ADDITIONAL TELEHEALTH AND OTHER STATE-SPECIFIC CONSENTS
Last Updated: 10/19/2023
Alaska
I understand my primary care provider may obtain a copy of my records of my telehealth encounter. (Alaska Stat. § 08.64.364).
Arizona
I understand that all medical records resulting from a telemedicine consultation are part of my medical record. (A.R.S. § 12-2291.)
California
California Physician Licensure Notice: All Forward physicians licensed to practice in the State of California are licensed and regulated by the Medical Board of California. To check on a physician’s license or to file a complaint, go to [www.mbc.ca.gov], email [licensecheck@mbc.ca.gov], call (800) 633-2322 or use this QR code:
California Open Payments Disclosure: The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. For informational purposes only, a link to the federal Centers for Medicare and Medicaid Services (CMS) Open Payments web page is provided here: [https://openpaymentsdata.cms.gov]. The federal Physician Payments Sunshine Act requires that detailed information about payment and other payments of value worth over ten dollars ($10) from manufacturers of drugs, medical devices, and biologics to physicians and teaching hospitals be made available to the public.
Colorado
I am informed that if I want to register a formal complaint about a provider, I should file at [https://dpo.colorado.gov/FileComplaint].
Connecticut
I understand that my primary care provider may obtain a copy of my records of my telehealth encounter, and that I can revoke my consent at any time. (Conn. Gen. Stat. Ann. § 19a-906).
D.C.
I have been informed of alternate forms of communication between me and a physician for urgent matters. (D.C. Mun. Regs. tit. 17, § 4618.10).
Florida
This informed consent form concerns the potential benefits and risks associated with weight loss treatments. By agreeing to the treatment, you acknowledge that the procedures, such as diet modifications, physical activities, and medications, are designed to assist in losing weight and preserving general health. Potential benefits include improved physical health, lower risk of chronic diseases like diabetes, heart disease, and improvements in mental health and self-confidence. Despite these positives, potential risks exist. These may include, but are not limited to, cardiovascular issues, thyroid issues, nutritional deficiencies, metabolic changes, side effects related to medication (like abdominal discomfort, pancreatitis), and mental health challenges like developing an unhealthy obsession with body image or food. You should carefully review any materials provided for any drugs you are prescribed for weight loss. By providing your informed consent, you assert your understanding and acceptance of these potential benefits and risks.
Georgia
I have been given clear, appropriate, accurate instructions on follow-up in the event of needed emergent care related to the treatment. (Ga. Comp. R. & Regs. 360-3-.07(7)).
Iowa
I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here: [https://medicalboard.iowa.gov/consumers/filing-complaint].
Idaho
I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here: [https://elitepublic.bom.idaho.gov/IBOMPortal/AgencyAdditional.aspx?Agency=425&AgencyLinkID=650].
Illinois
I have been informed that if I want to register a formal complaint about a provider, I should visit the Illinois Division of Professional Regulation at [https://www.idfpr.com/admin/DPR/DPRcomplaint.asp].
Indiana
As a Medicaid patient, I have the right to choose between an in-person visit or telehealth visit. I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here: [https://www.in.gov/attorneygeneral/2434.htm].
Kansas
I understand that if I have a primary care provider or other treating physician, the person providing telemedicine services must send within three business days a report to such primary care or other treating physician of the treatment and services rendered to me during the telemedicine encounter. (Kan. Stat. Ann. § 40-2,212(2)(d)(2)(A). I understand that the complaint process may be found here: [http://www.ksbha.org/complaints.shtml].
Kentucky
I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here: [https://kbml.ky.gov/grievances/Pages/default.aspx].
Louisiana
I understand the role of other health care providers that may be present during the consultation other than the telehealth provider. (46 La. Admin. Code Pt XLV, § 7511).
Maine
I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here: [https://www.maine.gov/md/discipline/file-complaint.html].
Maryland
Regarding audiologists, speech language pathologists, and hearing aid dispensers, I recognize the inability to have direct, physical contact with the patient is a primary difference between telehealth and direct in-person service delivery. The knowledge, experiences, and qualifications of the consultant providing data and information to the provider of the telehealth services need not be completely known to and understood by the provider. The quality of transmitted data may affect the quality of services provided by the provider. Changes in the environment and test conditions could be impossible to make during delivery of telehealth services. Telehealth services may not be provided by correspondence only. (Md. Code Regs. 10.41.06.04). I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here: [https://www.mbp.state.md.us/forms/complaint.pdf].
Nebraska
If I am a Medicaid recipient, I retain the option to refuse the telehealth consultation at any time without affecting my right to future care or treatment and without risking the loss or withdrawal of any program benefits to which the patient would otherwise be entitled. All existing confidentiality protections shall apply to the telehealth consultation. I shall have access to all medical information resulting from the telehealth consultation as provided by law for access to my medical records. Dissemination of any patient identifiable images or information from the telehealth consultation to researchers or other entities shall not occur without my written consent. I understand that I have the right to request an in-person consult immediately after the telehealth consult and I will be informed if such consult is not available. (Neb. Rev. Stat. Ann. § 71-8505; 471 Neb. Admin. Code § 1-006.05). I have been informed that if I want to register a formal complaint about a provider, I should visit: [https://dhhs.ne.gov/Pages/Complaints.aspx]
New Hampshire
I understand that the telehealth provider may forward my medical records to my primary care or treating provider. (N.H. Rev. Stat. § 329:1-d).
New Jersey
I understand I have the right to request a copy of my medical information and I understand my medical information may be forwarded directly to my primary care provider or health care provider of record, or upon my request, to other health care providers. (N.J. Rev. Stat. Ann. § 45:1-62).
