Informed Consent to
Telehealth Services
Last Updated: June 21, 2024
LifeMD, Inc. (“LifeMD”) provides a secure platform for working with health providers of the following affiliated medical P.C.s and P.A.s: LifeMD Southern Patient Medical Care, P.C.; LifeMD Atlantic Patient Medical Care, P.C.; LifeMD Kansas Patient Medical Care, P.A., LifeMD Midwest Patient Medical Care, P.C.; LifeMD New England Patient Medical Care, P.A.; LifeMD Puerto Rico Patient Medical Care, P.C.; LifeMD South Central Patient Medical Care, P.A.; New York Patient Medical Care, P.C.; and Puopolo M.D., P.C. d/b/a LifeMD Western Patient Medical Care P.C. (“LifeMD Affiliated PCs”) in the delivery of healthcare services using electronic communications, information technology, and/or remote means of communication (“Telehealth”). The purpose of this form is to obtain your consent to participate in Telehealth visits with one of LifeMD Affiliated PCs’ health providers via LifeMD’s Telehealth platform.
Table of Contents
- General Consent and Authorization for Treatment.
- Consent to Treatment Using Telemedicine.
- Limits of Telehealth Technology.
- Acknowledgment of Receipt of Notice of Privacy Practices.
- Disclosures to Friends and/or Family Members.
- Consent for Photographing or Other Recording for Security and/or Health Care Operations.
- Consent to Email, Cellular Telephone, or Text Usage for Appointment Reminders and Other Healthcare Communications.
- Release of Information.
- Health Savings Account (HSA) and Flexible Spending Account (FSA).
- Third Party Collection.
- Consent to Receive Telephone Calls, Texts and Emails for Financial Communications.
- Insurance Patient Consents and Acknowledgments.
1. General Consent and Authorization for Treatment
1.1 This consent provides LifeMD Affiliated PCs with permission to perform reasonable and necessary medical examinations, testing and treatment. I hereby authorize LifeMD Affiliated PCs, including affiliated physicians, nursing, and health professional staff, assisted by the employees of LifeMD, to provide medical treatment to me or the patient identified in connection with this consent.
1.2 I agree to diagnostic tests and procedures, including the administration/injection of pharmaceutical products and medication, in addition to the drawing of blood. I understand and authorize the administration of pharmaceutical agents and medications. I understand that certain recommended diagnostic tests and procedures may require me to visit an unaffiliated third-party facility such as a laboratory services provider. I acknowledge that no guarantees or assurances have been made to me concerning the results or findings intended from treatment or examination at LifeMD Affiliated PCs.
1.3 I have the right to be informed about my condition and the recommended medical or diagnostic procedure to be used so that I may make the decision whether or not to undergo any suggested treatment or procedure after knowing the risks and hazards involved.
1.4 I have the right at any time to discontinue services. I have the right to discuss my treatment plan with my health care provider including the purpose, potential risks and benefits of any test ordered for me. If I have any concerns regarding any test or treatment recommended by my health care provider, I am encouraged to ask questions. I voluntarily request a physician, and/or mid-level provider (nurse practitioner, physician assistant, or clinical nurse specialist), and other health care providers or designees as deemed necessary, to perform reasonable and necessary medical examination, testing and treatment for the condition which has brought me to seek care at this practice.
2. Consent to Treatment Using Telemedicine
2.1 I consent to treatment involving the use of electronic communications to enable health care providers at different locations to share individual patient medical information for the purpose of improving patient care.
2.2 Providers may include primary care practitioners, specialists and/or subspecialists, nurse practitioners, registered nurses, medical assistants, and other healthcare providers who are part of my clinical care team. In addition to myself and the members of my clinical care team, I may choose to have my family members, caregivers, or other legal representatives or guardians join and participate in the telehealth/telemedicine service, and I agree to share my personal information with such family members, caregivers, legal representatives, or guardians. The information may be used for diagnosis, therapy, follow-up and/or education.
2.3 Telehealth/Telemedicine requires transmission, via Internet or telecommunication device, of health information, which may include:
- Progress reports, assessments, or other intervention-related documents
- Bio-physiological data transmitted electronically
- Videos, pictures, text messages, audio, and any digital form of data
2.4 The laws that protect the privacy and confidentiality of health and care information also apply to telehealth/telemedicine. Information obtained during telehealth/telemedicine that identifies me will not be given to anyone without my consent except as described in the Notice of Privacy Practices. By agreeing to use the telehealth/telemedicine services, I am consenting to LifeMD Affiliated PCs sharing of my protected health information with certain third parties as more fully described in the Notice of Privacy Practices. I understand, agree, and expressly consent to LifeMD Affiliated PCs obtaining, using, storing, and disseminating to necessary third parties, information about me, including my image, as necessary to provide the telehealth/telemedicine services.
