Telehealth Consent
This consent explains how you'll receive care through telehealth, and what to expect. Please read it before starting your online visit. You'll be asked to confirm that you agree.
Who provides your care
Your care is provided by independent, US-licensed healthcare providers with [Medical group name] (the "Medical Group"). When you agree to this consent, you are agreeing to receive telehealth services from the Medical Group and its providers.
StackRx provides the technology platform (the "Platform") you use to reach the Medical Group, such as the intake questionnaire, photo upload, and secure messaging. StackRx is not a medical practice or a pharmacy, and it does not make decisions about your care.
Your provider will be licensed in the state where you're located during your visit. [How the provider's name, credentials, and license information are shown to the patient]
What telehealth means here
Telehealth is healthcare delivered using technology instead of an in-person visit. Through the Platform, it may include:
- An online questionnaire about your health history, current medications, and goals.
- Photos you upload, when your provider needs them.
- Secure written messages between you and your provider.
- A phone or video visit, if your provider decides one is needed or your state's law requires it.
How your visit works
Most visits are asynchronous. That means your provider reviews your answers and photos on their own time, rather than in a live conversation with you. Your provider may then:
- Message you with questions, or ask for more information or photos.
- Ask you to complete a phone or video visit.
- Prescribe a treatment, if they decide it's appropriate for you.
- Recommend a different option, or recommend that you see a provider in person.
- Decline to prescribe.
Asynchronous review can take time. [Typical provider response time]
Possible benefits
- You can get care from home, without traveling or taking time off.
- You can answer questions and send messages when it suits you.
- You can reach a licensed provider for conditions that may not need an in-person exam.
Possible risks and limits
Telehealth has limits. By agreeing to this consent, you understand that:
- There's no physical exam. Your provider relies on what you tell them and the photos you send. Some conditions can't be properly assessed without an in-person exam or tests.
- Missing or inaccurate information can lead to poor decisions. If your answers are incomplete or wrong, your provider may make a decision that isn't right for you, including prescribing something that could harm you.
- Photos have limits. Poor lighting, focus, or angle may make photos hard to assess.
- There may be delays. Reviews and replies aren't instant, and technical problems can slow things down.
- Technology can fail. Information could be lost or delayed. Despite reasonable safeguards, there is a small risk that information could be accessed by someone who shouldn't see it.
- Medications can have side effects. Any medication, including a compounded one, can cause side effects or interact with other medications or conditions.
Your responsibilities
- Give complete, truthful answers, including about all medications and supplements you take, allergies, health conditions, and, where relevant, pregnancy or breastfeeding.
- Complete the visit yourself, for your own care only.
- Tell your provider if your health or medications change.
- Follow your provider's instructions and the directions from your pharmacy.
- Contact your provider about side effects or concerns, and get in-person care when you need it.
Prescriptions and compounded medications
Your provider will prescribe only what they believe is appropriate for you. There's no guarantee you'll receive a prescription.
Treatments offered through the Platform are compounded by independent, state-licensed pharmacies. Compounded medications are not FDA-approved, and the FDA does not review them for safety, effectiveness, or quality before they're dispensed. Your provider can explain why a compounded medication may be an option for you, and what other options exist.
[Whether the patient may ask to have a prescription sent to a pharmacy of their choice, and how]
Your right to refuse or stop
You don't have to use telehealth. You can decline it, choose in-person care instead, or withdraw this consent at any time by contacting [Medical Group contact email]. Withdrawing won't affect care you've already received, and it won't affect your right to future care elsewhere.
You can also decline any treatment your provider recommends.
Emergencies and follow-up care
Telehealth through the Platform is not for emergencies. If you think you're having a medical emergency, call 911 or go to the nearest emergency room right away.
If you have severe or worrying side effects, stop using the medication and get medical help right away. Then let your provider know.
This service does not replace your primary care provider. Please keep seeing your own doctor for routine, ongoing, and follow-up care. We encourage you to tell your doctor about any treatment you receive through the Platform.
Your records and privacy
Your questionnaire answers, photos, messages, and prescriptions become part of your medical record, which the Medical Group keeps. You can ask the Medical Group for a copy of your record at [Medical Group contact email].
The Medical Group may share your information with the pharmacy that fills your prescription, and with StackRx to the extent needed to run the Platform, as allowed by law. [HIPAA role and any authorization required for these disclosures]
The Medical Group's Notice of Privacy Practices explains how your medical information is used and shared, and your rights: [Link to Medical Group Notice of Privacy Practices]. You can also read StackRx's Privacy Policy.
Where you need to be
You must be physically located in a state where StackRx is available whenever you complete your visit or communicate with your provider. Currently, those states are Arizona, Colorado, Florida, Georgia, Illinois, Indiana, Kentucky, Missouri, Ohio, Pennsylvania, South Dakota, Tennessee, and Wisconsin.
State-specific notices
[State-specific telehealth notices and consent requirements for each available state, as required]
Your acknowledgment
By checking the box and continuing, you confirm that:
- You're at least 18 years old.
- You've read and understood this consent, and you've had the chance to ask questions.
- You understand the benefits, risks, and limits of telehealth described above.
- You agree to receive telehealth services from the Medical Group and its providers through the Platform.
This consent stays in effect until you withdraw it. The Medical Group may ask you to review and confirm an updated version from time to time.
Questions
- About your care: [Medical Group contact email]
- About your account or order: [Support email]