Informed Consent: State Regulatory Information

Alaska

You understand your primary care provider may obtain a copy of your records of your telehealth encounter. (Alaska Stat. § 08.63.210(C)(2)).

Arizona

You understand that all medical records resulting from a telemedicine consultation are part of your medical record. (Ariz. Rev. Stat. Ann. § 36-3602(D)).

California

All physicians licensed to practice in the State of California are licensed and regulated by the Medical Board of California. To check on a physician's license or to file a complaint, go to www.mbc.ca.gov, email licensecheck@mbc.ca.gov, or call (800) 633-2322.

Connecticut

You understand that your primary care provider may obtain a copy of your records of your telehealth encounter, and that you can revoke your consent at any time. (Conn. Gen. Stat. Ann. § 19a-906).

D.C.

You have been informed of alternate forms of communication between you and a physician for urgent matters. (D.C. Mun. Regs. tit. 17, § 4618.10). Relevant communications with the physician, including those done via electronic methods shall be documented and filed in your medical record. (D.C. Mun. Regs. tit. 17, § 4618.9).

Florida

Patients that are prescribed GLP-1 medications, such as Semaglutide, for weight-loss — You have been provided with the Weight-Loss Consumer Bill of Rights.

Georgia

You have been given clear, appropriate, accurate instructions on follow-up in the event of needed emergent care related to the treatment. (Ga. Comp. R. & Regs. 360-3-.07(7)).

Idaho

You have been informed that if you want to register a formal complaint about a provider, you should visit the medical board's website, here: https://dopl.idaho.gov/filing-a-complaint/ (Idaho Guidelines for Appropriate Regulation of Telemedicine). You further understand that your informed consent for the use of telehealth services shall be obtained by applicable law. Idaho Statutes 54-5708.

Indiana

If a prescription is issued to you, and subject to your consent the prescriber shall notify your primary care provider of any prescriptions the prescriber has issued for you if the primary care provider's contact information is provided by you. This requirement does not apply if: (A) The practitioner is using an electronic health record system that your primary care provider is authorized to access. (B) The practitioner has established an ongoing provider-patient relationship with the patient by providing care to the patient at least 2 consecutive times through the use of telehealth services. If the conditions of this clause are met, the practitioner shall maintain a medical record for you and shall notify your primary care provider of any issued prescriptions. Ind. Code Ann. 25-1-9.5-7.

Iowa

To file a complaint, fill out the complaint form and email it to the medical board at ibmcomplaints@iowa.gov. Iowa Admin. Code 653-13.11(147,148,272C)(13.11(18)).

As appropriate your provider will identify the medical home or treating physician(s) for you, when available, where in-person services can be delivered in coordination with the telemedicine services. Your provider shall provide a copy of the medical record to your medical home or treating physician(s). Iowa Admin. Code 653-13.11(147,148,272C)(13.11(11))

Kansas

You understand that if you have a primary care provider or other treating physician, the person providing telemedicine services must send within three business days a report to such primary care or other treating physician of the treatment and services rendered to you during the telemedicine encounter. (Kan. Stat. Ann. § 40-2,212(2)(d)(2)(A)).

Kentucky

You have been informed that if you want to register a formal complaint about a provider, you should visit the medical board's website, here: https://kbml.ky.gov/board/Pages/default.aspx.

If requested by you, your physician must share the medical record with your primary care physician and other relevant members of your existing care team. Kentucky Board Opinion on the Use of Telemedicine Technologies (2014), as amended September 15, 2022.

Louisiana

You understand the role of other health care providers that may be present during the consultation other than the telehealth provider. (46 La. Admin. Code Pt XLV, § 7511).

Maine

You have been informed that if you want to register a formal complaint about a provider, you should visit the medical board's website, here: https://www.maine.gov/md/complaint/file-complaint. (Code Me. R. tit. 02-373 Ch. 11, § 3.).

New Hampshire

You understand that the telehealth provider may forward your medical records to your primary care or treating provider. (N.H. Rev. Stat. § 329:1-d).

New Jersey

You understand that you have the right to request a copy of your medical information and you understand your medical information may be forwarded directly to your primary care provider or health care provider of record, or upon your request, to other health care providers. If you do not have a primary care provider or other health care provider of record, the health care provider engaging in telemedicine or telehealth may advise you to contact a primary care provider, and, upon request by you, may assist you with locating a primary care provider or other in-person medical assistance that, to the extent possible, located within reasonable proximity to you. N.J. Rev. Stat. Ann. § 45:1-62.

New York

Patients that are prescribed GLP-1 medications, such as Semaglutide, for weight-loss — You have been provided with the Weight-Loss Consumer Bill of Rights.

