Telehealth Consent

Consent to Telehealth

Telehealth is a mode of delivering health care services via communication technologies to facilitate diagnosis, consultation, treatment, education, care management, and self-management of a patient's healthcare. The purpose of this consent form ("Consent") is to provide you with information about telehealth and to obtain your informed consent to the use of telehealth in the delivery of healthcare services to you by nurse practitioners, physician assistants, and/or physicians ("Providers") using the online platforms owned and operated by [dayla Healthcare Partners, PC] and/or its affiliates and/or subsidiaries (the "Service"). In this Consent, the terms "you" and "yours" refer to the person using the Service.

You are reviewing and acknowledging this Telehealth Consent Form because you are seeking services from [dayla Healthcare Partners, PC] and its affiliated entities (collectively, the "Practice") utilizing telehealth technologies facilitated through the dayla website, mobile app, or any partner platform (collectively, the "Platform"). This Telehealth Consent Form supplements but does not modify or supersede our Terms of Use or Notice of Privacy Practices.

By clicking "I consent to telehealth," you indicate that you have reviewed this Telehealth Consent Form or had it explained to you, that you understand the risks and limitations of using telehealth technologies, that you have been given the opportunity to ask questions and that such questions have been answered to your satisfaction, and that you consent to receiving services from licensed health care providers employed by or contracted with Practice ("Providers") who are located at sites remote from you. If you would like to speak to our privacy team, please email us at hello@daylahealth.com.

Treatment-Specific Consent

By clicking "I consent to telehealth," you understand and agree to the following:

1. I understand that Practice offers telehealth visits, which are conducted through videoconferencing, telephonic, and asynchronous technology, and my Provider will not be present in the room with me.
2. I am consenting to Practice importing and accessing my medical records and medication list, including prescription records.
3. To protect the confidentiality of my health information, I agree to undertake my telehealth visit in a private location, and I understand that my Provider will similarly be in a private location. If any other individuals are present (e.g., for technological or translation assistance), I will be informed of the individual's presence and role, and I will be given the opportunity to consent to such individual's presence.
4. I understand there are potential risks to the use of telehealth technology, including but not limited to interruptions, delays, unauthorized access, other technical difficulties, data processing errors, AI misinterpretation, recording failures, and ambient listening inaccuracies. I understand that either my Provider or I can discontinue the telehealth appointment if the technical connections are not adequate for my visit. I AGREE TO HOLD HARMLESS PRACTICE, TOGETHER WITH ITS EMPLOYEES, CONTRACTORS, AGENTS, DIRECTORS, MEMBERS, MANAGERS, SHAREHOLDERS, OFFICERS, REPRESENTATIVES, ASSIGNS, PREDECESSORS, AND SUCCESSORS, FOR DELAYS IN EVALUATION OR FOR INFORMATION LOST DUE TO SUCH TECHNICAL FAILURES OR FOR ANY ISSUES ARISING FROM THE USE OF AI TECHNOLOGIES, RECORDINGS, OR AMBIENT LISTENING SYSTEMS.
5. I understand that my telehealth visit may involve the use of artificial intelligence (AI) technologies for various purposes, including but not limited to transcription of conversations, analysis of medical information, clinical decision support, quality assurance, and improvement of telehealth services. AI processing may occur in real-time during my visit and/or after my visit has concluded. Information processed by AI systems will be protected in accordance with applicable privacy laws and Practice's privacy policies and procedures. I have the right to request information about what AI technologies are being used during my care and how my information is being processed.
6. I understand that, as part of my care, my Provider may use AI tools to assist with analyzing medical data or records, supporting clinical decision making, generating summaries or documentation, or recommending potential diagnoses or treatment options. AI tools are intended to support, not replace, the professional judgment of my Provider. I understand and acknowledge that my Provider will review any AI-assisted outputs before making clinical decisions, and I have the right to ask questions about how AI is used in my care and to request that AI not be used in certain aspects of my treatment, where feasible.
7. I understand that my telehealth visit may be recorded (audio and/or video) for purposes including quality assurance, provider training, clinical documentation, and care coordination. I will be notified at the beginning of any session that is being recorded. Recordings may be retained for a specified period of time in accordance with applicable laws and Practice's retention policies. I have the right to request access to recordings of my telehealth visits, subject to applicable laws and Practice's policies.
8. I understand that ambient listening technologies may be used during my telehealth visit to capture relevant clinical information, and that such technologies may include third parties contracted by Practice. I can request that ambient listening be disabled during portions of my visit by notifying my Provider. I have the right to know when ambient listening technologies are active during my visit.
9. I understand that in some cases, my Provider might be a nurse practitioner or a physician assistant and not a physician.
10. I understand that I could seek an in-office visit rather than obtain care from a Provider, and I am choosing to participate in a telehealth visit with a Provider. I further understand that my Provider may not have access to a complete copy of my medical records and will not have the ability to perform an in-person examination, which could result in negative health outcomes from the recommended treatment (e.g., adverse drug interactions or allergic reactions). I further understand that while using telehealth technologies may benefit me, no such benefits or specific results are guaranteed, and my condition may not improve.
11. Certain technology, including the Service, may be used while still in a beta testing and development phase. Technology used to deliver care may contain bugs or other errors, including ones which may limit functionality, produce erroneous results, render part or all of such technology unavailable or inoperable, produce incorrect records, transmissions, data, or content, or cause records to be corrupted or lost, any or all of which could limit or otherwise impact the quality, accuracy, and/or effectiveness of the medical care or other services that you receive from your Provider(s).
12. The delivery of healthcare services via telehealth is an evolving field. No potential benefits from the use of telehealth or other technology can be guaranteed, including any laboratory testing results or related diagnosis or treatment by your Provider(s). Your condition may not be cured or improved, and in some cases may get worse. There are limitations in the provision of medical care via telehealth, and you may not be able to receive diagnosis and/or treatment through telehealth for every condition for which you seek diagnosis and/or treatment.
13. I agree that any information I provide as part of any telehealth visit is accurate, true, and complete.
14. I understand that my Provider may determine that a telehealth visit is not appropriate for me due to my particular health concern or for other reasons related to my health status. In such a case: (i) I will receive an alert notifying me that I will be unable to use the Services for the particular issue I submitted; (ii) my request for a telehealth visit will not be submitted to my Provider; (iii) my Provider will not receive any of the information that I submitted; and (iv) I will need to seek any needed care in another way.
15. I understand that participating in a telehealth visit is not a guarantee that I will be given a prescription, and that the decision as to whether a prescription is appropriate for my condition will be made in the professional judgment of my Provider.
16. I understand that while the Platform may make available access to certain pharmacy services, I may request to use any pharmacy of my preference, where permitted.
17. I understand that I am responsible for payment of any amounts due and owing resulting from my telehealth visit.
18. I understand that Providers do not address medical emergencies via the Platform, and that the responsibility of my Provider may be to direct me to emergency medical services, such as an emergency room.
19. I agree that [dayla Health, Inc.] is a third-party beneficiary of this Telehealth Consent Form and has the right to enforce it against me.
20. I understand and agree that I give permission to Providers to use and disclose my protected health information, including my entire medical record, for the purpose of telehealth treatment.
    • If the person or entity receiving this information is not a health care provider or health plan covered by HIPAA, the information described above may be redisclosed to other individuals or institutions and therefore no longer protected by HIPAA.
    • I may refuse to agree to this authorization. My refusal to sign will not affect my payment, ability to obtain treatment, or eligibility for health plan benefits unless this authorization is requested prior to research related to treatment, enrollment in a health plan, or providing health care that is solely for the purpose of giving that information to a third party.
    • I may inspect or copy the protected health information to be used or disclosed under this authorization.
    • I may revoke this authorization in writing at any time by emailing hello@daylahealth.com. My notice of revocation will not apply to actions taken by Providers prior to the date of receipt of the notice.

