Telehealth Informed Consent

This document is a template and should be reviewed by legal counsel before use.

Last updated: January 1, 2026

This Telehealth Informed Consent (“Consent”) describes the terms under which Elm Tree Health (“Elm Tree,” “we,” “us,” or “our”) provides healthcare services via telehealth technology. Please read this document carefully before participating in a telehealth visit.

1. Nature of Telehealth Services

Telehealth involves the delivery of healthcare services using electronic communications, information technology, or other means between a healthcare provider and a patient who are not in the same physical location. Our telehealth services use real-time audio and/or video communication to conduct Medicare Annual Wellness Visits. Telehealth is not the same as a direct, in-person patient/provider visit, and certain limitations may apply.

2. Risks and Benefits

Benefits

• Convenient access to preventive healthcare from the comfort of your home.
• Reduced need for travel, particularly beneficial for individuals with mobility challenges or those in rural areas.
• Timely access to a licensed healthcare provider for your Annual Wellness Visit.
• A personalized prevention plan to help you stay healthy.

Risks

• Technology failures may interrupt or prevent the visit. Poor internet connection, hardware malfunctions, or software issues may affect the quality of the session.
• The provider cannot perform a physical examination, which may limit the ability to diagnose certain conditions.
• Although we use encrypted, secure platforms, electronic communications carry an inherent risk of unauthorized access.
• In rare cases, information transmitted may be insufficient to allow for appropriate decision-making by the provider.
• Delays in evaluation or treatment may occur due to technology deficiencies.

3. Patient Rights

As a telehealth patient, you have the right to:

• Receive the same standard of care as an in-person visit.
• Be informed of the identity and qualifications of all healthcare providers involved in your care.
• Refuse telehealth services at any time without affecting your right to future care.
• Request that a specific individual not be present during the telehealth session.
• Access your medical records related to telehealth visits.
• Have your medical information kept confidential in accordance with HIPAA and applicable state laws.
• Ask questions about the telehealth process before, during, and after your visit.

4. Technology Requirements

To participate in a telehealth visit, you will need:

• A telephone or internet-connected device (smartphone, tablet, or computer) with audio capability.
• For video visits: a device with a camera, microphone, and speaker, plus a stable internet connection (minimum 1 Mbps recommended).
• A private, quiet location where you can speak freely about your health.

You are responsible for ensuring your technology is functioning properly prior to the visit. If technical issues prevent the completion of your visit, we will work with you to reschedule.

5. Privacy and Security

We use HIPAA-compliant, encrypted telehealth platforms to protect the confidentiality and security of your health information. All telehealth interactions are subject to our Privacy Policy. While we take reasonable precautions to protect your information, we cannot guarantee that electronic communications will be completely secure. We recommend you conduct your telehealth visit in a private setting to further protect your confidentiality.

6. Consent to Treatment

By scheduling and participating in a telehealth visit with Elm Tree Health, you consent to receiving healthcare services via telehealth technology. You acknowledge that:

• You have read and understand this Telehealth Informed Consent.
• You voluntarily consent to participate in a telehealth visit.
• You understand the risks, benefits, and alternatives to telehealth services.
• You have had the opportunity to ask questions and have received satisfactory answers.
• Your consent is valid for all future Elm Tree Health telehealth visits unless you withdraw it in writing.

7. Right to Withdraw Consent

You may withdraw your consent to telehealth services at any time, either before or during a telehealth visit, without affecting your right to future care or treatment. To withdraw consent, you may notify your provider during the visit or contact us in writing. Withdrawal of consent will not affect any services provided prior to the withdrawal.

8. Open Payments Disclosure

For general information regarding industry relationships with physicians and teaching hospitals, visit the Centers for Medicare & Medicaid Services (CMS) Open Payments website at openpaymentsdata.cms.gov. This federal database contains information about payments and other transfers of value made by applicable manufacturers and group purchasing organizations to physicians and teaching hospitals.

9. Contact Us

If you have questions about this Telehealth Consent or our telehealth services, please contact us:

• Email: support@elmtreehealth.com
• Phone: (800) 555-0142
• Mail: Elm Tree Health, 1234 Wellness Ave, Suite 200, Arlington, VA 22201