This consent applies to all telehealth services provided to you by providers practicing through Arima Health, P.C. and associated medical group entities (collectively, the “Professional Entities”). 

Telehealth is the use of Internet-based technologies to provide remote health care services. Such services may be provided by physicians, advanced practice clinicians, nurses, and professional health educators. 

Your Arima provider (“Provider”) may provide evaluation, diagnosis, testing, consultation, treatment, and continuity of care through telehealth (a “Telehealth Appointment”) using synchronous and asynchronous telecommunications technologies, including audio-video visits conducted remotely via a web-based platform. 

The telehealth platform incorporates network and security protocols designed to protect your information against intentional or unintentional corruption. The telehealth platform hosts software only and does not provide medical advice or clinical decision-making. 

Telehealth services may be provided as deemed medically appropriate by your Provider or requested by you. Your Provider’s credentials will be made available to you prior to or at the beginning of your Telehealth Appointment. 

BENEFITS, RISKS, AND LIMITATIONS 

Telehealth may offer benefits such as improved access to care, convenience, and more efficient evaluation and management, including access to specialty expertise as appropriate. 

Telehealth also involves risks and limitations, including: 

• Delays in evaluation or treatment due to deficiencies or failures of equipment, software, or connectivity 

• The possibility that the quality of transmitted information may be inadequate for clinical decision-making 

• The possibility that the Telehealth Appointment may need to be rescheduled, converted to an in-person visit, or that you may be directed to seek local care 

YOU UNDERSTAND AND ACKNOWLEDGE THAT DURING A TELEHEALTH APPOINTMENT 

• Details of your medical history and personal health information may be discussed with you and/or other health professionals. 

• Audio, video, or photo information containing medical details may be transmitted via secure channels, and those details may become part of your permanent medical record. 

• All confidentiality protections granted to you by applicable state and federal laws apply to care provided via telehealth. 

• Industry-standard network and software security protocols are used to protect the privacy of communications and to safeguard transmitted information against eavesdropping and corruption; however, there may still be privacy and security risks associated with Internet-based communications. 

• Telehealth has benefits and limitations compared to an in-person visit, including limitations resulting from you not being in the same physical location as your Provider. 

• Either you or your Provider may discontinue the Telehealth Appointment if either of you believes the information obtained through remote communications is not adequate for diagnostic decision-making or for the care you desire. 

• You will be informed of any other person(s) who may be present during the appointment, and you have the right to request that such person(s) leave the viewing and listening area. 

• To maintain privacy, you must ensure that your viewing and listening area is limited to yourself and any other person who has a legitimate need to participate in the appointment. 

• Due to limitations of telehealth that may be outside of your control (including unreliable Internet connectivity), you will call local authorities (9-1-1) in the event of a medical emergency. 

• You have the right to omit or withhold details of your medical history and/or aspects of the encounter that are personally sensitive. 

• Your Provider may advise you to seek immediate treatment or determine there is a medical emergency, and local authorities may be provided your personal information to assist you. 

• The communication is privileged and confidential, and you will not record audio or video of the Telehealth Appointment without first obtaining your Provider’s permission. 

CONSENT AND ACKNOWLEDGMENTS 

By participating in a Telehealth Appointment, you acknowledge and agree that: 

• You wish to engage in remote audio-visual communication with your Provider, and asynchronous communication when appropriate under the applicable standard of care. 

• You understand the risks and benefits of using Internet-based communications and understand that no results can be guaranteed. 

• If your Provider determines that remote communication is insufficient for treatment, consultation, or evaluation, you will be offered alternate services or options, as appropriate. 

• You may be responsible for co-payments, deductibles, or other charges from the Professional Entities and/or your Provider, and additional charges may occur for services related to this appointment. 

• Certain aspects of an exam or testing may be performed by individuals at your location or at a third-party testing facility, as clinically appropriate. 

• You acknowledge that your Provider’s Notice of Privacy Practices has been made available to you at: privacypolicyurl 

• You understand you may ask questions directly to your Provider about this Telehealth Appointment, including questions regarding the Notice of Privacy Practices. If your questions are not answered to your satisfaction, you have the right to discontinue the Telehealth Appointment. 

• You have read, understand, and agree to Arima Health’s Terms & Conditions. 

• You consent to your Provider and/or service providers acting on the Provider’s behalf contacting you at the phone numbers (including cell phone) or email addresses you provide, including by unencrypted text messages or emails, and by automated or prerecorded messages where permitted by law. You understand and accept that unencrypted communications may be intercepted by unauthorized individuals. If you do not wish to receive unencrypted communications, you may email contact@arimahealth.com to opt out. 

• You have read, understand, and agree to Arima Health’s Communications Terms & Conditions. 

• You have read and understand the disclosures for the state in which you are located at the time of your telehealth encounter, as set forth in the State Disclosures Appendix below. 

• You certify that you are at least 18 years of age or the age of consent for treatment in your state. 

