Register with Functional Medicine of Idaho

Functional Medicine of Idaho, LLC, ("Functional Medicine of Idaho") through its Physician(s) and Physician Assistant(s), collectively the "Physician(s)", agrees to provide Patient with the Services described in this Agreement on the terms and conditions set forth in this Agreement.

1. Patient. A patient is defined as those persons for whom the Physician(s) shall provide Services, and who are signatories to, or listed on the Patient Registration Form that is incorporated by reference in this Agreement.
2. Services. As used in this Agreement the term Services shall mean a package of services, both medical and non-medical, and certain amenities (collectively "Services"), offered by Functional Medicine of Idaho, subject to change without further notice and further described at AppletonClinics.com and the Patient Registration Form.
3. Fees. In exchange for the services described herein, Patient agrees to pay Functional Medicine of Idaho the amounts as set forth in the Patient Registration Form. These fees are payable upon execution of this Agreement, and are in payment for the services provided to Patient during the term of this Agreement. If this Agreement is cancelled by Functional Medicine of Idaho before the Agreement termination date, then Functional Medicine of Idaho shall refund the Patient's prorated share of the original payment remaining after deducting individual charges for services rendered to Patient up to cancellation. If Patient cancels this Agreement, no refunds will be given. In any event, no refunds will be given for registration fees paid.
4. Non-Participation in Insurance. Patient acknowledges that neither Functional Medicine of Idaho nor the Physician(s) participate in any health insurance or HMO plans or panels and all have opted out of Medicare. Neither of the above make any representations whatsoever that any fees paid under this Agreement are covered by any health insurance or other third- party payment plans applicable to the Patient. The Patient shall retain full and complete responsibility for any such determination. If the Patient is eligible for Medicare, or during the term of this Agreement becomes eligible for Medicare, then Patient will sign the opt out agreement and incorporated by reference. This agreement acknowledges your understanding that the Physician has opted out of Medicare, and as a result, Medicare cannot be billed for any services performed for you by the Physician. You agree not to bill Medicare or attempt Medicare reimbursement for any such services. Patient shall renew and sign the opt out agreement each year.
5. Insurance or Other Medical Coverage. Patient acknowledges and understands that this Agreement is not an insurance plan, and not a substitute for health insurance or other health plan coverage (such as membership in an HMO). Functional Medicine of Idaho will not cover hospital services, specialist visits, emergency room visits, surgeries, advanced radiology and imaging, worker's compensation claims or any other services not personally provided by Functional Medicine of Idaho or its Physicians. Patient acknowledges that Functional Medicine of Idaho has advised that patient obtain or keep in full force such health insurance policy (ies) or plans that will cover Patient for general healthcare costs. Patient acknowledge that this Agreement is not a contract that provides health insurance, and this Agreement is not intended to replace any existing or future health insurance or health plan coverage that Patient may carry.
6. Medical Services. As used in this Agreement, the term Medical Services shall mean those medical services that the Physician is permitted to perform under the laws of the State of Colorado and/or Idaho and that are consistent with the training and experience of a family medicine physician, as the case may be. A list of current services offered is available at AppletonClinics.com and is subject to change without further notice.
7. Availability. The Physician may, from time to time, due to vacations, sick days, and other similar situations, not be available to provide the services referred to above in this paragraph 6. During such times, Patient's calls to the Physician, or to the Physician's office, will be directed to a licensed medical provider who is "covering'' for the Physician during his absence. Functional Medicine of Idaho will make every effort to arrange for coverage but cannot guarantee such coverage.
8. Pharmacy services. Functional Medicine of Idaho has an on-site limited pharmacy. Patient is free to fill prescriptions at any pharmacy of their choice. If Patient elects to have the prescription filled at Functional Medicine of Idaho, the cost of the medication will be charged to Patient and collected as any other fees are collected. Functional Medicine of Idaho will not bill any insurance or other entity for medication costs.
9. Third-Party Referrals and Preferred Rates. Physician may elect to coordinate with third party medical specialists to whom Patient is referred and may assist Patient in obtaining specialty care. Patient understands that fees paid under this Agreement do not include and do not cover specialists' fees or fees due to any third-party medical professional other than the Functional Medicine of Idaho Physician(s). In the event Functional Medicine of Idaho is able to negotiate a preferred rate on behalf of Patient for third party services (including, but not limited to advanced imaging, specialist visits, laboratory work, hospitalizations and other third-party medical services), and such preferred rates require Functional Medicine of Idaho to collect payment for services on behalf of the third party, such payments shall be paid by You to Functional Medicine of Idaho in advance of Patient receiving such services. Any such payments on behalf of a Patient do not create any obligation on behalf of Functional Medicine of Idaho other than to pay the third-party provider. Patient is under no obligation to use such referrals.
10. Term; Termination. This Agreement will commence on the date first written above and will extend monthly thereafter. Notwithstanding the above, both Patient and Functional Medicine of Idaho shall have the absolute and unconditional right to terminate the Agreement, without the showing of any cause for termination, upon giving 30 days' prior written notice to the other party. Unless previously terminated as set forth above, at the expiration of the initial one-month term (and each succeeding monthly term,) the Agreement will automatically renew for successive monthly terms upon the payment of the monthly fee for the contract month. Alternatively, if the parties agree to provide and accept a membership on an annual basis, such termination and renewal policies shall adjust to an annual basis instead of a monthly basis.
11. Electronic Communications. You acknowledge that communications with the Physician using e-mail, facsimile, video chat, texting instant messaging and cell phone (collectively, "Electronic Communications") are not guaranteed to be secure or confidential methods of communications. As such, You expressly waive the Physician's obligation to guarantee confidentiality with respect to correspondence using such means of communication. You acknowledge that all such communications may become a part of your medical records. Patient authorizes Functional Medicine of Idaho, and its Physicians to communicate with Patient by Electronic Communications regarding Patient's "protected health information" (PHI) (as that term is defined in the Health Insurance Portability and Accountability Act (HIPAA) of 1996 and its implementing regulations).
    Patient further acknowledges that:
    1. Electronic Communications are not necessarily secure mediums for sending or receiving PHI and, there is always a possibility that a third party may gain access;
    2. Although Functional Medicine of Idaho and the Physician will make all reasonable efforts to keep Electronic Communications confidential and secure, neither Functional Medicine of Idaho nor the Physician can assure or guarantee the absolute confidentiality of Electronic Communications;
    3. In the discretion of the Physician(s), Electronic Communications may be made a part of Patient's permanent medical record; and,
    4. Electronic Communications are not an appropriate means of communication regarding emergency or other time-sensitive issues or for inquiries regarding sensitive information. In the event of an emergency, or a situation in which Patient could reasonably expect to develop into an emergency, Patient shall call 911 or the nearest emergency room, and follow the directions of emergency personnel.
    5. If Patient does not receive a response to an Electronic Communication within one day, Patient must use another means of communication to contact the Physician(s). Neither Functional Medicine of Idaho nor the Physician(s) will be liable to Patient for any loss, cost, injury, or expense caused by, or resulting from, a delay in responding to Patient as a result of technical failures, including, but not limited to,
       1. technical failures attributable to any internet service provider,
       2. power outages, failure of any electronic messaging software, or failure to properly address e-mail or text messages,
       3. failure of the Clinic's computers or computer network, or faulty telephone or cable data transmission,
       4. any interception of Electronic Communications by a third party; or
       5. your failure to comply with the guidelines regarding use of Electronic Communications as set forth in this paragraph.
12. Change of Law. If there is a change of any law, regulation or rule, federal, state or local, that affects the Agreement including these Terms & Conditions, that are incorporated by reference in the Agreement, or the activities of either party under the Agreement, or any change in the judicial or administrative interpretation of any such law, regulation or rule, and either party reasonably believes in good faith that the change will have a substantial adverse effect on that party's rights, obligations or operations associated with the Agreement, then that party may, upon written notice, require the other party to enter into good faith negotiations to renegotiate the terms of the Agreement including these Terms & Conditions. If the parties are unable to reach an agreement concerning the modification of the Agreement within forty-five days after of date of the effective date of change, then either party may immediately terminate the Agreement by written notice to the other party.
13. Severability. If for any reason any provision of this Agreement shall be deemed, by a court of competent jurisdiction, to be legally invalid or unenforceable in any jurisdiction to which it applies, the validity of the remainder of this Agreement shall not be affected, and that provision shall be deemed modified to the minimum extent necessary to make that provision consistent with applicable law and in its modified form, and that provision shall then be enforceable.
14. Reimbursement for services rendered. If this Agreement is held to be invalid for any reason, and if Functional Medicine of Idaho is therefore required to refund all or any portion of the monthly fees paid by Patient, Patient agrees to pay Functional Medicine of Idaho an amount equal to the reasonable value of the Services actually rendered to Patient during the period of time for which the refunded fees were paid.
15. Amendment. No amendment of this Agreement shall be binding on a party unless it is made in writing and signed by all the parties. Notwithstanding the foregoing, Functional Medicine of Idaho may unilaterally amend this Agreement to the extent required by federal, state, or local law or regulation ("Applicable Law") by sending You 30 days advance written notice of any such change. Any such changes are incorporated by reference into this Agreement without the need for signature by the parties and are effective as of the date established by Functional Medicine of Idaho, except that Patient shall initial any such change at Functional Medicine of Idaho' request. Moreover, if Applicable Law requires this Agreement to contain provisions that are not expressly set forth in this Agreement, then, to the extent necessary, such provisions shall be incorporated by reference into this Agreement and shall be deemed a part of this Agreement as though they had been expressly set forth in this Agreement.
16. Assignment. This Agreement, and any rights Patient may have under it, may not be assigned or transferred by Patient.
17. Relationship of Parties. Patient and the Physician(s) intend and agree that the Physician(s), in performing his/her duties under this Agreement, is an independent contractor, as defined by the guidelines promulgated by the United States Internal Revenue Service and/or the United States Department of Labor, and the Physician(s) shall have exclusive control of his/her work and the manner in which it is performed.
18. Legal Significance. Patient acknowledges that this Agreement is a legal document and creates certain rights and responsibilities. Patient also acknowledges having had a reasonable time to seek legal advice regarding the Agreement and has either chosen not to do so or has done so and is satisfied with the terms and conditions of the Agreement.
19. Miscellaneous. This Agreement shall be construed without regard to any presumptions or rules requiring construction against the party causing the instrument to be drafted. Captions in this Agreement are used for convenience only and shall not limit, broaden, or qualify the text.
20. Entire Agreement. This Agreement contains the entire agreement between the parties and supersedes all prior oral and written understandings and agreements regarding the subject matter of this Agreement.
21. Jurisdiction. This Agreement shall be governed and construed under the laws of the State of Colorado and all disputes arising out of this Agreement shall be settled in the District Court of Mesa County, Colorado.

Financial Agreement

Please read and sign the following policies and procedures of our office regarding the collection of any account balances.

Procedure

1. Payment is required at the time of service for all co-pays and current account balances.
2. We require a credit card to be one file for copays and other designated fees.
3. For self-pay patients, if you are unable to pay in full at the time of service, then we require a deposit of $150 that will go toward the charges for the services provided. For services such as lab work, payment in full will be due at the time of service.
4. We do not accept any insurance plans that are out of network with our facility.  We can provide a detailed receipt for services performed for you to submit to your insurance carrier directly.
5. You will receive a monthly statement reflecting any balance on your account.  Any balances owed must be paid within 30 days. Once an account balance is over 60 days past due, you will be considered for collection referral.
6. It is your responsibility to have a current address and phone number on file with our office to receive statements. It is also your responsibility to notify us of any updates on your insurance information prior to receiving services.
7. If you account is 120 days past due, you will be sent a letter warning you of your delinquent account.  If your account balance is not paid in full by the date specified in the letter, your account will be turned over to a collection agency.  Once your account is turned over to a collection agency, we will cover any emergency care and refill prescriptions for 30 days. After 30 days, you will no longer be a patient in our office.
8. We recommend that you keep and learn to read the explanation of benefits (EOB) you receive from your insurance company regarding your medical claim payments.  If you have any questions regarding your statement or your EOB, we are happy to help.

Other Fees and Policies

1. We require 48 business hours notice to reschedule or cancel any appointment. There is a $150.00 fee for missed New Patient appointment. Established Patient appointmentss are $100, and missed Nutrition appointments are $50. It is your responsibility to keep track of your appointments. Please be advised if you cancel and/or no-show multiple appointments then your provider may discharge you from care. Initial Here
2. In addition to your co-pay, there will be a $150 deductible retainer due at the time of service if you have not yet met your policy's deductible. This retainer will be applied to the total cost of your appointment. If you have met your policy's deductible, or if this is a wellness exam covered by your insurance policy, the $150 will not be applied.
3. If you are paying through a Health Savings Account (HSA) or Flex Spending, payment is still due at the time of service and you are responsible to pay your account balance within 30 days of receiving a statement.  When we take your payment in office, we can give you a receipt to send to your HSA or Flex Spending to seek reimbursement. We are able to run most HSA cards in our office.
4. 3. There will be an additional $25.00 charge for all returned checks.
5. If you need a copy of your entire chart, there is a minimum $25.00 charge .  We do not charge for current labs or recent notes needed by other physicians.  Please allow 30 days for your chart to be copied.
6. Any fees incurred other than office visits and labs cannot be billed to your insurance.

Financial Responsibility

I understand that I am financially responsible for the payment of medical charges incurred on my behalf with any medical provider at Functional Medicine of Idaho regardless of third party coverage. I further give Functional Medicine of Idaho authority to charge my credit card for copays, cancellation, and no show fees.

I have read and understand this policy.

Consent for Treatment and HIPAA Consent

I request and authorize health care service by any provider at Functional Medicine of Idaho and their designee(s) as my provider may deem advisable and in my best interest. This may include routine diagnostic, telemedicine, radiology and laboratory procedures, and medication administration.

I understand that excluding emergency or extraordinary circumstances, no substantial procedures will be performed without providing me an opportunity to give informed consent. Informed consent means the medical provider must disclose information to me including expected benefits and risks of a particular procedure and/or treatment. This understanding includes that no research or experimental procedures may be done without my knowledge and consent.

By participating in Shared Medical Visits at Functional Medicine of Idaho, I understand that in the course of the class, my personal medical information may be shared if I so choose with others attending the group. I will not be required to share any personal medical information beyond my personal comfort. I also agree not to share other attendees personal medical information outside of the class discussion.

HIPAA Policy

The Health Insurance Portability and Accountability Act (HIPAA) provide safeguards to protect your privacy. Functional Medicine of Idaho has developed privacy practices based on HIPAA. These practices are outlined in our Notice of Privacy Practices (NPP) that provides explanation of your individual rights with respect to your personal health information. Please take a few minutes to review our NPP.

Please initial here that you have been provided with access to our Notice of Privacy Practices.

If you wish to disclose your health information, please designate those individuals below.

I choose to disclose all of my financial and billing information with the following persons: I choose to disclose all of my medical information with the following persons: Other: Emergency Contact:

Lab Information

COST:
In order to have an estimate of the cost of your labs, please reach out to the lab where you plan to be drawn for the CPT codes & lab specific pricing. Only YOUR insurance will be able to tell you what is covered and what is not. Insurance is less likely to cover the entirety of labs ordered since they are functional in nature. This varies by plan and payer so please call your insurance so that you know beforehand what to expect regarding what your coverage will be. If your insurance does NOT cover the labs ordered, we recommend calling the lab you plan to be drawn at to get a price estimate. Your lab order has been uploaded to your patient portal, which you may use for the process above. We recommend calling your insurance to ask what labs have the highest coverage for your personal plan. We anticipate prices for your lab work should be similar or slightly less with LabCorp. LabCorp's insurance capabilities with UHC, Aetna and Regence show patient savings by using LabCorp. For those of you that have the Blue Cross Federal Plan, you may ONLY utilize LabCorp's Eagle Road location at 1965 S Eagle Road Suite 130, Meridian ID 83642 due to credentialing reasons.

"WHERE CAN I GET MY LABS DRAWN?".... Wherever you'd like!

• LabCorp
  To find a location near you go to: https://locations.labcorp.com/id/meridian/23329/
  They schedule lab draws appointments, but also take walk-ins. We have LabCorp draw stations in our Boise and Meridian locations which are WALK IN APPOINTMENTS only.


• Express Lab
  Please call (208) 472-1082 or visit https://www.expresslabidaho.com/locations-clinical-medical-laboratory-idaho-falls-pocatello-rexburg/ for draw station locations.


• Interpath Lab
  Locations can be found at: https://www.interpathlab.com/locations/


• Other lab options may be used such as St. Luke's, St. Al's, Quest Diagnostics etc.

**If you go to a lab other than LabCorp, please print the order in your patient portal and take it to the lab with you.This is the only way they will know what labs need to be drawn.**

If in network with your insurance, we recommend being drawn at LabCorp as we have a partnership that allows your results to be automatically electronically uploaded into our records system. If another lab is utilized, please let our team know via portal message so that we can track down those results. In this case, you may need to fill out a request for medical records in the patient portal to allow those facilities to send us your results.

**Please have your labs drawn at least 3-4 weeks prior to your follow up appointment to ensure we have your results**

If you have any questions, feel free to reach out to our team! Thank you!

Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

This notice describes our practices and

• Any health care professional authorized to enter information into your chart.
• Any member of a volunteer group we allow to help you while you are in the office.
• All employees, staff and other personnel.

All these entities, sites and locations follow the terms of this notice. In addition, these entities, sites and 1ocations may share medica1 information with each other for treatment, payment or health care operations purposes described in this notice.

We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive at the office. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by the office, whether made by office personnel or your personal doctor. Your personal doctor may have different policies or notices regarding the doctor's use and disclosure of your medical information created in the doctor's office or clinic.

This notice will tell you about the ways in which we may use and disclose medical information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of medical information.

We are required by law to:

• Make sure that medical information that identifies you is kept private (with certain exceptions);
• Give you this notice of our legal duties and privacy practices with respect to medical information about you; and
• Follow the terms of the notice that is currently in effect.

How We May Use and Disclose Medical Information about You

The following categories describe different ways that we use and disclose medical information. For each category of uses or disclosures we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.

At Your Request

We may disclose information when requested by you. This disclosure requires a written consent.

For Treatment

We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, health care students, or other office personnel who are involved in taking care of you at the office. For example, a doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. In addition, the doctor may need to tell the dietitian if you have diabetes so that we can arrange for appropriate meals. The office also may share medical information about you in order to coordinate the different things you need, such as prescriptions, lab work and X-rays. We also may disclose medical information about you to people outside the center who may be involved in your medical care after you leave the office, such as ski1led nursing facilities, home health agencies, and physicians or other practitioners. For example, we may give your physician access to your health information to assist your physician in treating you.

For Payment

We may use and disclose medical information about you so that the treatment and services you receive at the office may be billed to and payment may be collected from you, an insurance company or a third party. For example, we may need to give your health plan information about surgery you received at the office so your health plan will pay us or reimburse you for the surgery. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment. We may also provide basic information about you and your health plan, insurance company or other source of payment to practitioners outside the office who are involved in your care, to assist them in obtaining payment for services they provide to you.

For Healthcare Operations

We may use and disclose medical information about you for health care operations. These uses and disclosures are necessary to run the office and make sure that all of our patients receive quality care. For example, we may use medical information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also combine medical information about many office patients to decide what additional services the office should offer, what services are not needed, and whether certain new treatments are effective. We may also disclose information to doctors, nurses, technicians, medical students, and other office personnel for review and learning purposes. We may also combine the medical information we have with medical information from other offices to compare how we are doing and see where we can make improvements in the care and services we offer. We may remove information that identifies you from this set of medical information so others may use it to study health care and health care delivery without learning who the specific patients are.

Appointment Reminders

We may use and disclose medical information to contact you as a reminder that you have an appointment for treatment or medical care at the office.

Treatment Alternatives

We may use and disclose medical information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.

Health-Related Products and Services

We may use and disclose medical information to tell you about our healthcare-related products or services that may be of interest to you.

Fundraising Activities

We may use medical information about you, or disclose such information to a foundation related to the office, to contact you in an effort to raise money for the office and its operations. We only would release contact information, such as your name, address and phone number and the dates you received treatment or services at the office. If you do not want the office to contact you for fundraising efforts, you must notify the office administrator in writing.

