Telehealth Informed Consent

1. What Is Telehealth?

Telehealth is the delivery of healthcare services using electronic communications technology.

Depending on your specific service, telehealth may include:

• Secure online medical intake forms;
• Asynchronous review of medical information;
• Video consultations;
• Telephone or audio consultations;
• Secure electronic messaging;
• Patient portals;
• Electronic transmission of medical records;
• Remote monitoring;
• Digital photographs or other patient-submitted information;
• Electronic prescriptions; and
• Other telecommunications technologies used to provide healthcare.

Telehealth may allow you to receive certain healthcare services without traveling to a physical medical office.

2. How My Telehealth Care Will Work

Depending on the service requested, you may be asked to:

1. Provide identifying information;
2. Provide your current physical location;
3. Complete a medical history and health questionnaire;
4. Provide information about medications, allergies, and medical conditions;
5. Provide photographs, measurements, laboratory results, or other health information when clinically appropriate;
6. Participate in a video, telephone, or other remote consultation;
7. Communicate with a healthcare professional through a secure platform;
8. Complete additional medical forms;
9. Complete laboratory testing when requested; and
10. Participate in follow-up care when medically appropriate.

Your healthcare provider will determine whether telehealth is appropriate for your circumstances.

Not every medical condition can be appropriately evaluated or treated through telehealth.

3. Healthcare Provider

Your telehealth services will be provided by an appropriately licensed healthcare professional authorized to provide healthcare services in the jurisdiction where you are located at the time of the telehealth encounter.

Healthcare providers are responsible for exercising independent professional judgment and determining whether telehealth is appropriate for your care.

The provider may determine that:

• Telehealth is not appropriate;
• Additional information is necessary;
• Laboratory testing is required;
• An in-person examination is necessary;
• An in-person referral is appropriate;
• Emergency care is necessary;
• A particular medication or treatment is not appropriate; or
• You should seek care from another healthcare professional.

4. Benefits of Telehealth

Potential benefits of telehealth may include:

• Convenient access to healthcare;
• Reduced travel time;
• Greater access to healthcare professionals;
• Ability to receive certain services from your home or another location;
• Increased scheduling flexibility;
• Easier follow-up communication;
• Reduced transportation barriers; and
• Continued access to certain healthcare services when an in-person visit is inconvenient or unavailable.

There is no guarantee that telehealth will provide the same benefits as an in-person visit.

5. Limitations of Telehealth

Telehealth has limitations.

A healthcare professional may not be able to perform every physical examination, diagnostic test, procedure, or assessment through telehealth.

The provider may have limited ability to:

• Physically examine you;
• Measure certain vital signs;
• Perform hands-on examinations;
• Observe physical findings;
• Perform diagnostic procedures;
• Immediately obtain laboratory or imaging results; or
• Evaluate conditions requiring in-person examination.

As a result, the provider may recommend that you receive an in-person evaluation.

6. Risks of Telehealth

I understand that telehealth involves potential risks, including but not limited to:

• Technology failures;
• Internet connectivity problems;
• Audio or video interruptions;
• Delays in communication;
• Miscommunication;
• Incomplete information;
• Difficulty performing certain examinations;
• Delayed diagnosis;
• Incorrect or incomplete diagnosis;
• Delayed treatment;
• Need for an in-person evaluation;
• Unauthorized access to electronic information;
• Privacy or confidentiality breaches;
• Cybersecurity incidents; and
• Other risks associated with electronic communication.

Although Helix uses reasonable safeguards designed to protect health information, no electronic communication system can be guaranteed to be completely secure.

7. Privacy and Confidentiality

Helix takes reasonable measures to protect the privacy and security of your health information.

Where applicable, your protected health information (“PHI”) will be handled in accordance with applicable federal and state privacy laws, including HIPAA.

Telehealth communications may involve electronic transmission of sensitive medical information.

To help protect your privacy, you should:

• Participate from a private location whenever possible;
• Use a private and secure internet connection;
• Use a password-protected device;
• Keep your device software updated;
• Avoid allowing unauthorized individuals to observe or listen to the session;
• Use headphones when appropriate; and
• Protect your login credentials.

You should inform the healthcare provider if another person is present during a telehealth encounter.

