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, the telehealth provider (“Provider”) will use telehealth technology 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 Provider 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 Beluga Health, P.A.’s Privacy Policy and Notice of Privacy practices.

Follow-Up Care; Emergencies: The Provider does not provide primary care services. If a technical failure prevents you from communicating with the 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.

Phone #: +1 646 819 0309
Hours of Operation: Monday to Friday, 9am - 5pm (except federal Holidays)

By signing this form, I understand that telehealth involves the use of electronic information and communication technologies by a healthcare 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 Provider(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.

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. 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 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 us at:

  • I understand that the Provider has a financial relationship with Beluga Health, P.A. 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, Beluga Health, P.A. 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.
  • I have read and understand the information above and all of my questions have been answered to my satisfaction.
  • I have read, understand, and agree to the terms of the Beluga Health Privacy Policy and Terms of Service.

The Practice may communicate with me, including about my personal medical information, using the methods outlined in the Terms of Service, including without limitation, by email, by leaving me a voicemail message, and by texting me at the mobile number I have provided.

I understand that the above methods of unencrypted communication will be used to communicate with me about Beluga Health, P.A.’s services, for my own convenience, and I accept all risks associated with them (including, without limitation, risks of improper exposure of my medical information). I have read the Terms of Service and Privacy Policy.

For purposes of this informed consent, I understand and agree that checking the box above shall constitute my electronic signature.

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