Consent to Telehealth

Informed Consent Regarding Use of Telehealth

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Acceptance of Terms

By clicking “I Agree,” checking the acceptance box, or otherwise indicating acceptance, you acknowledge that you have read, understood and agree to be bound by this Telehealth Informed Consent (“Consent”). If you do not agree, do not create an account or use the Service. You authorize any party acting on your behalf who indicates acceptance to bind you to this Consent. A digital copy of this Consent is available via email at support@getzealthy.com or through the Service. This form will be placed in your medical records.

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Medical Emergencies. 

If you are experiencing a medical emergency or life-threatening situation, call 9-a-a immediately. Do not attempt to contact Zealthy, Inc. or your Provider through the Service for emergency care. After receiving emergency treatment, follow up with your local primary care provider. 

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Purpose. 

This Consent informs you (“patient,” “you,” or “your”) about telehealth, including its methods, risks, and limitations, and obtains your informed consent to receive healthcare services via telehealth from physicians or other healthcare providers (“Providers”) using the online platforms owned and operated by Zealthy, Inc. and/or its subsidiaries (“Service”). Zealthy, Inc. provides administrative and management services to Providers and does not itself provide medical services. This Consent should be read in conjunction with the Services’s Terms of Use.

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What is Telehealth

Telehealth involves delivering healthcare using electronic communications, information technology, or other means between a Provider and a patient not in the same physical location. It may include: 

• Electronic transmission of medical records, images, or health data; 
• Audio, video, or text-based interactions (e.g. messaging, email); 
• Use of data from medical devices, sound, or video files; 
• Appointment scheduling, medical intake forms, prescription refills, or consultation reports.  

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Telehealth may be used for diagnosis, treatment, follow-up, or patient education. You understand that telehealth may have limitations compared to in-person care, such as the inability to perform physical examinations, potential technical failures, and differences in communication. Alternative care options, such as in-person visits, are available, and you may choose an alternative at any time after discussing with your Provider.  You may withdraw consent to telehealth at any time, but this may result in Providers discontinuing care. 

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Specific Benefits and Risks of the Services You Are Receiving

To learn more about the specific benefits and risks of the Services you are seeking, please select from the offered Services below: 

• Weight Loss
• Hair Loss
• ED
• Skincare
• Birth Control
  

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Expected Benefits

Telehealth may offer: 

• Improved access to care from your preferred location; 
• Convenient follow-up care (contact your Provider via the Zealthy messaging portal for non-emergent needs or support@getzealthy.com for non-clinical issues); 
• Efficient evaluation and management (clinical questions typically answered within 48 hours, monday through friday, excluding holidays); and
• Access to specialists unavailable for in-person consultations. 

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Possible Risks

Telehealth involves risks, including: 

• Delays due to equipment, technology failures, or Provider availability; 
• Inadequate data quality affecting diagnosis or treatment; 
• Rare instances where Providers require rescheduling or in-person visits due to poor data quality; 
• Potential privacy breaches if security protocols fail; 
• Incomplete medical records leading to adverse drug interactions, allergic reactions, or clinical errors; 
• Technology errors (e.g., bugs, data corruption) limiting functionality or producing incorrect results; 
• Inability to perform in-person tests or assess vital signs, potentially preventing diagnosis or identifying emergencies; 
• Regulatory limits on prescriptions or treatment options; 
• Missed visual, auditory or other cues compared to in-person visits; 
• Patient withholding of key medical information; 
• Possible information loss due to technical failures. 

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You accept that telehealth consultations, including any “physical exam” (e.g. via photos, video or questionnaires), may involve uncertainty or inaccuracy compared to in-person exams. Report adverse side effects to your Provider, local doctor, or seek emergency care if needed. 

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Limited Nature of Services

Telehealth services, provided by Bruno Health, P.A. and affiliated medical groups (the “Group”) and their Providers, may include consultations, diagnoses, treatment recommendations, prescriptions, or referrals to in-person care, as deemed clinically appropriate. Providers are licensed in your state or meet licensure exceptions and establish a limited provider-patient relationship for the specific service purchased. 

These services do not replace primary care or emergency care. Providers are not your general or specialized healthcare providers, and their role is limited to the service engaged. Responsibility for your overall care remains with your local primary care provider, if you have one, and you are encouraged to establish one if you do not. Providers may deny care for potential misuse or if deemed medically or ethically inappropriate. 

a. Disclaimer- No Professional Licensure

Our weight‑loss coaches are not licensed dietitians, nutritionists, physicians, or other state‑regulated healthcare professionals. All information, suggestions, and support they provide are general wellness and behavioral‑change coaching only. The coaching does not diagnose, treat, cure, or prevent any disease, does not constitute “medical nutrition therapy,” and does not replace individualized advice from a licensed healthcare provider. Always seek the guidance of a licensed physician or registered dietitian for questions about a medical condition or before making major dietary changes. By enrolling in this program you acknowledge and agree to these limitations.

You agree to inform Providers of any conditions affecting your ability to receive services and to follow up with your primary care provider for any issues arising during or related to the services. Providers do not guarantee the accuracy, completeness or adequacy of services. 

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Privacy and Security

The Service uses network and software security protocols to protect patient data, complying with the Health Insurance Portability and Accountability Act (HIPAA). Your identity will be verified, and your Provider’s credentials are available upon request. Personal or protected health information will not be disclosed to third parties without your consent, except as authorized by law (e.g. for consultation, treatment, billing, or as outlined in your Provider’s Notice of Privacy Practices). 

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Email or text communications may involve your health information but are less secure than other channels, risking unauthorized access. By using these methods, you accept these risks, and Zealthy, Inc. is not responsible for unauthorized access during transmission or delivery. No telehealth sessions will be recorded by you or your Provider. Patient-identifiable images or information will not be shared for research or education without your affirmative consent. You acknowledge that no system is completely risk-free, and there is a possibility of information loss due to technical failures. 

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Service Limitations

Telehealth cannot replicate direct physical contact, so some clinical needs may require in-person care, as determined by your Provider. Group has no in-person clinic locations. If you require urgent or emergent care, seek treatment at an emergency room or appropriate facility. For non-urgent issues, use the Service’s secure messaging portal. In case of technical failures, contact support@getzealthy.com or call 877-870-0323 Monday through Friday between the hours of 9a.m. and 6p.m. (EST). 

You must provide truthful, accurate and complete information, including updates to your medical or mental health status and emergency contact details for local providers.  Medical records are stored in a secure database with reasonable safeguards, but some information may be shared for scheduling or billing purposes. 

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Prescriptions

If a Provider prescribes medication (not guaranteed), you are responsible for all associated costs (e.g. copayments, deductibles) not explicitly included in the Service, including any additional fees as required by state law. You must review risks, side effects and drug interactions with your Provider, local doctor, or pharmacist. Report adverse effects immediately and seek emergency care if needed. Prescriptions are issued by licensed providers (e.g. physicians, nurse practitioners). 

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Laboratory Products and Services

Some services may require at-home diagnostic or laboratory tests provided by third-party laboratories. Neither Zealthy nor Providers guarantee the accuracy or reliability of these tests, which may yield false negatives, positives, or inconclusive results, potentially affecting diagnosis or treatment. Test defects could also impact care quality. 

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Location of Services

You must provide accurate information about your physical location, and Zealthy will match you with a Provider licensed in your state, as required.  If your location changes, notify your Provider immediately.  By using the Service, you agree that services are provided in the state where the Provider is licensed, not your physical location, and you will not bring actions or complaints in your state. You agree to cooperate with Zealthy and Providers if your state asserts jurisdiction over them. 

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Open Payments Notice

The federal Open Payments database (Open Payments) provides information on payments over $10 from drug, device or biologic manufacturers to physicians and teaching hospitals, as required by the Physician Payments Sunshine Act. 

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Patient Acknowledgments

By consenting, you agree to the following: 

1. Services are provided via telehealth, potentially by non-physician providers (e.g. nurse practitioners), and do not replace your primary care provider. 
2. You understand the benefits and risks of telehealth, as outlined above, and that alternatives (e.g. in-person care) are available. 
3. You may withdraw consent to telehealth at any time without affecting future care, this this may end Provider services. 
4. You have the right to select a Provider, review their credentials, or choose the next available Provider. 
5. Certain tests (e.g. labs, bloodwork) may be conducted at another location under Provider direction. These may involve additional costs. 
6. Technical failures may disrupt services, and you hold Zealthy, Group, and Providers harmless for resulting delays or data loss. 
7. Laboratory tests or technology may contain defects or errors impacting care quality, accuracy or effectiveness. 
8. You will provide complete, accurate and current medical history and updates via the Patient Portal. 
9. No benefits, results, or prescripts are guaranteed, and your condition may not improve or may worsen. 
10. Providers may deny care if deemed inappropriate, and you agree to their medical assessment for telehealth services. 
11. You accept risks of unsecure communication methods (e.g. email, text) and will not hold Zealthy liable for unauthorized access. 
12. Your medical records are confidential under federal and state laws, accessible via the Patient Portal at a reasonable cost. 
13. Others (e.g. technical staff) may be present during consultations to operate technology, and you may request their exclusion or omit sensitive details. 
14. Zealthy has commercial relationships with Providers, Affiliates, and Pharmacy partners, but you may choose other providers or pharmacies. 
15. You will pay all costs associated with the Service, including any additional fees as required by state law, and will not submit claims to Medicare, other federal payors, or insurers. 
16. You understand that consent may be required annually or per encounter, depending on state requirements. 
17. Your Provider has determined that telehealth is appropriate for your care, based on the information provided. 

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If you have concerns about a Provider, contact your state’s Medical Board (list available at AAFP Legal Requirements).

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State-Specific Consents

The following consents apply to users accessing the Service for the purposes of participating in a telehealth consultation as required by the states listed below: 

• Alaska: I understand my primary care provider may obtain a copy of my records of my telehealth encounter. (AK Stat. 08.64.364).
• Arizona: I understand I am entitled to all existing confidentiality protections pursuant to A.R.S. § 12-2292. I also understand all medical reports resulting from the telemedicine consultation are part of my medical record as defined in A.R.S. § 12-2291. I also understand dissemination of any images or information identifiable to me for research or educational purposes shall not occur without my consent, unless authorized by state or federal law. (A.R.S. § 36-3602).
• California: Physicians and midwives and other practitioners are licensed and regulated by the Medical Board of California. To confirm a license or file a complaint, go to www.mbc.ca.gov or call (800) 633-2322.
• Connecticut: I understand that my primary care provider may obtain a copy of my records of my telehealth encounter. (C.G.S.A. § 19a-906).
• D.C.: I have been informed of alternate forms of communication between me and a physician for urgent matters. (17 DCMR § 4618.10).
• Idaho: I acknowledge that my identity has been verified, and I have been informed about my Provider’s credentials. I understand the security measures in place to protect my health information and have been informed about the possibility of information loss due to technical failures.
• Kentucky: If I am a Medicaid recipient, I recognize I have the option to refuse the telehealth consultation at any time without affecting the right to future care or treatment and without risking the loss or withdrawal of a Medicaid benefit to which I am entitled. I understand that I have the right to be informed of any party who will be present at the site during the telehealth consult and I have the right to exclude anyone from being present. I also understand that I have the right to object to the videotaping of the telehealth consultation. (KY Admin. Regs. Tit. 907, 3:170).
• Louisiana: I understand the role of other health care providers that may be present during the consultation other than the Telehealth Group provider. I further understand that I may decline to receive medical services via telemedicine and may withdraw from such care at any time. (46 La. Admin. Code Pt XLV, § 7511). 
• Maryland: I understand that dissemination of image or information identifiable to me shall not be disseminated to other entities without my consent, unless there is an emergency preventing the practitioner from obtaining such consent. (Code of MD Reg. 10.09.49.09). Regarding audiologists, speech language pathologists, and hearing aid dispensers, I recognize the inability to have direct, physical contact with the patient is a primary deference between telehealth and direct in-person service delivery. The knowledge, experiences, and qualifications of the consultant providing data and information to the provider of the telehealth services need not be completely known to, and understood by the provider. The quality of transmitted data may affect the quality of services provided by the provider. Changes in the environment and test conditions could be impossible to make during delivery of telehealth services. Telehealth services may not be provided by correspondence only. (Code of MD Reg. 10.41.06.04). 
• Nebraska: If I am a Medicaid recipient, I retain the option to refuse the telehealth consultation at any time without affecting my right to future care or treatment and without risking the loss or withdrawal of any program benefits to which the patient would otherwise be entitled. All existing confidentiality protections shall apply to the telehealth consultation. I shall have access to all medical information resulting from the telehealth consultation as provided by law for access to my medical records. Dissemination of any patient identifiable images or information from the telehealth consultation to researchers or other entities shall not occur without my written consent. I understand that I have the right to request an in-person consult immediately after the telehealth consult and I will be informed if such consult is not available. (NE Revised Stat.71-8505; NE Admin. Code Tit. 471, Ch. 1). 
• Nevada: I consent to the forwarding of my medical records to my primary care provider or other designated healthcare providers. 
• New Hampshire: I understand that the Telehealth Group provider may forward my medical records to my primary care or treating provider. (N.H. Rev. Stat. §329:1-d). 
• New Jersey: I understand I have the right to request a copy of my medical information and I understand my medical information may be forwarded directly to my primary care provider or health care provider of record, or upon my request, to other health care providers. (NJ Rev. Stat. §45:1-62). 
• Ohio: I agree to hold harmless Zealthy, Inc., the Group and my Provider for any delays or disruptions in service due to technical failures. 
• Pennsylvania: I understand that I may be asked to confirm my consent to behavioral health or tele-psych services. 
• Rhode Island: If I use email or text-based technology to communicate with my Telehealth Group provider, then I understand the types of transmissions that will be permitted and the circumstances when alternate forms of communication or office visits should be utilized. I have also discussed security measures, such as encryption of data, password-protected screen savers and ata files, or utilization of other reliable authentication techniques, as well as potential risks to privacy. I acknowledge that my failure to comply with this agreement may result in the Telehealth Group provider terminating the email relationship. (Rhode Island Medical Board Guidelines). 
• South Carolina: I understand my medical records may be distributed in accordance with applicable law and regulation to other treating health care practitioners. (S.C. Code 1976 §40-47-37). 
• Tennessee: I understand that I may request an in-person assessment before receiving a telehealth assessment if I am a Medicaid recipient. 
• Texas: I acknowledge that for telehealth services in Texas, consent must be obtained prior to each encounter or annually. I have been informed about any additional fees associated with telehealth services and agree to pay them as part of the service cost. 
• Vermont: I understand that I have the right to receive a consult with a distant-site provider and will receive one upon request immediately or within a reasonable time after the results of the initial consult. I understand that receiving tele-dermatology or tele-ophthalmology services via Telehealth Group does not preclude me from receiving real-time telemedicine or face-to-face services with the distant provider at a future date. (VT Stat. Ann. §9361). If receiving audio-only services, I understand the availability of alternative delivery methods and the insurance implications. 
• Wisconsin: I confirm that my identity and my Provider’s credentials have been verified, the technology used has been explained, and that telehealth is appropriate for my care, with security measures in place. 

Compliance with State Laws

This Telehealth Informed Consent is designed to comply with the laws and regulations of all 50 states regarding telehealth services. If you reside in a state with specific requirements not listed above, please inform your provider, and additional consents may be obtained as necessary. 

By clicking “I Agree,” checking the agreement box or a related box to signify my acceptance, using other acceptance protocol presented through the Website, App or Service, or otherwise indicating acceptance, I, _______________________________,  acknowledge that I have read, understand and agree to this Consent and consent to receive telehealth services. 

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I acknowledge and understand that I will digitally receive a copy of this Consent (you have the ability to print, PDF, copy/pase, or screenshot a copy of this Consent). 

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THIS FORM MUST BE PLACED IN THE MEDICAL RECORD. A COPY OF THIS DOCUMENT CAN BE ACCESSED BY EMAILING SUPPORT@GETZEALTHY.COM OR BY ACCESSING THE CONSENT HERE.