otherwise affirmatively accepting this Consent, I acknowledge that I have read and understood this Telehealth Informed Consent.
- I understand the nature of telehealth, its potential benefits, risks, limitations, and alternatives.
- I understand that I may ask questions before proceeding.
- I voluntarily consent to receive healthcare services through telehealth from appropriately licensed healthcare professionals.
- I understand that a copy of this Consent is available at [TELEHEALTH CONSENT URL] and may also be provided upon request.
22. Contact Information
- Platform / Brand: Voyocare
- Management / Technology Entity: PYLOT LLC
- Medical Group / Provider Entity: [separate PC/PLLC — physician-owned]
- Website: voyocare.com
- Support Email: support@voyocare.com
- Medical Records Contact: records@voyocare.com
- Privacy Contact: privacy@voyocare.com
- Telehealth Consent URL: voyocare.com/telehealth-consent
Publication checklist: Replace every bracketed field; identify the actual MSO/platform entity, professional medical group, provider relationship, pharmacies, records custodian, and communication channels; add treatment-specific safety disclosures where needed; confirm the patient-location workflow; maintain current state-specific consent and complaint language; separate telehealth consent from billing/subscription consent; and obtain healthcare counsel approval before publication.