Telehealth Informed Consent

Services Provided

Electronic Transmissions

The types of electronic transmissions that may occur using the telehealth platform include, but are not limited to:

• Appointment scheduling;
• Completion, exchange, and review of clinical intake forms and other clinically relevant information (for example: health records; images; AI chats, text messages, 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 and/or treatment recommendations, as deemed clinically relevant and within Provider's scope of practice; and/or
• Other electronic transmissions for the purpose of rendering clinical care to you.
• Clara Health uses artificial intelligence (AI) technology to assist in generating clinical communications, health assessments, and care recommendations. All AI-assisted clinical content is reviewed and approved by a licensed healthcare provider before being delivered to you.

Expected Benefits

• Improved access to careby enabling you to remain in your preferred location while your Provider consults with you. Our telehealth services are accessible 24 hours a day, 7 days a week, allowing you to submit messages, access your health records, and manage your care at any time. Clinical responses are typically provided within 24 hours during normal business hours (Monday – Friday, 8:00 AM – 5:00 PM).
• Convenient access to follow-up care. If you need to receive non-emergent follow-up care related to your treatment, please contact your Provider by visiting your patient dashboard and sending a secure message or scheduling a follow-up appointment.
• More efficient care evaluation and management.Patients can access further follow-up care with their Provider by booking an appointment in their patient dashboard. Providers are typically available for appointments on Monday – Friday, 8:00 AM – 5:00 PM.

Service Limitations

Security Measures

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”).

Possible Risks

• 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, please contact the Group at support@askclara.com.
• In rare events, your Provider may determine that the transmitted information is of inadequate quality, thus necessitating a rescheduled telehealth consult or an in-person meeting with your local in-person provider.
• In very rare events, security protocols could fail, causing a breach of privacy of personal health information.

Patient Acknowledgments

I further acknowledge and understand the following:

1. Prior to the telehealth visit, I have elected to visit with the next available Provider from the Group.
2. I understand that I may be asked to provide my identification and confirm my physical location prior to or during the telehealth visit.
3. 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.
4. I may elect to seek services from a group with in-person clinics as an alternative to receiving telehealth services from the Group.
5. 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.
6. 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 reports resulting from the telehealth visit are part of my patient health record.
7. The 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. I consent to the Group using and disclosing my health information for purposes of my treatment and care coordination, to receive reimbursement for the Services provided to me, and for the Group's healthcare operations.
8. Dissemination of any patient-identifiable images or information from the telehealth visit to researchers or other educational entities will not occur without my consent unless authorized by state or federal law.
9. There is a risk of technical failures during the telehealth visit beyond the control of the Group.
10. Persons may be present during the telehealth visit other than my Provider who will be participating in, observing, or listening to my consultation with my Provider (e.g., 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 understand that by creating a treatment plan for me, my Provider has reviewed my clinical history and clinical information and, in my Provider's professional assessment, has made the determination that the provider is able to meet the same standard of care as if the health care services were provided in-person when using the selected telehealth technologies, including but not limited to, asynchronous store-and-forward technology.
13. I have the right to request a copy of my health records. I can request to obtain or send a copy of my health records to my primary care or other designated healthcare provider by contacting support@askclara.com. A copy will be provided to me at reasonable cost of preparation, shipping and delivery.
14. It is necessary to provide my Provider a complete, accurate, and current clinical history. I understand that I can log into my “Portal” at any time to access, amend, or review my health information.
15. There is no guarantee that I will be treated by a Provider of the Group. 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 clinically or ethically appropriate.

Additional State-Specific Consents

The following consents apply to patients accessing the Group's website for the purposes of participating in a telehealth consultation as required by the states listed below: