Last updated: January 2026

NO MEDICAL EMERGENCY SERVICES
ILSA Health does not provide emergency or urgent medical care. If you believe you are experiencing a medical emergency, call 911 immediately or seek immediate care from a licensed emergency provider.

Please Read Carefully

Telehealth involves the delivery of healthcare services using electronic communications and information technologies when you and your healthcare provider are not in the same physical location. By proceeding, you confirm that you have read and understood this Consent to Telehealth Services (this “Consent”), and that you voluntarily agree to receive healthcare services via telehealth where clinically appropriate and legally permitted.

This Consent is intended to ensure you understand how telehealth works, what to expect, the potential benefits and risks, and your rights and responsibilities.

1. What Telehealth Is

Telehealth may include, without limitation:

• Live, interactive video visits

• Telephone visits

• Secure messaging and electronic communications (including asynchronous communications where permitted)

• Online medical intake forms, questionnaires, and symptom assessments

• Remote review of medical history, patient-reported information, photos (if you submit them), and available records

• Review of laboratory results and other diagnostics ordered by your treating provider

Telehealth may occur through a secure patient portal, a telehealth platform, a phone call, or secure electronic communications, depending on clinical appropriateness, your location, and applicable law.

2. Voluntary Participation and Right to Refuse

Your participation in telehealth is voluntary. You understand and agree that:

• You may refuse telehealth at any time.

• You may withdraw this consent at any time by notifying your treating provider and/or using the support pathways available to you.

• Refusal or withdrawal of consent may limit your access to certain services that are designed to be provided remotely, and may require an in-person visit or referral to an in-person provider.

If you withdraw consent, you understand that care may be discontinued if telehealth is the primary or only available method for services in your area or under your program.

3. When Telehealth May Not Be Appropriate

You understand that telehealth has limitations and may not be appropriate for all conditions. A healthcare provider may determine, in their professional judgment, that:

• Telehealth is not clinically appropriate for your situation, or

• An in-person evaluation is required, or

• You should be referred to urgent care, emergency care, or another specialist.

You understand that the provider may decline to diagnose, treat, or prescribe based on telehealth if clinical standards or legal requirements cannot be met.

4. Provider Credentials and Clinical Decision-Making

Telehealth services are provided by independent U.S.-licensed healthcare providers operating through their professional medical practices.

You understand and agree that:

• Your treating provider is responsible for determining the appropriate standard of care, including whether telehealth is appropriate for you.

• Your treating provider is responsible for diagnosis, treatment planning, prescribing decisions, and follow-up recommendations.

• Clinical decisions will be based on the information you provide, your medical history, and the provider’s medical judgment.

5. Benefits of Telehealth

Potential benefits may include:

• Convenient access to healthcare without travel

• Reduced wait times for certain services

• Ability to receive care in a location that is comfortable for you

• Increased continuity of care for follow-up monitoring

You understand that benefits are not guaranteed and depend on your individual circumstances and clinical needs.

6. Risks and Limitations of Telehealth

You understand the potential risks and limitations of telehealth, which may include:

• Technology failures such as disconnections, poor video/audio quality, platform outages, or device issues

• Delays caused by technical problems or scheduling limitations

• Limits on the provider’s ability to perform a hands-on physical exam

• Potential for incomplete assessment if the information you provide is inaccurate, incomplete, or not current

• Rare risk of unauthorized access to information despite reasonable security measures

• Potential misunderstandings due to communication constraints

You understand that these limitations could affect the provider’s ability to make a diagnosis or treatment recommendation.

7. Technology, Environment, and Patient Responsibilities

You agree that you will:

• Use a compatible device and a stable internet or phone connection

• Participate from a private, safe location to protect your confidentiality

• Avoid participating while driving, operating machinery, or in any unsafe setting

• Ensure your camera and audio (if video is used) allow the provider to communicate effectively

• Inform the provider immediately if you cannot hear, see, or understand the provider

You understand that your provider may ask you to adjust your environment (lighting, camera angle, privacy) or may reschedule or end the visit if conditions make the encounter clinically inappropriate or unsafe.

8. Identity Verification and Accurate Information

You understand that for safety and legal compliance, you may be asked to verify your identity. You agree that:

• You will provide accurate identifying information and will not impersonate another person

• You will provide truthful, complete, and current information about your symptoms, history, medications, allergies, and prior diagnoses

• You will disclose relevant medical conditions and contraindications

• You will promptly update significant changes in your health status

You understand that inaccurate or incomplete information may lead to inappropriate clinical decisions, and may result in the provider being unable to treat you safely via telehealth.

9. Location Requirements and Cross-State Care

You understand that healthcare providers generally must be licensed in the state where you are physically located at the time of the telehealth encounter.

