Consent to Treatment

By agreeing to this consent, I voluntarily request and authorize MyTeleHealthPoint and its licensed healthcare providers to evaluate, diagnose, and treat my medical condition(s) using telehealth technologies. This may include, but is not limited to, review of medical history, physical examination (via video or patient-reported information), ordering of tests, prescribing medications, and providing medical advice.

Use of Electronic Communications

I acknowledge that telehealth involves the use of secure electronic systems such as video, audio, text, and digital transmission. I understand that:

• While MyTeleHealthPoint uses industry-standard encryption and HIPAA-compliant platforms, no electronic system is 100% risk-free of potential breaches, interruptions, or unauthorized access.
• Technical failures may occur, and if the visit cannot be completed, I may need to seek in-person care.
• I am responsible for ensuring I am in a safe, private location during the telehealth visit.

Risks and Limitations of Telehealth

I understand that telehealth has both benefits and limitations, including:

• Benefits: Convenience, accessibility, reduced travel, faster access to care.
• Limitations: The inability to perform certain physical exams, diagnostic tests, or procedures virtually.
• If the provider believes my condition requires in-person evaluation, I will be advised to seek immediate emergency care or schedule an in-person visit.

Patient Responsibilities

I agree to:

• Provide accurate and complete information about my health, symptoms, and history.
• Disclose all medications, allergies, and conditions that may impact my care.
• Follow the treatment plan as advised, or seek clarification if I do not understand the recommendations.

Insurance and Payment

I understand that MyTeleHealthPoint operates on a cash-pay/direct-pay basis unless otherwise stated. I am responsible for all charges incurred. If applicable, I may submit my receipt to my insurance for possible reimbursement, depending on my plan’s telehealth coverage.

Privacy

I understand that MyTeleHealthPoint complies with HIPAA and other applicable privacy laws. My information will not be shared without my consent, except as required by law (e.g., threats to self or others, child abuse, court orders).

Minor Patients

If I am signing on behalf of a minor, I confirm that I am the parent, legal guardian, or legal representative authorized to consent to medical treatment for the named minor. I understand that state-specific laws may allow minors to consent for certain types of care independently (e.g., STI testing, mental health, substance abuse services).

Acknowledgment of Risks and Release of Liability

By providing this consent, I acknowledge that:

• Telehealth is not a substitute for all in-person medical care.
• MyTeleHealthPoint and its providers make medical decisions based on the information I provide and the limitations of virtual platforms.
• I release, discharge, and hold harmless MyTeleHealthPoint, its providers, staff, and affiliates from any and all liability, claims, or damages arising out of or related to my use of telehealth services, except in cases of gross negligence or willful misconduct.

Electronic Signature & Consent

By clicking “I Agree” or otherwise providing my consent electronically, I affirm that I have read, understood, and agree to this Telehealth Consent to Treat. I consent to the use of electronic signatures and records in connection with this agreement, consistent with the ESIGN Act (15 U.S.C. § 7001 et seq.).

If I am unable to provide an electronic signature, I may affirm consent by typing my full legal name and date in the designated acknowledgment field, which will serve as my binding electronic signature.