STATE DISCLOSURES APPENDIX 

• All disclosures remain law-accurate. References to “your provider” or “telehealth provider” are used, and no third-party entity references appear. 

• Alaska: You understand your primary care provider may obtain a copy of your records of your telehealth encounter. (Alaska Stat. § 08.64.364). 

• Arizona: You understand that all medical records resulting from a telemedicine consultation are part of your medical record. (A.R.S. § 12-2291.) 

• Colorado: If you want to register a formal complaint about a provider, you should file at: https://dpo.colorado.gov/FileComplaint. 

• Connecticut: You understand your primary care provider may obtain a copy of your records of your telehealth encounter, and that you can revoke your consent at any time. (Conn. Gen. Stat. Ann. § 19a-906). 

• D.C.: You have been informed of alternate forms of communication between you and a physician for urgent matters. (D.C. Mun. Regs. tit. 17, § 4618.10). 

• Georgia: You have been given clear, appropriate, accurate instructions on follow-up in the event of needed emergent care related to the treatment. (Ga. Comp. R. & Regs. 360-3-.07(7)). 

• Iowa: If you want to register a formal complaint about a provider, visit: https://medicalboard.iowa.gov/consumers/filing-complaint. 

• Idaho: If you want to register a formal complaint about a provider, visit: https://dopl.idaho.gov/filing-a-complaint/. 

• Illinois: If you want to register a formal complaint about a provider, visit: https://idfpr.illinois.gov/admin/dpr/complaint.html 

• Indiana: If you want to register a formal complaint about a provider, visit: https://inoag.my.salesforce-sites.com/ConsumerComplaintForm. 

• Kansas: If you have a primary care provider or other treating physician, the person providing telemedicine services must send within three business days a report to such primary care or other treating physician of the treatment and services rendered during the encounter. (Kan. Stat. Ann. § 40-2,212(2)(d)(2)(A)). Complaint process: http://www.ksbha.org/complaints.shtml. 

• Kentucky: If you want to register a formal complaint about a provider, visit: https://kbml.ky.gov/grievances/Pages/default.aspx. 

• Louisiana: You understand the role of other health care providers who may be present during the consultation other than the telehealth provider. (46 La. Admin. Code Pt XLV, § 7511). 

• Maine: If you want to register a formal complaint about a provider, visit: https://www.maine.gov/md/complaint/file-complaint. 

• Maryland: Telehealth services may not be provided based solely on an online questionnaire. Complaint form: https://www.mbp.state.md.us/forms/complaint.pdf. 

• Nebraska: All confidentiality protections apply to the telehealth consultation. You may access medical information resulting from the telehealth consultation as provided by law. No dissemination of identifiable images or information is permitted without written consent. You may request an in-person consult immediately after the telehealth consult and will be informed if one is unavailable. Complaint process: https://dhhs.ne.gov/Pages/Complaints.aspx. 

• New Hampshire: You understand the telehealth provider may forward your medical records to your primary care or treating provider. (N.H. Rev. Stat. § 329:1-d). 

• New Jersey: You have the right to request a copy of your medical information and understand it may be forwarded directly to your primary care provider or other provider of record. (N.J. Rev. Stat. Ann. § 45:1-62). 

• Ohio: You understand the telehealth provider may forward your medical records to your primary care or treating provider. (Ohio Admin. Code 4731-11-09(C)). 

• Oklahoma: Complaint resources: http://www.okmedicalboard.org/complaint and https://www.ok.gov/osboe/faqs.html. 

• Rhode Island: You understand the permitted types of transmissions, when alternate communication or office visits should be used, security measures, and potential risks to privacy. (Rhode Island Medical Board Guidelines). 

• South Carolina: You understand your medical records may be distributed in accordance with applicable law to other treating health care practitioners. (S.C. Code Ann. § 40-47-37). 

• South Dakota: You received disclosures regarding delivery models, treatment methods or limitations, and discussed diagnosis and risks/benefits of treatment options. (S.D. Codified Laws § 34-52-3). 

• Texas: You understand your medical records may be sent to your primary care physician. (Tex. Occ. Code Ann. § 111.005). NOTICE CONCERNING COMPLAINTS: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018. Phone: 1-800-201-9353. www.tmb.state.tx.us. 

• Utah: You understand fee disclosures, information rights, emergency limitations, privacy risks, and security standards. You may access, supplement, amend, request copies, and request transfer of your telemedicine medical record. (Utah Admin. Code r. 156-1-603). 

• Virginia: You acknowledge receipt of required security and privacy disclosures and provide consent to forward identifiable information to a third party. (Virginia Board of Medicine Guidance Document 85-12). 

• Vermont: You understand you have the right to receive a consult with a distant-site provider and may request one immediately or within a reasonable time. Complaint process: http://www.healthvermont.gov/health-professionals-systems/board-medical-practice/file-complaint