Informed Consent to Use of Telehealth

Informed Consent to Use of Telehealth

Patient Consent to Use of Telehealth Note from Alpha: We want to make it easier and more convenient for you to get great healthcare by connecting you with clinicians via our website and mobile application (collectively the “Alpha Website”). Providing healthcare via technology is often referred to as “telehealth.” This document describes the potential benefits and risks and asks you to consent to the use of telehealth as part of the Alpha Service. While we believe the benefits of telehealth outweigh the risks, we want you to make an informed decision about your care and ask you to read this patient consent carefully.

In using the Alpha Website, you/your child will be consulting with a licensed clinician (“Provider”) solely via the use of “telehealth.” Telehealth involves the delivery of healthcare services using electronic communications, information technology or other means between a healthcare provider and a patient or his or her surrogate who are not in the same physical location. Telehealth may be used for diagnosis, treatment, follow-up and/or patient education, and may include, but is not limited to:

Electronic transmission of medical records, photo images, personal health information or other data between you and/or your child and a Provider.

Interactions between you and/or your child and a Provider via audio, video and/or data communications.

Use of output data from medical devices, sound and video files.

Provider(s) using the Alpha Website will be interacting with you/your child solely via use of the Alpha Website. As a result, all of the medical care and treatment received from such Providers will be provided via telehealth, and you/your child will not be able to meet with your Provider "in-person."

The electronic systems used in the Alpha Website will incorporate network and software security protocols to protect the privacy and security of health information and imaging data, and will include measures to safeguard the data to ensure its integrity against intentional or unintentional corruption.

ANTICIPATED BENEFITS: The use of telehealth by Providers through the Alpha Website may have the following benefits:

Making it easier and more efficient for you/your child to access medical care for the conditions treated by Providers.

Reducing wait times for diagnosis, treatment, and appropriate prescriptions.

Allowing you/your child to obtain medical care and treatment by Providers at times that are convenient for you.

Avoiding unnecessary travel and allowing you/your child  to obtain medical care from the comfort and privacy of your home.

Enabling ongoing care and follow-up communication with Providers on your/your child’s terms and without travel or missed work/school.

POSSIBLE RISKS: While the use of telehealth may provide numerous benefits, there are also potential risks. These risks include, but may not be limited to, the following:

The information transmitted to your Provider(s) may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision-making by the Provider(s).

The inability of your Provider(s) to conduct certain tests, examine a patient, or assess vital signs in-person may in some cases prevent the Provider(s) from providing a diagnosis or treatment or from identifying the need for emergency care.

Your Provider may not be able to provide medical treatment for your/your child’s particular condition, and you/your child may be required to seek alternative healthcare or emergency care services.

Delays in medical evaluation/treatment could occur due to unavailability of Providers or the possibility of deficiencies or failures of the technology or electronic equipment used. In rare instances, security protocols or safeguards could fail, causing a breach of privacy.

Given regulatory requirements in certain jurisdictions, your Provider(s) treatment options, especially pertaining to certain prescriptions, may be limited.

In rare cases, a lack of access to all of your medical records may result in adverse drug interactions or allergic reactions or other judgment errors.

How to Contact Us at Alpha to Use your Rights

For general inquiries or to request a physical copy of your/your minor child’s medical record, please e-mail us at: or write to us at:

555 Bryant St, Suite 814

Palo Alto, CA 94301

How to Submit a Complaint

To submit a complaint to Alpha please submit your complaint in writing to:

The Privacy Office

℅ Alpha Medical

555 Bryant St, Suite 814

Palo Alto, CA 94301

Formal complaints may also be submitted to your state officials. To learn where and how to submit a complaint within your state please visit our FAQ page available here

In addition you can submit your complaint to: Secretary of the U.S. Department of Health and Human Services Attention : Regional Manager 50 United Nations Plaza, Room 322 San Francisco, California 94102 For additional information, call (800) 368-1019 or U.S Office of Civil Rights (866) 627-7748 (Voice) or (866) 788-4989 (TTY)

Acknowledgement of Consent

BY CHECKING THE BOX CORRESPONDING TO THIS PATIENT CONSENT, I UNDERSTAND AND AGREE TO THE FOLLOWING: All medical care and treatment I or my child receive from Providers using the Alpha Website will be provided using telehealth and my Providers will not be able to provide any medical care and treatment to me/my child without the use of telehealth. The delivery of healthcare services via telehealth is an evolving field and the use of telehealth in my/my child’s medical care and treatment from Providers may include uses of technology not specifically described in this Patient Consent. While the use of telehealth may provide potential benefits to me, as with any medical care service (in-person or using telehealth technology) no such benefits or specific results can be guaranteed. There are certain potential risks to me in the use of telehealth, including but not limited to the risks described in this Patient Consent. I have the right to withhold or withdraw my consent to the use of telehealth at any time by terminating my use of the Alpha Website. I understand I may request a physical copy of my/my child’s medical record at any time. In certain instances, I understand that Alpha may be unable to provide me with a minor child’s medical records due to state or federal law. I have read the Privacy Policy on the Alpha Website, and I understand that my medical information is subject to all applicable laws regarding the confidentiality of healthcare information. I am responsible for providing all information relevant to my medical care, including all relevant information to my/my child’s Provider. My Provider may determine in his or her sole discretion that my/my child’s condition is not suitable for treatment using the Alpha Website and that I/my child may need to seek medical care and treatment from a specialist or other healthcare provider outside of the Alpha Website.

I represent that I have read this Patient Consent carefully, understand the benefits and risks of the use of telehealth in the medical care and treatment provided to me/my child by Providers using the Alpha Website, and give my informed consent to the use of telehealth by Providers using the Alpha Website.

Last updated on 12/09/2020