Telehealth Consent Form

Last updated: June 2026

OUR HEALTHCARE PROVIDERS DO NOT ADDRESS MEDICAL EMERGENCIES. IF YOU BELIEVE YOU ARE HAVING A MEDICAL EMERGENCY, YOU SHOULD DIAL 911 OR GO TO THE NEAREST EMERGENCY ROOM. IF YOU ARE EXPERIENCING A MENTAL HEALTH CRISIS OR HAVING THOUGHTS OF SELF-HARM, CALL OR TEXT 988, OR TEXT CONNECT TO 741741.

Introduction

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 health care.

You are reviewing and acknowledging this Telehealth Consent Form because you are seeking healthcare services (the “Services”) from OpenLoop Healthcare Partners, PC and its affiliated entities (OpenLoop Healthcare Partners California, PC, OpenLoop Healthcare Partners Colorado, PC, OpenLoop Healthcare Partners New Jersey Professional Corporation, OpenLoop Healthcare Partners, Wisconsin, S.C., OpenLoop Healthcare Partners Puerto Rico, P.C., Reliant MD Medical Associates PLLC), and M & D Integrations, Inc. (DBA MD Integrations) and its affiliated professional entities (collectively, the “Practice”), utilizing telehealth technologies facilitated through the OpenLoop Health Inc. or MD Integrations websites and applications, or any partner platform, mobile app, or web technologies (collectively, the “Platform”). The specific professional entity and provider responsible for your care depend on the product you select and the state in which you are located. This Telehealth Consent Form supplements but does not modify or supersede any Terms of Use, Privacy Policy, or Notice of Privacy Practices of the Practice, OpenLoop Health Inc., MD Integrations, or other healthcare providers offering services via the Platform.

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 allowed to ask questions and that such questions have been answered to your satisfaction, and that you consent to receiving the Services from licensed health care providers employed by or contracted with the Practice (“Providers”) who are located at sites remote from you.

Treatment-Specific Consent

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

1. I understand that the 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 the 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 (i.e., 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, and other technical difficulties. 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 THE PRACTICE AND ITS MANAGEMENT COMPANIES, OPENLOOP HEALTH, INC. AND M & D INTEGRATIONS, INC., TOGETHER WITH THEIR 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.
5. I understand that in some cases, my Provider might be a nurse practitioner or a physician assistant and not a physician.
6. 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.
7. I agree that any information I provide as part of any telehealth visit is accurate, true, and complete.
8. 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.
9. 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.
10. I understand that while the Platform may make available access to certain pharmacy or diagnostic lab services, I may request to use any pharmacy or lab of my preference.
11. I understand that I am responsible for payment of any amounts due and owing resulting from my telehealth visit.
12. I understand that Providers do not address medical emergencies via the Platform. I understand that the responsibility of my Provider may be to direct me to emergency medical services, such as an emergency room.
13. I (we), the parent(s) or legal guardian of a minor, do hereby authorize consent to any medical order, laboratory order, medical diagnosis, or treatment, and represent that I (we) have legal authority to consent to such treatment or order.
14. I agree that OpenLoop Health, Inc. and M & D Integrations, Inc. are third-party beneficiaries of this Telehealth Consent Form and have the right to enforce it against me, each with respect to the Services it facilitates.
15. I understand and agree that I give permission to Providers to use and disclose my protected health information, including my entire medical record. This protected health information is being used or disclosed for the purpose of telehealth treatment. This authorization expires when you contact support@myrnk.com.
    1. 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.
    2. 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, such as to a court for a legal proceeding.
    3. I may inspect or copy the protected health information to be used or disclosed under this authorization. For protected health information created as part of a clinical trial, my right to access is suspended until the clinical trial is completed.
    4. I may revoke this authorization in writing at any time by sending a written notification to the privacy contact identified by the Practice. My notice of revocation will not apply to actions taken by Providers prior to the date of receipt of the notice.

Additional Treatment-Specific Consent (Compounded Medications)

The following consent applies to patients who receive a prescription from a Provider for compounded medications.

1. I understand that the FDA does not approve nor review compounded products for safety, effectiveness, or quality.
2. I understand that compounding pharmacies must adhere to strict quality control standards to ensure the safety and effectiveness of the medications they prepare. Compounding pharmacies are licensed pharmacies subject to state and federal regulations.
3. I understand that my prescribed medication is dispensed and shipped by an independent, licensed third-party pharmacy, and that the timing, packaging, and delivery of my medication are handled by that pharmacy.

Additional Treatment-Specific Consent (Alcohol Use Disorder / Naltrexone)

The following consent applies to patients accessing the Services to receive a telehealth consultation and treatment for alcohol use disorder (AUD), which may include a prescription for naltrexone.

1. I understand that naltrexone is an FDA-approved medication for the treatment of alcohol use disorder, and that it will be prescribed only if a licensed Provider determines, in their professional judgment, that it is clinically appropriate for me.
2. I understand that this program is available only to patients between 21 and 74 years of age, and that I must be within this age range to be eligible for treatment for alcohol use disorder.
3. I understand that not all patients qualify for this program, and that certain medical conditions, medications, or histories may exclude me from treatment for my safety.
4. I understand that I must provide accurate information about my alcohol use, medical history, current medications (including any opioid use), and mental health, and that withholding information may put my health at risk. I understand that naltrexone should not be taken if I am currently using or dependent on opioids.
5. I understand that treatment for AUD may be delivered on an asynchronous (questionnaire-based) basis and may include periodic follow-up, and that I may be asked to complete follow-up intakes to continue receiving medication.
6. I understand that if I report serious side effects, concerning mood changes, or thoughts of self-harm, my Provider may contact me directly, adjust or pause my treatment, or direct me to a higher level of care. If I am experiencing a mental health crisis or having thoughts of self-harm, I will call or text 988, or text CONNECT to 741741.
7. I understand that medication is one component of care and that results may vary; treatment may be combined with care coaching or other support services where appropriate.

Additional Treatment-Specific Consent (Teletherapy)

The following consent applies to patients accessing the Services to receive a telehealth consultation related to mental or behavioral health.

I acknowledge that I may be offered a telehealth consultation related to my mental or behavioral health as part of the Services. This type of telehealth consultation, known as “Teletherapy,” involves the communication of my mental health information to my Provider. Teletherapy has the same purpose or intention as therapy sessions conducted in person. However, due to the nature of the technology used, I understand that Teletherapy may be experienced somewhat differently than face-to-face treatment sessions.

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

1. I have the right to withhold or withdraw consent for my treatment at any time without affecting my right to future care or treatment.
2. The laws that protect the confidentiality of my medical information also apply to Teletherapy. The information disclosed by me during a Teletherapy session generally is confidential unless an exception applies (e.g., mandatory reporting of child, elder, or vulnerable adult abuse; if my Provider believes I may be a danger to myself or others; or if I raise emotional or mental health as an issue in a legal proceeding).
3. I understand that Teletherapy services and care may not be as complete as face-to-face services. If my Provider believes I would be better served by another form of therapeutic services, I will be referred to a professional who can provide such services in my area.
4. I understand that I may benefit from Teletherapy, but that results cannot be guaranteed or assured. Despite my efforts and those of my Provider, my condition may not improve and in some cases may get worse.
5. I accept that Teletherapy is not meant to cover emergency situations. If I am having suicidal thoughts or making plans to harm myself, I can call or text 988 (Suicide and Crisis Lifeline) for free 24-hour support. Patients who are actively at risk of harm to self or others are not suitable for Teletherapy services; if this is or becomes the case, my Provider will recommend more appropriate services.
6. I understand that dissemination of any personally identifiable images or information from the Teletherapy interaction to researchers or other entities shall not occur without my written consent.
7. I understand that my Provider may need to contact my emergency contact and/or the appropriate authorities in case of an emergency. I agree to inform my Provider of the address where I am located at the beginning of each session, and to provide the name of a contact person who my Provider may contact on my behalf in an emergency.