2.5 As with any Internet-based communication, I understand there is a risk of security breach. Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.
2.6 Individuals other than my clinical care team or consulting providers may also be present and have access to my information for the telehealth/telemedicine session. This is so they can operate or repair the video or audio equipment used. These people will adhere to applicable privacy and security policies.
2.7 Telehealth/telemedicine sessions may not always be possible. Disruptions of signals or problems with the Internet’s infrastructure may cause broadcast and reception problems (e.g., poor picture or sound quality, dropped connections, audio interference) that prevent effective interaction between consulting clinician(s), participant, patient, or care team. I hereby release and hold harmless LifeMD Affiliated PCs, LifeMD, and all members of my care team from any loss of data or information due to technical failures associated with the telehealth/telemedicine service.
2.8 I understand and agree the health information I provide at the time of my telehealth/telemedicine service may be the only source of health information used by the medical professionals during my evaluation and treatment at the time of my telehealth/telemedicine visit, and such professionals may not have access to my full medical record or information held at LifeMD Affiliated PCs or LifeMD.
2.9 I understand I will be given information about proposed test(s), treatments(s) and procedures(s), as applicable, including the benefits, risks, possible problems or complications, and alternate choices for my medical care through the telehealth/telemedicine visit.
2.10 I have the right to withhold or withdraw consent to the use of telehealth/telemedicine services at any time and revert to traditional in-person clinic services. I understand if I withdraw my consent for telehealth/telemedicine, it will not affect any future services or care benefits to which I am entitled.
3. Limits of Telehealth Technology
In addition to the risks described above, I acknowledge that in some instances treatment with Telehealth technology may present certain risks and limitations, which include, but are not limited to, the following:
3.1 Information transmitted to my health provider via Telehealth may not in every case be sufficient to allow for appropriate medical decision-making by the health provider.
3.2 The inability of my health provider to conduct certain tests or assess vital signs in-person may, in certain cases, prevent the health provider from making accurate diagnoses, providing appropriate treatments, or identifying the need for emergency medical care or treatment.
3.3 My health provider may not be able to provide all of the necessary medical treatment for my particular condition via the Telehealth visit, in which case I will need to rely on alternative and/or specialized medical care.
3.4 Delays in medical evaluation/treatment may occur due to unexpected failures in technology associated with providing Telehealth.
3.5 My health provider’s treatment options may be limited by regulatory requirements in certain states.
4. Acknowledgment of Receipt of Notice of Privacy Practices
I acknowledge receipt of the Notice of Privacy Practices, which outlines how health information about me may be used or disclosed by LifeMD and/or the LifeMD Affiliated PCs, and how I may obtain access to and control this information. To the extent permitted by law, I consent to the use and disclosure of my information for the purposes described in the Notice of Privacy Practices.
5. Disclosures to Friends and/or Family Members
I may give permission for my Protected Health Information to be disclosed for purposes of communicating results, findings and care decisions to the family members and others. When I give such permission I will communicate the Name, Relationship, and contact information to the clinical team to ensure it is documented.
6. Consent for Photographing or Other Recording for Security and/or Health Care Operations
I consent to photographs, digital or audio recordings, and/or images of me being recorded for patient care, security purposes and/or LifeMD Affiliated PCs health care operations purposes (e.g., quality improvement activities). I understand that LifeMD Affiliated PCs and/or LifeMD retains the ownership rights to the images and/or recordings. I understand that these images and/or recordings will be securely stored and protected. Images and/or recordings in which I am identified will not be released and/or used outside the facility without a specific written authorization from me or my legal representative unless otherwise permitted or required by law.
7. Consent to Email, Cellular Telephone, or Text Usage for Appointment Reminders and Other Healthcare Communications
If at any time I provide an email address or cellphone number at which I may be contacted, I consent to receiving unsecure instructions and other healthcare communications at the email or text address I have provided. These communications may include, but are not limited to: post-care instructions, follow-up instructions, educational information, and prescription information. Other healthcare communications may include, but are not limited to, communications to family or designated representatives regarding my treatment or condition, or reminder messages to me regarding appointments for medical care.
8. Release of Information
I hereby authorize LifeMD Affiliated PCs and the physicians or other health professionals involved in my care to release healthcare information as is necessary for purposes of treatment, payment, or healthcare operations. I also acknowledge that healthcare information regarding a prior service(s) with other LifeMD Affiliated PC providers may be made available to subsequent LifeMD Affiliated PCs providers to coordinate care.
