Allara Medical Group, P.A.Telehealth Informed Consent 

• Appointment scheduling;
• Completion, exchange, and review of medical intake forms and other clinically relevant information (for example: health records; images; output data from medical devices; sound and video files; diagnostic and/or lab test results) between you and your Provider via:
  - asynchronous communications;
  - two-way interactive audio in combination with store-and-forward communications;
  - and/or two-way interactive audio and video interaction;
• Treatment recommendations by your Provider based upon such review and exchange of clinical information;
• Delivery of a consultation report with a diagnosis, treatment and/or prescription recommendations, as deemed clinically relevant;
• Delivery of a consultation report with a diagnosis, treatment and/or prescription recommendations, as deemed clinically relevant;
• Communications and exchange of information with your health plan if applicable;
• Communications and exchange of information with your other providers if applicable;
• Prescription refill reminders (if applicable); and/or
• Other electronic transmissions for the purpose of rendering clinical care to you.

• Improved access to care by enabling you to remain in your preferred location while your Provider consults with you.  Our telehealth services are available approximately 10 hours a day, 7 days a week.
• Convenient access to follow-up care.  If you need to receive non-emergent follow-up care related to your treatment, please contact your Provider or Patient Concierge team vial messaging.
• More efficient care evaluation and management. Emails and messages can be sent 24/7 and will be responded to within 24 hours.

• 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 ASTRID HEALTH, INC., GROUP, OR YOUR PROVIDER.  AFTER RECEIVING EMERGENCY HEALTHCARE TREATMENT, YOU SHOULD VISIT YOUR LOCAL PRIMARY CARE PROVIDER.
• Our 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.
• Group does not have any in-person clinic locations.

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.  All the Services delivered to the patient through telehealth will be delivered over a secure connection that complies with the requirements of the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”). However, we cannot promise that data sent over the Internet or through a data storage facility will be perfectly secure. So, although we try to protect your personal information, we cannot guarantee the security of any information you send to us. You agree to take on the risk for information lost due to technology problems.
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We may share your health records with the following individuals under the following circumstances:

• With your other health care providers (including your primary care provider), either directly or through our participation in health information exchanges, and for healthcare coordination, operations and treatment purposes. This may include information relating to genetic tests, substance abuse, mental health, communicable diseases and other health conditions. 
• With other individuals involved in your care such as caregivers or family members.  
• With your health plan, either directly or through our participation in health information exchanges, and for healthcare payment, coordination, operations and treatment purposes (such as eligibility verification, processing your claims, and audits of our services). This may include information relating to genetic testing, substance abuse, mental health, communicable diseases and other health conditions.
• As otherwise permitted in our Health Information Privacy Practices and by applicable law.  

• Delays in evaluation and treatment could occur due to deficiencies or failures of the equipment and technologies, or provider availability.
• In the event of an inability to communicate as a result of a technological or equipment failure or other follow-up care, please contact the Group at concierge@allarahealth.com.
• In rare events, your Provider may determine that the transmitted information is of inadequate quality or that Provider does not have enough information to make healthcare decisions, thus necessitating a rescheduled telehealth consult or an in-person meeting with your local primary care doctor.
• In very rare events, security protocols could fail, causing a breach of privacy of personal medical information.

Each bill for all charges must be paid by the date shown on the bill. Your insurance may cover some of our offered services. You understand that if your health insurance coverage does not cover the charges for your services in full, you may be fully or partially responsible for payment. If you have to pay a deductible, copayment or coinsurance for your healthcare, the usual cost-sharing rules will apply.

You agree that all people or companies (third parties) who pay any part of your Group bill shall and are authorized to pay these amounts directly to Group (instead of you). You agree that we may submit claims to such insurance or other third parties on your behalf. You understand that you must pay Group any costs not paid by your insurance or other third parties (“Your Costs”), unless state or federal regulations do not allow this.