You agree that:

• You will disclose your physical location (state and, if requested, city/county) at the time of each telehealth interaction

• You will notify the provider if your location changes during the course of care

• If your location is outside a state where the provider is authorized to practice, the provider may be unable to proceed and may direct you to appropriate local care

Providing incorrect location information can impact legality and safety of care and may result in termination of telehealth services.

10. Prescriptions, Treatment Plans, and Follow-Up

You understand that:

• A prescription may be issued only if the provider determines it is clinically appropriate and legally permitted

• Some medications may not be available via telehealth, may require in-person evaluation, or may require laboratory testing

• The provider may modify, discontinue, or decline treatment based on clinical judgment, safety considerations, or legal requirements

• You are responsible for following the provider’s instructions, including dosage, administration, storage, and monitoring

You agree to ask questions if you do not understand any part of your treatment plan.

11. Laboratory Testing, Imaging, and Referrals

If the provider determines that laboratory testing, imaging, or referrals are needed, you understand that:

• The provider may order tests and direct you to independent laboratories or facilities

• Test results may be required before treatment is started or continued

• Failure to complete recommended tests may prevent the provider from safely diagnosing or treating you

• You may be referred to an in-person provider or specialist when clinically appropriate

12. Asynchronous Messaging and Response Times

Telehealth may include secure messaging. You understand that:

• Messages are not continuously monitored

• Response times vary based on clinical availability and workflow

• Messaging is not appropriate for emergencies

If you believe you have an urgent or emergency condition, you agree to seek immediate in-person care or call 911.

13. Emergencies and Urgent Situations

Telehealth is not intended for emergency care.

If you believe you are experiencing a medical emergency, you agree to:

• Call 911, or

• Go to the nearest emergency room

If your provider believes you may have an urgent or emergency condition, the provider may instruct you to seek immediate in-person care.

You agree that you are responsible for choosing emergency services when needed and for following emergency instructions.

14. Privacy, Confidentiality, and Security

Telehealth uses technologies designed to protect confidentiality and privacy. However, you understand that:

• No system can guarantee absolute security

• There is a risk of unauthorized access despite safeguards

• Your privacy can be affected by your own environment and device security

You agree to safeguard your login credentials and to use reasonable privacy practices (private location, secured device, avoiding shared/public Wi-Fi when possible).

15. Recording of Visits

Unless you are explicitly notified otherwise and give your consent where required:

• Telehealth visits are not recorded as part of routine care.

You agree not to record telehealth visits without the provider’s consent, except where permitted by applicable law. If recording is legally permitted by you, you understand that recording may affect the provider’s willingness or ability to conduct the visit, subject to applicable law.

16. Technical Failures and Backup Plan

If a telehealth session is interrupted due to technical problems, you agree that:

• The provider or staff may attempt to reconnect by video, phone, or secure messaging

• The provider may convert the encounter to a telephone visit when clinically appropriate and legally permitted

• The provider may reschedule the visit if an adequate clinical encounter cannot be completed

• If your condition appears urgent, you may be instructed to seek in-person evaluation

You understand that technical failure may limit what can be safely assessed.

17. Consent to Electronic Signatures and Electronic Communications

You consent to:

• Receiving this Consent and related notices electronically

• Using electronic signatures, acknowledgments, and records

• Receiving communications about scheduling, care coordination, and relevant service updates electronically (email, portal notifications, or text where you have opted in)

You understand that electronic consent has the same legal effect as a signed paper document.

18. Patient Rights and Questions

You confirm that:

• You had the opportunity to read this Consent carefully

• You may ask questions before, during, or after a telehealth visit

• You may request additional information about telehealth processes

• You understand you can withdraw consent at any time

19. Complaints and Concerns About Telehealth

If you have concerns about the telehealth experience (technology, communication, access, scheduling, or safety concerns), you may contact support:

Email: [email protected]

You may also contact your treating provider’s practice through the patient portal or the practice’s official support channel.

20. No Guarantee of Outcomes

You understand that medicine involves uncertainty and that:

• Results and outcomes cannot be guaranteed

• Telehealth does not guarantee a specific diagnosis, prescription, or treatment result

• Providers may determine that no treatment is appropriate based on clinical judgment

21. Acknowledgment and Consent

By clicking “I Agree”, signing electronically, or otherwise indicating acceptance, you acknowledge and confirm all of the following:

1. You have read and understood this Consent to Telehealth Services.

2. You understand telehealth involves healthcare delivered through electronic communications rather than in-person visits.

3. You understand the potential benefits, risks, and limitations of telehealth, including technical failures and limitations of remote assessment.

4. You agree to provide accurate information, verify your identity when required, and disclose your physical location at the time of telehealth encounters.

5. You understand telehealth is not for emergencies and agree to call 911 or seek emergency care when needed.

6. You voluntarily consent to receive healthcare services via telehealth when clinically appropriate and legally permitted.

Contact

For questions about this Telehealth Consent:
[email protected]