9. Health Savings Account (HSA) and Flexible Spending Account (FSA)
I understand that I may use HSA/FSA cards on “Qualified Medical Expenses'', as defined by the Internal Revenue Service (IRS) Code, Section 213. While many of the services offered by LifeMD and the LifeMD Affiliated PCs are considered “Qualified Medical Expenses” and eligible for HSA/FSA coverage, I understand that I am responsible for any amount not covered by my HSA/FSA.
10. Third Party Collection
I acknowledge that LifeMD and/or the LifeMD Affiliated PCs may use the services of a third-party business associate or affiliated entity as an extended business office for medical account billing and servicing.
11. Consent to Receive Telephone Calls, Texts and Emails for Financial Communications
I agree that, in order for LifeMD and/or the LifeMD Affiliated PCs and collection agents, to service my account or to collect any amounts I may owe, I hereby consent to LifeMD and the LifeMD Affiliated PCs or their business associate (s) to contact me by voice call, postal mail, text message and/or email at the account contact homes address, telephone number (s), and email address (es) reflected on my account, regarding the services rendered, or my related financial obligations.
12. Insurance Patient Consents and Acknowledgments
If a LifeMD Affiliated PC has an applicable contract with my insurance company and I choose to utilize my insurance to assist with payments for clinical consultations and services delivered to me by a LifeMD affiliated PC, I acknowledge and agree to the following:
12.1 Insurance Patient Financial Policy.
- Payment of my bill is considered part of my treatment. Fees are payable when services are rendered. LifeMD Affiliated PCs accept credit cards and pre-approved insurance for which they are a contracted provider and are the designated Primary Care Provider (“PCP”), if applicable.
- It is my responsibility to know my own insurance benefits, including whether LifeMD Affiliated PCs are a contracted provider with my insurance company, and any pre-authorization requirements of my insurance company.
- LifeMD Affiliated PCs will attempt to confirm my insurance coverage prior to my treatment. It is my responsibility to provide current and accurate insurance information, including any updates or changes in coverage. Should I fail to provide this information, I will be financially responsible.
- If LifeMD Affiliated PCs has an applicable contract with my insurance company, it will bill my insurance company first, less any copayment(s) or deductible(s), and then bill me for any amount determined to be my responsibility. This process generally takes 45 – 60 days from the time the claim is received by my insurance company.
- If LifeMD Affiliated PCs does not have an applicable contract with my insurance company, I will be expected to pay for all services rendered at the end of my visit.
- I acknowledge that I will be responsible for any clinical service fees not reimbursed by my insurer, whether such clinical services relate to a synchronous real-time telehealth consultation or an asynchronous telehealth consultation utilizing store-and-forward technology.
- Proof of payment and photo ID are required for all patients. LifeMD Affiliated PCs will ask me to make a copy of my ID and insurance card for its records. Providing a copy of my insurance card does not confirm my coverage is effective or the services rendered will be covered by my insurance company.
12.2 Credit Card on File Policy.
At the time of patient registration, LifeMD Affiliated PCs will request my credit card information. My credit card numbers will be encrypted and stored securely. Once LifeMD Affiliated PCs receive my Explanation of Benefits (“EOB” – that is, what your insurance company will pay towards your visit), I will be given 30 days to pay the balance on my account. If my balance is not paid in that time, my credit card will be charged for the outstanding balance that is my responsibility. Co-pays must be paid at the time of visit. If I have any questions about this payment policy, I may contact the Billing Office at (800) 735-2176. All my rights with respect to the use of my credit card will remain in effect. This policy will in no way prevent me from being able to dispute a charge or question my insurance company’s determination of payment. I acknowledge that this Credit Card on File Policy is specific to treatment I receive at LifeMD Affiliated PCs and shall in no way limit the ability of LifeMD to charge my card for non-clinical non-covered services. My credit card on file can only be used by LifeMD Affiliated PCs for the following reasons:
- Payment was not collected from me at the beginning of the visit
- No-show or late cancellation charges
- Insurance discrepancies
- Outstanding balance greater than 31 days past due
12.3 Assignment of Benefits
I hereby assign to LifeMD Affiliated PCs any and all rights, title, and interest that I have in any insurance proceeds or benefits payable to me or on my behalf for services rendered to me by LifeMD Affiliated PCs, whether such services are considered “in” or “out” of network with respect to any third-party payor. I therefore authorize and direct my insurance carrier and/or health care plan to make payment of any and all such amounts directly to LifeMD Affiliated PCs, rather than to myself or any other insured. I acknowledge that as a member of a health care plan, I may be responsible to notify my primary care physician or obtain pre‐certification for services. I understand that I am financially responsible to LifeMD Affiliated PCs for all charges, including those not paid by insurers or health care plans for services not authorized as specified in my benefit package, incurred by me or on my behalf.