By initially providing us with your credit card information and associated billing information, you are authorizing us to save on file and charge your credit card for agreed upon purchases and your continued use of the services (e.g. Subscription Fees, Your Costs including any copayments, deductibles and co-insurance, etc. for any and all visits with us) with no additional consent required by you. If your health plan has arranged with us to pay the fee or any portion of the fee, or if the fee is pursuant to some other arrangement with us, that fee adjustment will be reflected in the fee that you are ultimately charged.   


As part of providing services, we will communicate with you via SMS text messages and emails, including for purposes such as informational, clinical, product or service-related reminders and announcements. If you have provided us with a cell phone number and email address, we may send you SMS text messages and emails. Text messages and emails are not always secure because they travel over unencrypted networks that we do not control.

By signing below and providing us your cell phone number and email address, you permit us to communicate with you by SMS text message and email as further described in the Allara Terms of Use.  To stop receiving text messages, text a reply to us with the word STOP. You understand that you may have to pay data costs to receive SMS text messages that we send to your mobile phone.  

Practice Policies:

We understand you may have to reschedule or cancel an appointment from time to time. We ask that you notify us at least 24 hours in advance of your scheduled appointment. If you fail to notify us within this 24-hour window, we reserve the right to charge you for any missed appointments. 

If you repeatedly miss scheduled appointments or you fail to pay for appointments with us, you understand that you may be terminated from the Group and no longer have access to your Provider(s). 

By checking the “Agree” box you accept all of the terms and conditions set forth in this Consent to Telehealth, and you acknowledge your understanding and agreement to the following:

1. Prior to the telehealth visit, I will be given an opportunity to select a provider as appropriate, including a review of the provider’s credentials, or I have elected to visit with the next available provider from Group, and have been given my Provider’s credentials.
2. If I am experiencing a medical emergency, I will be directed to dial 9-1-1 immediately and my Provider is not able to connect me directly to any local emergency services.
3. I may elect to seek services from a medical group with in-person clinics as an alternative to receiving telehealth services.
4. 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.
5. Federal and state law requires health care providers to protect the privacy and the security of health information.  I am entitled to all confidentiality protections under applicable federal and state laws.  I understand all medical reports resulting from the telehealth visit are part of my medical record.  
6. Group will take steps to make sure that my health information is not seen by anyone who should not see it. Telehealth may involve electronic communication of my personal health information to other health practitioners who may be located in other areas, including out of state.
7. Dissemination of any patient identifiable images or information from the telehealth visit to researchers or other educational entities will not occur without my affirmative consent.
8. There is a risk of technical failures during the telehealth visit beyond the control of Group.  I AGREE TO HOLD HARMLESS GROUP 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.
9. In choosing to participate in a telehealth visit, I understand that some parts of the Services involving tests (e.g., labs or bloodwork) may be conducted at another location such as a testing facility, at the direction of my Provider.
10. Persons may be present during the telehealth visit other than my Provider in order to operate the telehealth technologies. If another person is present during the telehealth visit, I will be informed of the individual’s presence and his/her role.
11. My Provider will explain my diagnosis and its evidentiary basis, and the risks and benefits of various treatment options.
12. I have the right to request a copy of my medical records.  I can request to obtain or send a copy of my medical records to my primary care or other designated health care provider by contacting Group at concierge@allarahealth.com.  A copy will be provided to me at reasonable cost of preparation, shipping and delivery.  
13. It is necessary to provide my Provider a complete, accurate, and current medical history.  I understand that I can log into my “Portal” linked at allarahealth.com at any time to access, amend, or review my health information.
14. There is no guarantee that I will be issued a prescription and that the decision of whether a prescription is appropriate will be made in the professional judgement of my Provider.  If my Provider issues a prescription, I have the right to select the pharmacy of my choice.
15. There is no guarantee that I will be treated by a Group provider. 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.  

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

Texas: I have been informed of the following notice:
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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.  
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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