Telehealth Authorization

The purpose of this form is to provide you with information about telehealth and to obtain your informed consent for a telehealth consultation. If you so consent, a telehealth company listed in Attachment A to this Telehealth Authorization (a “Telehealth Group”) will use telehealth technology to allow a health care provider (“Provider”) to deliver healthcare services to you. This service is not to be used for urgent or emergency consultations. Nor is it a replacement for primary care services.

Nature Of Telehealth: Telehealth is the use of electronic information and communication technologies to enable a healthcare provider and a patient at different locations to share medical information, including, for example, for the purpose of evaluation and consultation regarding certain healthcare screening results. The delivery of healthcare via telehealth allows the patient and provider to establish a relationship, much as they would during a traditional face-to-face appointment. For example, your telehealth encounter may include interaction through and with the use of some of the following technologies: synchronous video (e.g. videoconferencing) and/or asynchronous technology, such as store-and-forward technology to exchange medical data and secure messaging portal communication.

Benefits & Risks: The benefits of telehealth include improved access to health services and care, including the expertise of specialists and consultants who may not otherwise be available to you. There are potential risks to using telehealth technology, including interruptions to the connection, images and other information transmitted may not be clear enough to be useful for the consultation, unauthorized access, and technical difficulties. However, either the Provider or you can discontinue your telehealth visit if the telehealth technologies are not adequate for the situation or if the information obtained via telehealth was not sufficient or if telehealth is inappropriate for any reason. Other potential risks to using telehealth services include breach of privacy of protected health information due to security breaches or failures, as well as adverse drug interactions, allergic reactions, complications, or other errors due to a patient’s failure to provide complete medical information or records.

Alternatives: Alternative methods of care, such as in-person services, may be available to you. You may choose an alternative at any time.

Your Privacy Rights: The Telehealth Group uses security protocols to protect the confidentiality of your patient health information. Personal information that identifies you or contains protected health information will not be disclosed to any third party without your consent, except as permitted or authorized by law for the purposes of consultation, treatment, payment/billing, and certain administrative purposes, or as otherwise set forth in the Telehealth Group’s Privacy Policy and Notice of Privacy practices.

Follow-Up Care; Emergencies: The Telehealth Group does not provide primary care services. If a technical failure prevents you from communicating with the Telehealth Group and/or a Provider, or if you believe telehealth will not provide sufficient safety and quality, you should contact us as indicated below. In the event of an urgent health issue or concern, you must seek care in-person, at a facility or provider equipped to deliver urgent or emergent care.

IF THE SITUATION IS AN EMERGENCY, YOU MUST CALL 911.

General Terms

I understand that telehealth involves the use of electronic information and communication technologies by a Provider to deliver services to a patient when the patient is located at a different site than the Provider, and I hereby consent to the Telehealth Group(s) delivering health care services to me via telehealth.
I understand that telehealth technology will be used in connection with my screening, assessment or management and have been given the opportunity to ask questions regarding the technology.
I understand that this visit will not be the same as an in-person visit due to the fact that I will not be in the same physical location as the Provider, who will be at a distant site. I further understand that the Provider will determine whether telehealth is appropriate for me at this time.
I understand that I may benefit from telehealth, but that results cannot be guaranteed. I further understand that my telehealth visit will involve review of my medical data for screening, assessment or management purposes, and that I am responsible for any follow-up with my primary care provider or another specialist regarding any results, concerns, or abnormalities that may be identified based on my screening, assessment or management by the Provider. In addition, a summary of my visit may also be sent to my primary care provider of record in order to facilitate continuing care.
I understand that the Provider will inform me who will be present at the Provider’s location during the telehealth service, and I have the right to exclude anyone from being present, if I so choose.
I understand that the laws that protect privacy and the confidentiality of medical information also apply to telehealth. I understand that I have the right to inspect and obtain copies of all information received and recorded during any telehealth session, subject to the policies of the providers involved in my care. I may be charged a fee for copies of records in accordance with applicable State rules.
I understand that I have the right to withhold or withdraw my consent to the use of telehealth at any time, without affecting my right to future care. I may revoke my consent orally or in writing at any time by contacting Katherine Cary at: support@katherine.com.
I understand that the Provider has a financial relationship with the Telehealth Group(s) and that I am free to obtain a consultation elsewhere.
I understand that I will be responsible for any payments that apply to my telehealth visit. I understand that I may submit claims for these services to any commercial health insurance plan. I also understand that these services will not be reimbursable by any government health insurance plan. I further understand that neither the Provider, Telehealth Group, Katherine Cary, nor any facility through which I obtain any imaging, lab work, or testing will submit or facilitate the submission of any claims to my health insurer or other medical benefit plan.

Consent to Receive Telehealth Services

I authorize the Telehealth Group(s) to provide healthcare services to me via telehealth (including by video, telephone, email, and text message).
I understand that telehealth services involve certain risks, including potential privacy risks, and that no specific outcomes or results are guaranteed.
I understand that the Telehealth Group(s) are providing limited medical services under the Katherine Cary program and are not acting as my primary care provider.
I understand that the Telehealth Group(s) do not manage chronic controlled substances (such as opioids, benzodiazepines, or stimulants).

Privacy Practices and Communication Authorization

I authorize the Telehealth Group(s) to communicate with me via email, text message, and other electronic means for clinical, administrative, and scheduling purposes.
I acknowledge that electronic communications may not be encrypted or fully secure despite reasonable safeguards.
I understand that I may revoke this authorization at any time by providing written notice.

Limited Scope of Services

I understand that the services provided are limited to the Katherine Cary weight management program.
I agree to seek additional medical care from my primary care provider or other specialists as needed.

Authorization to Share Information

I authorize Katherine Cary, Inc. to share my completed questionnaires, intake information, signed consents, and relevant clinical data with the Telehealth Group(s) for the purpose of providing medical care under this program.

Acknowledgment and Consent

By clicking to accept or proceed during the enrollment process on Katherine.com, I acknowledge and agree that:

I have read and understand all of the information provided above, including the risks and benefits of receiving telehealth services through the Telehealth Group(s) under the Katherine Cary program.
I consent to receive services from the Telehealth Group(s), including via telehealth.
I authorize communication and sharing of my information as outlined above.
I understand and agree that this action constitutes my electronic signature, made pursuant to the federal E-SIGN Act and applicable state laws.

Attachment A

List of Telehealth Groups

1. Buoyant, LLC
- a. Phone #: (678) 835-2596
- b. Hours of Operation: Monday to Friday, 9am - 5pm (except federal Holidays)
2. Beluga Health, P.A.
- a. Phone #: (332) 333-3735
- b. Hours of Operation: Monday to Friday, 9am - 5pm (except federal Holidays)