Informed Consent for Virtual Telehealth Services

I hereby consent to telehealth with my (or my child’s, if consenting on behalf of minor child) Cedars-Sinai physician or a qualified member of the care team (as applicable). I understand that “telehealth” refers to the delivery of health care services through telecommunication technologies typically through the internet to facilitate consultation, diagnosis, and treatment virtually instead of, or conjunction with, an in-person visit. I understand that telehealth also involves the communication of my medical information electronically, verbally and/or visually, to health care providers located at Cedars-Sinai affiliated facilities or elsewhere.

I understand that I have the following rights with respect to telehealth:

1. The use of telehealth is voluntary, and I have the right to withhold or withdraw my consent at any time without affecting my right to future care or treatment or risking the loss or withdrawal of any program benefits to which I would otherwise be entitled. I understand that receiving treatment through telehealth does not mean I cannot receive in-person health care services, either today or in the future. I understand that there are limitations to the types of treatment that can be appropriately provided via telehealth, and that my provider determines whether or not it is appropriate for me to receive treatment via telehealth.
2. The laws that protect the confidentiality of my medical information also apply to telehealth. As such, I understand that the information disclosed by me during the course of my treatment is confidential. However, there are both mandatory and permissive exceptions to confidentiality, including but not limited to reporting child, elder, and depending adult abuse, expressed threats of violence towards an ascertainable victim, and where I make my physical, mental or emotional state an issue in a legal proceeding. My medical information may also be disclosed for treatment, payment and operational purposes. I also understand that the dissemination of any personally identifiable images or information from the telehealth interaction to other entities outside of Cedars-Sinai shall not occur without my written consent subject to exceptions consistent with applicable law. I understand that other Cedars-Sinai staff may be present during the telehealth service to assist the provider.
3. I understand that I may benefit from telehealth, but that results cannot be guaranteed or assured. I also understand that there are limitations and risks involved in receiving treatment via telehealth as compared to an in-person visit, such as interruption of the audio-video connection between me and my provider, information transmitted may not be sufficient (e.g., poor resolution of images) to allow for appropriate medical decision making by the provider; or delays in receiving medical treatment because of technological failures. In addition, I understand that that in receiving treatment via telehealth, I will not have an in-person physical examination from the treating provider that might identify a potentially serious medical condition, and that the absence of an in-person physical examination may affect the provider’s ability to diagnose any potential condition, disease, or injury.
4. I understand that additional diagnostic exams, blood tests, or other procedures may be needed to evaluate or treat my medical condition.
5. I understand that I have a right to access my medical information and copies of medical records in accordance with California and federal law.
6. I understand I may decline to continue the telehealth consultation at any time.
7. I understand that I am responsible for communicating with my provider from a private location to maintain my privacy and for security of the electronic device I use for such communications.
8. If I am a Medi-Cal beneficiary, I further understand that (a) I have the right to access Medi-Cal covered services through an in-person, face-to-face visit or through telehealth, and (b) Medi-Cal provides coverage for transportation to in-person services when other resources have been reasonably exhausted.
9. I understand that translation services are available to me.
10. I understand that as part of my telehealth visit, I may not be able to select a specific provider.  
11. I understand that any care that I receive is based on my symptoms and other information I provide or upload to the telehealth platform, either through the chatbot or that I provide directly to my provider(s) and care team, and that my telehealth providers will rely on the information I provide. Accordingly, in the event I elect to have a telehealth visit, I understand that a summary of the information I provide through the chatbot in connection with the visit in addition to any other information I provide to my care team shall be part of my medical record.
12. I understand that when receiving telehealth services, I may be required to upload a copy of my identification card (e.g., drivers’ license, state ID) and a self-photograph (“selfie”) or a photograph of my minor child seeking telehealth services (as applicable) for verification purposes, location purposes, and evaluation and treatment purposes. I also understand and agree that as part of the verification process, Cedars-Sinai’s vendors may utilize biometric measurements and analysis to compare and verify the image obtained from my ID and selfie. Such biometrics measurements will be deleted once they are no longer required.  
13. I understand that the telehealth providers do not prescribe U.S. Drug Enforcement Administration/DEA controlled substances, such as those containing opioids.  Providers reserve the right to deny care for actual or potential misuse of the telehealth services.

In addition to the above, I agree to the following conditions with respect to telehealth:

1. I am at least 18 years of age; and if applicable, that I am the parent or legal guardian of the minor child seeking telehealth services; and that I have the right to provide consent on behalf of my minor child under applicable law.
2. I understand that this consent remains valid and in effect until I revoke it; or until the minor child has reached age of majority under applicable law. I agree that if I am providing this consent on behalf of my minor child, I will notify Cedars-Sinai immediately if I am no longer legally authorized to access my child’s protected health information or consent to treatment on behalf of such child.
3. I agree and represent that due to state medical licensure laws I will use the telehealth services only when I (and my minor child, in the event I am seeking care of behalf of my child) am physically located in California and that I will notify my telehealth provider immediately if I (and my minor child, if applicable) am no longer located in California at the time of telehealth visit.
4. I assign and authorize direct payment to Cedars-Sinai of all insurance and health plan benefits payable for these services at a rate not to exceed actual charges. I understand and agree that I am responsible for all facility and provider bills for services rendered to me (or to my minor child) that are not paid by my insurance or health plan, if applicable, and as permitted by state and federal law. I agree to promptly pay such amounts for which I am responsible. I understand that I may be eligible for aid in accordance with Cedars-Sinai’s financial assistance policies, as permitted under state and federal law. If any account is referred to an attorney or collection agency for collection, I will pay actual attorney’s fees and collection expenses. All delinquent accounts shall bear interest at the legal rate, unless prohibited by law.
5. Audio or video recording of the video visit is strictly prohibited, and Cedars-Sinai does not consent to any such recording.
6. I understand that any physicians providing services to me during telehealth are not employees or agents of Cedars-Sinai for clinical purposes and that they are independent contractors for clinical purposes.
7. I understand that participation in telehealth cannot be used for legal purposes; and that my attorney cannot attend the virtual telehealth visits.  I further understand that my telehealth visit may be terminated should I fail to adhere to this.  
8. I agree to receive from Cedars-Sinai and its agents and representatives’ electronic communications, including email communications, push notification and SMS text messages about the telehealth services and my  care.  I understand that I can opt-out of from receiving emails, calls and text messages by contacting customer service at Support.csconnect@cedars-sinai.org, replying STOP to text message, or through my device settings to disable push notifications.  I acknowledge that opting out may impact my ability to use certain features of the telehealth services and that I have  to  unsubscribe from each service I consented to hereunder in order to completely withdraw from electronic communications.  Any withdrawal of my consent to electronic communications will be effective only after there has been a reasonable period of time to process my withdrawal request.

By beginning my (or my minor child’s) telehealth consult, I confirm that I have read and understand the information in this document, that my name and identity have been correctly identified, that I agree to the above conditions, and I agree to receive (or have my minor child receive, as applicable) treatment via telehealth. I understand that telehealth is not for emergency services, and if I am experiencing an emergency, I must call 911 or proceed to the nearest emergency room.