Ohio
I understand that the telehealth provider may forward my medical records to my primary care or treating provider. (Ohio Admin. Code 4731-11-09(C)).
Oklahoma
I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here: [http://www.okmedicalboard.org/complaint]. The Board of Osteopathic Examiners can be found at: [https://www.ok.gov/osboe/faqs.html].
Rhode Island
If I use e-mail or text-based technology to communicate with my provider, then I understand the types of transmissions that will be permitted and the circumstances when alternate forms of communication or office visits should be utilized. I have also discussed security measures, such as encryption of data, password protected screen savers and data files, or utilization of other reliable authentication techniques, as well as potential risks to privacy. I acknowledge that my failure to comply with this agreement may result in the telehealth provider terminating the e-mail relationship. (Rhode Island Medical Board Guidelines).
South Carolina
I understand my medical records may be distributed in accordance with applicable law and regulation to other treating health care practitioners. (S.C. Code Ann. § 40-47-37).
South Dakota
I have received disclosures regarding the delivery models and treatment methods or limitations. I have discussed with the telehealth provider the diagnosis and its evidentiary basis, and the risks and benefits of various treatment options. (S.D. Codified Laws § 34-52-3).
Tennessee
I understand that I may request an in-person assessment before receiving a telehealth assessment if I am a Medicaid recipient.
Texas
I understand that my medical records may be sent to my primary care physician. (Tex. Occ. Code Ann. § 111.005). I have been informed of the following notice:
NOTICE CONCERNING COMPLAINTS - Complaints about physicians, as well as other licensees and registrants of the Texas Medical Board, including physician assistants, acupuncturists, and surgical assistants may be reported for investigation at the following address: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018, Assistance in filing a complaint is available by calling the following telephone number: 1-800-201-9353, For more information, please visit our website at [www.tmb.state.tx.us].
AVISO SOBRE LAS QUEJAS- Las quejas sobre médicos, asi como sobre otros profesionales acreditados e inscritos del Consejo Médico de Tejas, incluyendo asistentes de médicos, practicantes de acupuntura y asistentes de cirugia, se pueden presentar en la siguiente dirección para ser investigadas: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018, Si necesita ayuda para presentar una queja, llame al: 1-800-201-9353, Para obtener más información, visite nuestro sitio web en [www.tmb.state.tx.us]
Utah
I understand (i) any additional fees charged for telehealth services, if any, and how payment is to be made for those additional fees, if the fees are charged separately from any fees for face-to-face services provided in combination with the telehealth services; (ii) to whom my health information may be disclosed and for what purpose, and have received information on any consent governing release of my patient-identifiable information to a third-party; (iii) my rights with respect to patient health information; (iv) appropriate uses and limitations of the site, including emergency health situations. I understand that the telehealth services meets industry security and privacy standards, and comply with all laws referenced in Subsection 26-60-102(8)(b)(ii). I was warned of: potential risks to privacy notwithstanding the security measures and that information may be lost due to technical failures, and agree to hold the provider harmless for such loss. I have been provided with the location of telehealth company’s website and contact information. I was able to select my provider of choice, to the extent possible. I was able to select my pharmacy of choice. I am able to a (i) access, supplement, and amend my patient-provided personal health information; (ii) contact my provider for subsequent care; (iii) obtain upon request an electronic or hard copy of my medical record documenting the telemedicine services, including the informed consent provided; and (iv) request a transfer to another provider of my medical record documenting the telemedicine services. (Utah Admin. Code r. 156-1-603).
Virginia
I acknowledge that I have received details on security measures taken with the use of telemedicine services, such as encrypting date of service, password protected screen savers, encrypting data files, or utilizing other reliable authentication techniques, as well as potential risks to privacy notwithstanding such measures; I agree to hold harmless Forward for information lost due to technical failures; and I provide my express consent to forward patient-identifiable information to a third party. (Virginia Board of Medicine Guidance Document 85-12).
Vermont
I understand that I have the right to receive a consult with a distant-site provider and will receive one upon request immediately or within a reasonable time after the results of the initial consult. I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here: [http://www.healthvermont.gov/health-professionals-systems/board-medical-practice/file-complaint]; the Board of Osteopathic Examiners can be found at: [https://www.sec.state.vt.us/professional-regulation/file-a-complaint-employer-mandatory-reporting.aspx].
Washington
I understand that this agreement does not provide comprehensive health insurance coverage. It provides only the health care services specifically described. (Wash. Rev. Code § 48.150.110(1)). I acknowledge that I am encouraged to obtain and maintain insurance for services not provided by Forward, and that Forward will not bill a carrier for services covered under this direct agreement. Furthermore, I understand that under this agreement I have the right to: terminate this agreement at any time with written notice to Forward (Wash. Rev. Code § 48.150.010(1)), receive a prorated refund of unearned direct fees already paid to Forward after Forward’s receipt of a notice of termination (Wash. Rev. Code § 48.150.030), and be notified of any additional charges for supplies, medications, and specific vaccines that are specifically excluded under the agreement prior to their administration or delivery, to the extent applicable (Wash. Rev. Code § 48.150.040(2)(c)). I have been informed of the specific health care services provided by Forward under this agreement and of my financial rights and responsibilities to Forward as provided under Wash. Rev. Code § 48.150. (Wash. Rev. Code §48.150.010(1); Wash. Rev. Code § 48.150.110(2)). I acknowledge that I may contact the Washington Office of the Insurance Commissioner at 800-562-6900 and learn more at [https://www.insurance.wa.gov/]. (Wash. Rev. Code § 48.150.110(2)).