Informed Consent for Telehealth Services

Introduction to Our Services

The Healthcare Providers at Palana, LLC (“Palana,” “we,” “us,” or “our”) provide telehealth services by using interactive audio and video technologies where you and your Healthcare Provider are not in the same physical location. Your Healthcare Providers may include Medical Doctors (M.D.) and Doctors of Osteopathic Medicine (D.O.). You can form an ongoing treatment relationship with a Palana Healthcare Provider, however, your initial visit may begin as a consultation (e.g. to determine the most appropriate treatment setting for you to receive care) and will not necessarily give rise to an ongoing treatment relationship until you engage in additional sessions. Your consultation or sessions may be recorded with your permission to maintain as a part of your medical record. You should seek follow-up care when recommended, following a consultation or session. In case of an emergency, dial 911 or go directly to the nearest emergency room or hospital. It is important that you understand the benefits and potentials risks of using telehealth for your medical care and treatment.

Anticipated Benefits of Using Telehealth

• Improved access to medical care by enabling a patient to remain at home, office, or other remote location while consulting or interacting in a session with a Healthcare Provider.
• Reduced risks of travel, exposure to pathogens or ill patients at in-person facilities.
• More time-efficient medical evaluation and continued health management.

Potential Risks of Using Telehealth:

• Information transmitted to Healthcare Providers during a telehealth visit may be more limited than in- person visits in certain ways, which may impact diagnosis, treatment, or for further recommendation relating to referrals.
• Disruptions can occur due to malfunctions of the electronic equipment or internet connection, hacking, or unauthorized access. Such disruptions may result in delays in medical evaluation and treatment. If this happens, you may be contacted by your Healthcare Provider by phone or other means of communication.
• Failure to provide a complete medical history, list of current medications, and other relevant medical information may result in adverse health outcomes or reduce overall effectiveness of treatment.
• Although Palana incorporates strong security protocols to protect the confidentiality of your health information, in rare instances, security protocols may fail, causing a breach of confidentiality.
• There may be limited availability of certain laboratory, x-ray, EKG, and other testing to assist your Healthcare Provider in certain diagnosis and treatment and may require coordinating care with your primary care provider.
• There may be unknown risks or negative outcomes associated with the use of telehealth for certain health conditions.

By accepting this consent, you acknowledge that you understand, accept, and agree with the following statements:

• I understand that my Healthcare Provider will be at a different location than me and I will receive healthcare services, including assessment, treatment, diagnosis, and education, using interactive audio, video, and data communications.
• I understand that Palana may determine that its services are not appropriate for some or all of my treatment needs and may elect not to provide services to me.
• I attest that I have the legal authority to sign for myself or to act as guardian or personal representative for all persons under the age of 18 years old registered under my Palana Account.
• I understand that Palana Healthcare Providers may share my health records with other healthcare providers for purposes relating to the provision, coordination or management of my care to meet my healthcare needs. This may include information relating to clinical and diagnostic testing, communicable diseases, and other health conditions, subject to the terms in the Palana Notice of Privacy Practices.
• I understand that individuals other than my Healthcare Provider may be present during my telehealth visit in order to operate the telehealth technologies. I will be informed of their presence and will have the right to: (1) limit the information I share; (2) ask non-clinical/unlicensed personnel to leave the telehealth visit at any time; and/or (3) terminate the telehealth visit at any time.
• I understand that while there are potential benefits in the use of telehealth, none of these benefits can be guaranteed or assured.
• Palana has explained to me the alternatives to a telehealth visit for certain conditions or treatments.
• In choosing to participate in a telehealth visit, I understand that some parts of the exam involving physical tests may be conducted by individuals at my remote location at the direction of the consulting Healthcare Provider.
• I understand that I may withhold or withdraw my consent to the use of telehealth at any time by notifying my Palana Healthcare Provider. I understand that the result of withdrawing my consent is that I may no longer receive services from Palana.

By selecting “I agree,” you hereby acknowledge that you have read this document carefully and understand the risks and the information provided above regarding the use of telehealth. You have had the opportunity to discuss this document and the information contained herein with a healthcare provider or other individual of your choosing and any questions you had have been answered to your satisfaction. You hereby give your consent to Palana to provide telehealth services to you for consultation, evaluation, diagnosis, and related treatment purposes under the terms described herein.