Telehealth Informed Consent

Telehealth involves the use of electronic communications to enable healthcare providers at different locations to share individual patient medical information for the purpose of improving patient care. Telehealth services offered via Oat Meds LLC contracted healthcare entity, Beluga Health, P.A. ("Beluga"), and Beluga's providers (our "Providers" or your "Provider") may also include chart review, remote prescribing, appointment scheduling, health information sharing, and non-clinical services, such as patient education. The information you provide may be used for diagnosis, therapy, follow-up and/or patient education, and may include any combination of the following:

  • Health records and test results
  • Images and asynchronous communications
  • Live two-way audio and video
  • Two-way interactive audio with store and forward
  • Output data from medical devices and sound and video files

The electronic communication systems we use will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

Beluga providers are an addition to, and not a replacement for, your local primary care provider. Responsibility for your overall medical care should remain with your local primary care provider, if you have one, and we strongly encourage you to locate one if you do not.

Oat Meds LLC does not provide the above services; it performs administrative, payment, and other supportive activities for Beluga and our Providers.

Expected Benefits:

  • Improved access to care by enabling you to remain in your home while your Provider consults and obtains test results at distant/other sites.
  • More efficient care evaluation and management.
  • Obtaining expertise of a specialist as appropriate.
  • You may contact your Provider for follow-up questions by directly sending a message to your Provider via our dashboard. Your Provider will be familiar with and have access to available medical resources in order to make an appropriate referral where medically indicated. Your Provider will typically respond within thirty-six hours.

Service Limitations:

The primary difference between telehealth and direct in-person service delivery is the inability to have direct, physical contact with the patient. Accordingly, some clinical needs may not be appropriate for a telehealth visit and your Provider will make that determination.

OUR PROVIDERS DO NOT ADDRESS MEDICAL EMERGENCIES. IF YOU BELIEVE YOU ARE EXPERIENCING A MEDICAL EMERGENCY, YOU SHOULD DIAL 9-1-1 AND/OR GO TO THE NEAREST EMERGENCY ROOM. PLEASE DO NOT ATTEMPT TO CONTACT OAT MEDS LLC, GROUP, OR YOUR PROVIDER. AFTER RECEIVING EMERGENCY HEALTHCARE TREATMENT, YOU SHOULD VISIT YOUR LOCAL PRIMARY CARE PROVIDER.

Possible Risks:

  • Delays in evaluation and treatment could occur due to deficiencies or failures of the equipment and technologies, or Provider availability.
  • In rare events, your Provider may determine that the transmitted information is of inadequate quality, thus necessitating a rescheduled telehealth consult or a meeting with your local primary care doctor.
  • In very rare events, security protocols could fail, causing a breach of privacy of personal medical information.
  • In rare events, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors.

By checking the box associated with "Informed Telehealth Consent", you acknowledge that you understand and agree with the following:

  • I hereby consent to receiving Beluga services via telehealth technologies. I understand that Beluga and its Providers offer telehealth-based medical services, but that these services do not replace the relationship between me and my primary care doctor. I also understand it is up to the Beluga Provider to determine whether or not my specific clinical needs are appropriate for a telehealth encounter.
  • I understand a licensed Provider from Beluga will be assigned to me prior to the consult, however, I can request a different licensed Provider at any time. I can review the credentials of my assigned Provider.
  • I understand that federal and state law requires health care providers to protect the privacy and the security of health information. I understand all medical reports resulting from the telehealth visit are part of my medical record.
  • I understand that Beluga will take steps to make sure that my health information is not seen by anyone who should not see it. I understand that telehealth may involve electronic communication of my personal medical information to other health practitioners who may be located in other areas, including out of state.
  • I understand there is a risk of technical failures during the telehealth encounter beyond the control of Beluga. I AGREE TO HOLD HARMLESS BELUGA AND ITS EMPLOYEES, CONTRACTORS, AGENTS, DIRECTORS, MEMBERS, MANAGERS, SHAREHOLDERS, OFFICERS, REPRESENTATIVES, ASSIGNS, PARENTS, PREDECESSORS, AND SUCCESSORS FOR DELAYS IN EVALUATION OR FOR INFORMATION LOST DUE TO SUCH TECHNICAL FAILURES.
  • I understand that I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time, without affecting my right to future care or treatment. I understand that I may suspend or terminate use of the telehealth services at any time for any reason or for no reason.
  • I understand that if I am experiencing a medical emergency, that I will be directed to dial 9-1-1 immediately and that my Provider is not able to connect me directly to any local emergency services.
  • I understand that alternatives to telehealth consultation, such as in-person services are available to me.
  • I understand that I may expect the anticipated benefits from the use of telehealth in my care, but that no results can be guaranteed or assured.
  • I understand that my healthcare information may be shared with other individuals for operational, quality assurance, scheduling and billing purposes. If I have a real-time consultation, persons may be present during the consultation other than the Provider during such real-time consultation in order to operate the telehealth technologies. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history/examination that are personally sensitive to me; (2) ask non-medical personnel to leave the telehealth examination; and/or (3) terminate the consultation at any time.
  • I understand that I will not be prescribed any narcotics for any reason, nor is there any guarantee that I will be given a prescription at all. I understand that the decision of whether a prescription is appropriate will be made in the professional judgement of my Provider.
  • I understand I can choose to fill my prescription at a pharmacy of my choice.
  • I understand that my Provider reserves the right to deny care for potential misuse of the Services or for any other reason if, in the professional judgment of my Provider, the provision of the Services is not medically or ethically appropriate.
  • I understand that if I participate in a consultation, that I have the right to request a copy of my medical records which will be provided to me at reasonable cost of preparation, shipping and delivery.
  • I understand if I communicate with my Beluga Provider in a language other than English, my Beluga Provider will utilize a third-party translation service to assist in communicating with me and such service will receive my personal information, including health information. This translation is free of charge. I understand I am solely responsible for providing complete and accurate information to my Beluga Provider and third-party translation service. I AGREE TO HOLD HARMLESS BELUGA AND ITS EMPLOYEES, CONTRACTORS, AGENTS, DIRECTORS, MEMBERS, MANAGERS, SHAREHOLDERS, OFFICERS, REPRESENTATIVES, ASSIGNS, PARENTS, PREDECESSORS, AND SUCCESSORS FOR ANY CLAIMS, LOSSES, OR DEMANDS CAUSED IN WHOLE OR IN PART BY THE USE OF A THIRD-PARTY TRANSLATION SERVICE.

Additional State-Specific Consents: The following consents apply to users accessing the website for the purposes of participating in a telehealth consultation as required by the states listed below:

  • Alaska: I understand my primary care provider may obtain a copy of my records of my telehealth encounter. (Alaska Stat. § 08.64.364). 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.
  • Arizona: I understand I am entitled to all existing confidentiality protections pursuant to A.R.S. § 12-2292. I also understand all medical reports resulting from the telemedicine consultation are part of my medical record as defined in A.R.S. § 12-2291. I also understand dissemination of any images or information identifiable to me for research or educational purposes shall not occur without my consent, unless authorized by state or federal law. (Ariz. Rev. Stat. Ann. § 36-3602).
  • California: The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. It can be found at https://openpaymentsdata.cms.gov.

    • 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.

    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.

    Indiana: 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.

    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.

    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; Or, the Maine Board of Osteopathic Licensure's website, here.

    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; Or, the Oklahoma Board of Osteopathic Examiners' website, here.

    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; Or, the Oklahoma Board of Osteopathic Examiners' website, here.

    Rhode island: 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.

    Texas: 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 Beluga provides meets industry security and privacy standards, and comply with all laws referenced in Subsection 26-60-102(9)(b)(ii), if applicable. 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 Beluga'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. 156-1-602).

    Vermont: 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; Or, the Vermont Board of Osteopathic Examiners' website, here. 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 understand that receiving tele-dermatology or tele-ophthalmology services via Beluga does not preclude me from receiving real-time telemedicine or face-to-face services with the distant provider at a future date. (Vt. Stat. Ann. § 9361(e)).

    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 Beluga 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).

Patient consent:

I have read this document carefully, and understand the risks and benefits of the telehealth consultation and have had my questions regarding the procedure explained and I hereby give my informed consent to participate in a telehealth consultation under the terms described herein.