Laboratory Products and Services

Certain healthcare services provided to you by Providers via the Service may require that you complete an at-home diagnostic test. These diagnostic tests are provided by third-party laboratories, and neither dayla nor your Provider(s) can guarantee the accuracy or reliability of these tests. These laboratory tests can provide false negative, false positive, or inconclusive results that could impact your Provider(s)' ability to correctly diagnose or treat your medical conditions.

Authorization to Bill Insurance and Assignment of Benefits

By clicking "I accept," I confirm that the above information is true, correct, and complete to the best of my knowledge. Where applicable, I authorize Practice to bill my insurance company directly, and I further authorize any third-party payer through which I have benefits to make payment directly to Practice. I understand that I am financially responsible for any balance. I also authorize Practice or my insurance company to use and disclose any healthcare information for the purpose of obtaining payment for services and determining insurance benefits. Services provided by outside companies (i.e., lab, pathology, radiology) are billed separately by those companies.

Consent to Text or Email Usage for Appointment and Other Healthcare Reminders

By clicking "I accept," I authorize Practice to contact me via phone call, SMS/text message, or email at the contact information I have provided, for the purposes of appointment reminders, patient feedback requests, and general health and wellness information. I understand and agree to the following:

• These communications may be generated in part by automated systems or artificial intelligence (AI).
• Standard messaging and data rates may apply.
• This authorization will remain in effect for future communications unless I revoke it in writing.
• I may opt out of receiving such communications at any time by following the opt-out instructions provided in each message or by contacting Practice directly.
• Using these communication methods presents a potential security risk of unauthorized access to protected health information (PHI). I accept this risk and consent to receiving communications through these methods.

If you prefer not to receive appointment reminders or health information via text or email, please notify us by emailing hello@daylahealth.com.

Additional State-Specific Disclosures

The following disclosures apply to patients accessing the Services within the states listed below, as required by state law:

Patients residing in New Jersey, New York, and Rhode Island have the right under each state's respective billing laws to request an itemized price list for laboratory results.

Formal Complaints

If you wish to register a formal complaint about a Provider, you should visit the applicable state medical board's website. Texas residents may also direct complaints to: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018. Assistance in filing a complaint is available by calling 1-800-201-9353, or visiting www.tmb.state.tx.us.