If another person is participating in or observing your telehealth encounter, the provider may identify that person and obtain appropriate consent when required.

8. Identity and Location Verification

Before or during a telehealth encounter, you may be asked to verify:

• Your identity;
• Your date of birth;
• Your physical location;
• Your contact information; and
• Other information reasonably necessary to provide healthcare services.

You agree to provide accurate information.

You understand that healthcare professionals may be restricted from providing telehealth services when you are physically located in a jurisdiction where the provider is not authorized to practice.

If your physical location changes during a telehealth encounter, you should notify your healthcare provider.

9. Emergency Care

TELEHEALTH SERVICES PROVIDED BY HELIX ARE NOT A SUBSTITUTE FOR EMERGENCY MEDICAL CARE.

If you are experiencing a medical emergency, call 911 or your local emergency service immediately or go to the nearest emergency department.

Do not use:

• Email;
• Website forms;
• Patient portal messages;
• Text messages;
• Appointment scheduling;
• Telehealth requests; or
• Other Helix communications

as a substitute for emergency medical care.

Examples of potentially serious symptoms requiring immediate emergency evaluation include:

• Chest pain;
• Difficulty breathing;
• Severe bleeding;
• Loss of consciousness;
• Severe allergic reaction;
• Stroke symptoms;
• Severe or sudden neurological symptoms;
• Severe abdominal pain;
• Suicidal thoughts or immediate danger; or
• Any other condition you believe requires immediate medical attention.

Helix cannot guarantee that electronic communications will be reviewed immediately.

10. Alternatives to Telehealth

You understand that alternatives to telehealth may include:

• An in-person visit with a healthcare provider;
• An urgent care facility;
• A primary care provider;
• A specialist;
• A hospital or emergency department;
• Laboratory or diagnostic testing; or
• Other healthcare services appropriate to your condition.

You may discuss alternatives with your healthcare provider.

11. Right to Ask Questions

You have the right to ask questions about:

• Telehealth;
• Your healthcare provider;
• The technology being used;
• Privacy and security;
• The risks and benefits of telehealth;
• Alternative treatment options;
• Your medical condition;
• Recommended treatment;
• Medications; and
• Any other aspect of your healthcare.

You should not hesitate to ask your provider to explain information that you do not understand.

12. Right to Withdraw Consent

You may withdraw your consent to receive telehealth services at any time, subject to applicable law and the circumstances of your care.

You may withdraw consent by notifying your healthcare provider or contacting Helix Health and Wellness.

Withdrawal of consent does not necessarily require Helix to delete medical records or other information that must be retained under applicable law.

If you withdraw consent, Helix or your healthcare provider may recommend or require an alternative method of receiving care, including an in-person evaluation.

Withdrawal of consent may affect Helix’s ability to provide certain services.

13. No Guarantee of Treatment or Prescription

You understand that consenting to telehealth does not guarantee:

• A diagnosis;
• A particular treatment;
• A prescription;
• A specific medication;
• Laboratory testing;
• A referral;
• Continued treatment; or
• A particular medical outcome.

Healthcare providers retain independent clinical judgment.

A provider may determine that a requested medication or treatment is medically inappropriate or legally unavailable.

14. Prescription Medications

If prescription services are offered, prescriptions will be issued only when a licensed healthcare professional determines that prescribing is medically appropriate and legally permitted.

You understand that:

• A prescription is not guaranteed;
• A particular medication may not be prescribed;
• A pharmacy may not have a medication in stock;
• A pharmacy may refuse to fill a prescription where legally permitted;
• Insurance may not cover a medication; and
• Additional evaluation or testing may be required before a medication is prescribed.

All prescribing decisions remain subject to applicable federal and state law and the independent professional judgment of the prescribing healthcare professional.

15. Patient Responsibilities

By consenting to telehealth, you agree to:

• Provide truthful and accurate information;
• Provide a complete medical history to the best of your knowledge;
• Disclose current medications;
• Disclose allergies;
• Disclose relevant medical conditions;
• Inform your provider of changes in your health;
• Provide accurate information about your physical location;
• Participate from a reasonably private location;
• Use reasonable measures to protect your privacy;
• Follow your provider’s instructions;
• Complete recommended testing or follow-up when appropriate;
• Notify your provider of significant changes in your condition; and
• Seek emergency care when appropriate.

