Nutree Clinic Telehealth Consent

For convenience of accessing care, NUTREE CLINIC, LLC, offers remote telehealth consultations between patients and clinicians via a secure video platform. Additionally, your healthcare provider may consult with other providers or specialists remotely about your care via video or phone. Please carefully review this consent by filling in a form, you agree to the following:

Potential Benefits of Telehealth

Convenience in accessing your providers from your home or another location.
Protection against the transmission of communicable illnesses between yourself and other patients and clinic staff.
Improvements to the quality of care when your clinician can consult with other providers as needed.

Technology Risks

Inherent in the use of telehealth are technological risks of disruption to the call or video connection and other technical difficulties. You or the provider may discontinue the telehealth consultation if either of you determine that technical difficulties are too disruptive to continue.

Privacy and Security

We take strong precautions to safeguard the privacy of your protected health information (PHI), including using only HIPAA-compliant platforms for telehealth. Nevertheless, there is an unavoidable risk of unauthorized access when sending/receiving PHI electronically (for example, via a video feed).

You are solely responsible for ensuring privacy and confidentiality on your side — by conducting the visit in a private space where others cannot overhear and cannot see private information on the screen.

We do not record (voice or video) telehealth consultations, but the health care provider will retain a medical record of care in their secure electronic health records system.

Limitations of Telehealth

Some visits — specifically, those that require the clinician to be physically present with you — are not suitable for telehealth. Your provider may ask that you schedule an in-person visit with your primary care provider for any issues that require in-person evaluation or treatment.

Telehealth is not a substitute for emergency care.
If you need urgent care, call 911 or go to the nearest urgent care facility.

Cost Responsibility

You are responsible for the cost of your telehealth consultation. If you are seeking insurance payment or reimbursement for the visit, note that insurance companies may require that you participate in the telehealth consultation from:

A hospital
A mental health facility
A physician's office
An adult care facility
Your home

Privacy Recommendations

I understand the following recommendations given to me about privacy:

If people are close to you, they may hear something you did not want them to know. You should be in a private place, so other people cannot hear you.
We use telehealth technology that is designed to protect your privacy.
There is a very small chance that someone could use technology to hear or see your telehealth visit.
If you use the Internet for telehealth, use a network that is private and secure.

Practice Policies

I have read and understood the following practice policies:

The patient must be located or reside in the State of Florida or reside where a licensed health care provider employed by NUTREE CLINIC is duly licensed to provide health care services at the time of the telehealth consult.
No recordings of audio or video are allowed.
Choose a quiet room. Other people will not be allowed to see or listen to the visit unless it is a legal tutor, or you need technical help.
Please do not drive during the appointment.
Make sure you are appropriately dressed as if you were visiting the office.
Make sure to turn off all other electronic devices or social media.
Make sure to be connected to the patient portal and ready for your visit at least 10 minutes prior to the scheduled time.
Controlled substances will not be prescribed.
If you have not submitted your payment or all patient forms have not been completed at least 15 minutes prior to the appointment, your appointment could be cancelled or rescheduled.
If we encounter technical difficulties the appointment may need to be rescheduled.

Patient Consent to the Use of Telehealth

I have read this form — or had it read and explained to me — in full. I fully understand its contents, including the risks, benefits, and alternatives.

I have been given opportunity to ask questions and any questions have been answered to my satisfaction.

I hereby give my informed consent to the use of telehealth in the course of my diagnosis and treatment.

By filling in a form, I acknowledge and agree that:

I have carefully read the information on this Telehealth Consent and understand I may be giving up some important legal rights by signing.