Office Directory

We may include certain limited information about you in the office directory while you are a patient at the office. This information may include your name, location in the office, your general condition (e.g., good, fair, etc.) and your religious affiliation. Unless there is a specific written request from you to the contrary, this directory information, except for your religious affiliation, may also be released to people who ask for you by name. Your religious affiliation may be given to a member of the clergy, such as a priest or rabbi, even if they don't ask for you by name. This information is released so your family, friends and clergy can visit you in the office and generally know how you are doing.

To Individuals Involved In Your Care or Payment for Your Care

We may release medical information about you to a friend or family member who is involved in your medical care. We may also give information to someone who helps pay for your care.

Unless there is a specific written request from you to the contrary, we may also tell your family or friends your condition and that you are in the office.

In addition, we may disclose medical information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location. If you arrive at the emergency department either unconscious or otherwise unable to communicate, we are required to attempt to contact someone we believe can make health care decisions for you (e.g., a family member or agent under a health care power of attorney).

NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT OF RECEIPT

By signing this form, you acknowledge receipt of the Notice of Privacy Practices. Our Notice of Privacy Practices provides information about how we may use and disclose your protected health information. We encourage you to read it in full.

Our Notice of Privacy Practices is subject to change. If we change our notice, you may obtain a copy of the revised notice by contacting our office.

If you have any questions about our Notice of Privacy Practices, please contact the practice administrator.

I acknowledge receipt of the Notice of Privacy Practices.

Narcotic Agreement

It is the policy that providers employed by Functional Medicine of Idaho, shall not initiate or refill narcotic (opiate pain medications), prescription addictive sleeping pills, tranquilizers or stimulant medications.

Consent For Telehealth Services

For convenience of accessing care, Functional Medicine of Idaho offers remote telehealth consultations between patients and clinicians via a secure video platform. Additionally, your healthcare provider may consult with other providers or specialists remotely about your care via video or phone. Please carefully review this form and indicate your acceptance below.

1. Verification

Identification of the patient by name

Patient date of birth:

Patient physical location at the time of the telehealth visit:

Please be advised that if you are in a state and/or location that the provider does not have sufficient credetialing to practice medicine in, the provider will not be able to continue the appointment.

Health Provider Name: Credentials:

Potential benefits of telehealth include:

• Convenience in accessing your providers from your home or another location.
• Protection against the transmission of communicable illnesses between yourself and other patients and clinic staff.
• Improvements to the quality of care when your clinician can consult with other providers as needed.

Inherent in the use of telehealth are technological risks of disruption to the call or video connection and other technical difficulties. You or the provider may discontinue the telehealth consultation if either of you determine that technical difficulties are too disruptive to continue.

We take strong precautions to safeguard the privacy of your protected health information (PHI), including using only HIPAA-compliant platforms for telehealth. Nevertheless, there is an unavoidable risk of unauthorized access when sending/ receiving PHI electronically (for example, via a video feed). You are solely responsible for ensuring privacy and confidentiality on your side - by conducting the visit in a private space where others cannot overhear and cannot see private information on the screen. We do not record (voice or video) telehealth consultations, but the health care provider will retain a medical record of care in their secure electronic health records system.

Some visits - specifically, those that require the clinician to be physically present with you - are not suitable for telehealth. Your provider may ask that you schedule an in-person visit for any issues that require in-person evaluation or treatment. Telehealth is not a substitute for emergency care. If you need urgent care, call 911 or go to the nearest urgent care facility.

You are responsible for the cost of your telehealth consultation. If you are seeking insurance payment or reimbursement for the visit, note that insurance companies may require that you participate in the telehealth consultation from a hospital, a mental health facility, a physician's office, an adult care facility, or your home.

Patient Consent To The Use of Telehealth

• I have read this form - or had it read and explained to me - in full. I fully understand its contents, including the risks, benefits, and alternatives.
• I have been given opportunity to ask questions and any questions have been answered to my satisfaction.
• I agree that the provider will determine whether or not the condition being diagnosed and/or treated is appropriate for telehealth services.

I hereby give my informed consent to the use of telehealth in the course of my diagnosis and treatment.