Additional Treatment-Specific Consent (HIV Testing)

The following consent applies to patients accessing the Services to receive a telehealth consultation related to Human Immunodeficiency Virus (“HIV”) testing.

HIV is the virus that causes acquired immunodeficiency syndrome (“AIDS”) and can be transmitted through unprotected sex with someone who has HIV; contact with blood, including via contaminated hypodermic needles or blood transfusions; by HIV-infected pregnant women to their infants during pregnancy or delivery; or while breastfeeding.

HIV can be detected via an HIV antibody test, a blood test that shows whether you have antibodies to the virus that causes AIDS. A positive result means you have been exposed to the virus and are infected with HIV. It does not mean you have AIDS or that you will become sick with AIDS in the future. A positive result also means you could pass the virus to other people. There is treatment for HIV that can help you stay healthy.

A negative test means you are unlikely to be infected with the virus. Because it takes time for the body to produce HIV antibodies, if you have been exposed to HIV recently, you will need to be retested in several months to be sure. Your Provider will explain this to you.

Taking an HIV test is entirely voluntary. If you do not wish to take the test, you may decline and we will not perform it. This test is not provided on an anonymous basis; please seek an anonymous test site if you prefer for your HIV test information and results to remain anonymous. There are federal and state laws that protect the confidentiality of your HIV test results, though we may disclose your results as required by law for reporting to appropriate public health authorities.

Additional Treatment-Specific Consent (Genetic Testing)

The following consent applies to patients accessing the Services to receive a telehealth consultation related to genetic testing.

I acknowledge that I may be offered genetic testing as part of the Services. Testing for genetic conditions can be complex, and the specifics of the test, including the methods for collecting a biologic specimen, will vary depending on the condition tested for. There are risks and benefits to genetic testing. If I am offered genetic testing, my Provider will explain the specifics of my particular test, and I will have the opportunity to obtain professional genetic counseling prior to completing the test to fully understand the risks and benefits.

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. I authorize the 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 the Practice. I understand that I am financially responsible for any balance. I also authorize the 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 Reminders and General Information

By clicking “I accept”, I further authorize the Practice to contact me by phone or SMS/text message at the telephone number I have provided, or to send emails at the email address I have provided, with appointment reminders and general health information. I understand that this request to receive emails and/or text messages will apply to all future appointment reminders, feedback, and health information unless I request a change in writing. I also acknowledge this means of communication is not considered secure for the transmission of private information.

Additional State-Specific Disclosures

The following consents apply to patients accessing the Services for the purposes of participating in a telehealth visit within the states listed below, as required by state law.

Alaska, Connecticut, New Hampshire, Ohio: I understand that my primary care provider or treating provider may obtain a copy of my records of my telehealth encounter.

Kansas: I understand that if I have a primary care provider or other treating physician, the person providing telemedicine services must send a report to such provider of the treatment and services rendered during the telemedicine encounter within three days of my providing consent.

New Jersey: I understand I have the right to request a copy of my medical information, and that 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.

South Carolina: I understand that my medical records may be distributed only with my consent and in accordance with applicable laws and regulations to other treating health care practitioners.

Texas: I understand that with my consent my medical records may be sent to my primary care physician within 72 hours after receiving Services.

California: The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals, available at https://openpaymentsdata.cms.gov. If I want to register a formal complaint about a provider, I may visit the Medical Board of California website.

Billing: 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: Patients in California, Georgia, Idaho, Indiana, Iowa, Kentucky, Maine, New York, Oklahoma, Oregon, Rhode Island, Texas, Vermont, and Wyoming may register a formal complaint about a provider by visiting their state medical board’s website.

Texas — Notice Concerning Complaints: Complaints about physicians, as well as other licensees and registrants of the Texas Medical Board, including physician assistants, acupuncturists, and surgical assistants, may be reported for investigation at: 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. For more information, visit www.tmb.state.tx.us.