You understand that withholding or providing inaccurate medical information may affect the safety and effectiveness of your care.

16. Technology Requirements

You may need access to:

• A smartphone, tablet, or computer;
• A working camera when video is required;
• A working microphone;
• Speakers or headphones;
• A reliable internet connection;
• A compatible web browser or application; and
• A private location.

You are responsible for maintaining the equipment and internet connection necessary to participate in telehealth.

If technical problems prevent a healthcare provider from adequately evaluating you, the provider may terminate or reschedule the encounter or recommend an in-person visit.

17. Recording of Telehealth Encounters

Telehealth encounters will not be recorded by Helix unless you are informed of the recording and the recording is permitted by applicable law and appropriate consent is obtained when required.

You should not record, photograph, screenshot, or distribute a telehealth encounter without appropriate consent and authorization from the participants, except where otherwise permitted by law.

18. Third-Party Participants

You may request that another person participate in your telehealth encounter, such as:

• A caregiver;
• Family member;
• Interpreter;
• Authorized representative; or
• Other person involved in your care.

You should inform the healthcare provider before another person joins the encounter.

The healthcare provider may require identification or consent from additional participants where appropriate.

19. Medical Records

Information obtained during a telehealth encounter may become part of your medical record.

Medical records will be maintained and handled in accordance with applicable federal and state law and Helix’s applicable privacy policies and Notice of Privacy Practices.

You may have rights concerning access to and copies of your medical records as provided by applicable law.

20. Electronic Communications

You understand that healthcare-related communications may occur through electronic methods, including:

• Patient portals;
• Secure messaging;
• Email;
• Telephone;
• SMS/text messaging; and
• Other electronic communication methods authorized by Helix.

Electronic communications may carry privacy and security risks.

You should not send highly sensitive information through an unsecured communication method unless instructed or permitted by Helix.

21. Telehealth Consent and Applicable Law

Telehealth services will be provided in accordance with applicable federal and state laws and the professional standards applicable to the healthcare provider.

Telehealth laws and requirements may vary depending on the state or jurisdiction where you are physically located when receiving care.

Florida law defines telehealth to include synchronous and asynchronous telecommunications technologies used to provide healthcare services and requires telehealth providers to practice within their applicable scope of practice and professional standards.

If you receive telehealth services while physically located outside Florida, additional laws and requirements may apply.

22. Patient Choice

You are not required to receive healthcare through telehealth when an appropriate alternative method of care is available and applicable law permits the alternative.

You may discuss available alternatives with your healthcare provider.

Your provider may determine that telehealth is not appropriate for your specific healthcare needs.

23. Understanding and Voluntary Consent

By signing or electronically accepting this Consent, I acknowledge that:

• I have read this Telehealth Informed Consent;
• I understand what telehealth is;
• I understand the potential benefits and limitations of telehealth;
• I understand the potential risks associated with telehealth;
• I understand the privacy and security considerations;
• I understand that telehealth may not be appropriate for every medical condition;
• I understand that an in-person examination may be recommended;
• I understand that telehealth is not intended for emergency care;
• I understand that my healthcare provider will exercise independent clinical judgment;
• I have had an opportunity to ask questions;
• My questions have been answered to my satisfaction, or I understand that I may ask additional questions;
• I understand that I may withdraw my consent to telehealth, subject to applicable law and the circumstances of my care; and
• I voluntarily consent to receive healthcare services through telehealth.

24. Electronic Signature and Acknowledgment

By selecting the acknowledgment checkbox, clicking “I Agree,” signing electronically, submitting this form, or otherwise indicating acceptance, I acknowledge that I have reviewed and understood this Telehealth Informed Consent and voluntarily consent to receive telehealth services from Helix Health and Wellness.

I understand that my electronic acknowledgment may be maintained as part of my healthcare or administrative records.

25. Questions and Contact Information

If you have questions regarding telehealth services or this Consent, contact:

Helix Health and Wellness
Email: cs@helixhealthandwellness.com

For emergencies, call 911 or go to the nearest emergency department.

Last updated: August 27, 2026
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