WEIGHT LOSS AND DIETING INFORMATION

1. WARNING! Rapid weight loss may cause serious health problems. Rapid weight loss is weight loss of more than 1½ to 2 pounds per week or weight loss of more than 1 percent of body weight per week after the second week of participation in a weight loss program.
2. Consult your physician before starting any weight loss program or using any diet medications or formulas.
3. Long term weight control is the safest and most important goal of any diet program. Permanent lifestyle changes such as eating nutritious foods, calorie control and increasing physical activity help promote long term weight loss according to medical experts.
4. Ask the person providing or selling you weight loss advice or diet products, medications or formulas about their qualifications and training in nutrition and health.
5. You have the right to:
   • Ask questions about the potential health risks of this program or product, its nutritional content, and its psychological-support and educational components;
   • Know the price of treatment, including the price of any extra products, services, supplements and laboratory tests; and
   • Know the program duration of the program recommended to you.

N.Y. Gen. Bus. Law § 642.

Ohio

You understand that the telehealth provider may forward your medical records to your primary care or treating provider. Ohio Admin. Code 4731-37-01(C)(4).

Oregon

If you have a concern or complaint about the providers providing care to you, you may contact a board agency to assist you. You understand that the provider may ask if you need more detail. ORS 17-52-677.097. See also Or. Medical Board, Statement of Philosophy: Telemedicine (Oct 2, 2020)

Complaints may be filed with:

Oregon Medical Board 1500 SW 1st Ave., Suite 620 Portland, OR 97201-5847 Complaint Resource Staff: 971-673-2702 | complaintresource@omb.oregon.gov

Rhode Island

If you use e-mail or text-based technology to communicate with your provider, then you understand the types of transmissions that will be permitted and the circumstances when alternate forms of communication or office visits should be utilized. You have also discussed security measures, such as encryption of data, password protected screen savers and data files, or utilization of other reliable authentication techniques, as well as potential risks to privacy. You acknowledge that your failure to comply with this agreement may result in the telehealth provider terminating the relationship. (Rhode Island Medical Board Guidelines).

South Carolina

You understand your medical records may be distributed in accordance with applicable law and regulation to other treating health care practitioners. You understand the value having of having a primary care medical home and, if requested, we can provide assistance in identifying available options for a primary care medical home. S.C. Code Ann. § 40-47-37.

South Dakota

You have received disclosures regarding the delivery models and treatment methods or limitations. You have discussed with the telehealth provider the diagnosis and its evidentiary basis, and the risks and benefits of various treatment options. (S.D. Codified Laws § 34-52-3).

Texas

You understand that your medical records may be sent to your primary care physician within 72 hours. Tex. Occ. Code Ann. § 111.005. You have been informed of the following notice:

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 the following address: 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 the following telephone number: 1-800-201-9353, For more information, please visit our website at www.tmb.state.tx.us.

AVISO SOBRE LAS QUEJAS — Las quejas sobre médicos, asi como sobre otros profesionales acreditados e inscritos del Consejo Médico de Tejas, incluyendo asistentes de médicos, practicantes de acupuntura y asistentes de cirugía, se pueden presentar en la siguiente dirección para ser investigadas: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018, Si necesita ayuda para presentar una queja, llame al: 1-800-201-9353, Para obtener más información, visite nuestro sitio web en www.tmb.state.tx.us

Utah

You are able to (i) access, supplement, and amend your patient-provided personal health information; (ii) contact your provider for subsequent care; (iii) obtain upon request an electronic or hard copy of your medical record documenting the telemedicine services, including the informed consent provided; and (iv) request a transfer to another provider of your medical record documenting the telemedicine services. Utah Admin. Code r. 156-1-602.

Virginia

You acknowledge that you have received details on security measures taken with the use of telemedicine services, such as encrypting date of service, password protected screen savers, encrypting data files, or utilizing other reliable authentication techniques, as well as potential risks to privacy notwithstanding such measures; You agree to hold harmless Alloy for information lost due to technical failures; and you provide your express consent to forward patient-identifiable information to a third party. (Virginia Board of Medicine Guidance Document 85-12).

Vermont

You understand that you have the right to receive a consult with a distant-site provider and will receive one upon request immediately or within a reasonable time after the results of the initial consult. You understand that receiving telehealth services via store-and-forward technologies by Alloy does not preclude you from receiving real-time telemedicine or face-to-face services with the distant provider at a future date. (Vt. Stat. Ann. § 9361).

You have been informed that if you want to register a formal complaint about a provider, you should visit the medical board's website, here: http://www.healthvermont.gov/health-professionals-systems/board-medical-practice/file-complaint; Board of Osteopathic Examiners can be found at: https://sos.vermont.gov/opr/complaints-conduct-discipline/#emr (Vt. Board of Medical Practice, Policy on the Appropriate Use of Telemedicine Technologies in the Practice of Medicine (March 1, 2023)).