Telehealth Informed Consent

Purpose of this consent

This document explains how telehealth services are provided through Protocol MD's affiliated provider network and asks for your informed consent before clinical care begins. By beginning the assessment and continuing through prescription and treatment, you indicate that you have read, understood, and consent to the matters described below.

1. What telehealth means

Telehealth is the use of secure electronic communications — including written intake forms, secure messaging, and where clinically appropriate, video — to deliver clinical care at a distance. Most consultations through Protocol MD are asynchronous: a US-licensed physician licensed in your state reviews your written intake (and any uploaded records or photographs), asks follow-up questions through the patient portal as needed, and prescribes a protocol if clinically appropriate. A scheduled video call is not required for most cases.

2. Your provider

Clinical care is provided by an independently practicing, US-licensed physician or other licensed practitioner (collectively, the "Provider") credentialed in your state of residence. Your clinical relationship is with the Provider, not with Protocol MD. Protocol MD is a technology and marketing platform that supports the Provider's practice but does not itself practice medicine.

3. Benefits and limitations of telehealth

Potential benefits of telehealth include convenient access to a qualified physician, asynchronous communication that does not require a scheduled appointment, and continuity of care across the cycle.

Potential limitations of telehealth include the inability to perform a complete physical examination, reduced ability to detect findings that would be apparent in person, and dependence on the accuracy and completeness of the information you provide. Technical issues such as interrupted connections or delayed messages may also occasionally affect care.

4. Risks and your responsibilities

• The Provider may not have access to all of your medical records and relies on the information you provide. You agree to provide complete and accurate information.
• The Provider may decline to prescribe, may modify the proposed protocol, or may refer you for in-person evaluation if telehealth care is not appropriate for your case.
• You agree to seek emergency care from your local emergency department or by calling 911 for any urgent or emergent symptoms. Telehealth is not appropriate for emergencies.
• You agree to notify the Provider promptly of any side effects, adverse reactions, or material changes in your health while on a prescribed protocol.

5. Privacy and security

Communications are conducted through secure, encrypted channels designed to protect your protected health information. As with any electronic communication, no system is perfectly secure. The Provider's use and disclosure of your protected health information is governed by the HIPAA Notice of Privacy Practices.

6. Your right to refuse or withdraw consent

You have the right to refuse telehealth services and to request in-person care. You have the right to withdraw your consent at any time without affecting your right to non-telehealth care. To withdraw consent, contact us at hello@protocolmd.com.

7. State-specific provisions

Telehealth statutes vary by state. Where state law provides additional rights or imposes additional disclosures (for example, identification of the prescribing physician, specific consent language, or restrictions on the use of asynchronous communication for controlled substances), those state-specific provisions apply and are deemed incorporated into this consent.

8. Acknowledgment

By continuing through the assessment and accepting a prescribed protocol, you acknowledge that you have read this consent, that your questions have been answered to your satisfaction, and that you consent to receive care via telehealth.