Telehealth Informed Consent

This form provides information about telehealth services offered by Altru Telehealth, LLC (“Altru”) and documents your informed consent to receive care through this format. Please read carefully before proceeding with a telehealth visit.

Telehealth involves the use of secure video, audio, or messaging-based technology to allow a healthcare provider to evaluate, diagnose, treat, and/or monitor a patient remotely, without an in-person visit.

Telehealth offers convenient access to care without the need for travel. As with any healthcare service, there are potential risks, including but not limited to: technical failures or interruptions during a visit; limitations in the provider’s ability to conduct a full physical examination remotely; the possibility that information transmitted may be insufficient for accurate diagnosis, leading to a need for follow-up in-person care; and the rare but possible risk of a breach of privacy or security despite reasonable safeguards.

You have the right to choose in-person care as an alternative to telehealth at any time. If your condition is determined to be inappropriate for telehealth evaluation, your provider will recommend in-person, urgent, or emergency care as clinically indicated.

Telehealth is not appropriate for medical emergencies. If you are experiencing a medical emergency, call 911 or go to the nearest emergency room. Do not use telehealth services for symptoms that may indicate a life-threatening condition.

Altru providers are nurse practitioners holding independent practice authority and currently provide telehealth services only to patients located in the following states: New York, Maryland, Virginia, the District of Columbia, Florida, Maine, Nevada, Arizona, Oregon, New Mexico, Massachusetts, Rhode Island, Connecticut, Utah, New Hampshire, Colorado, South Dakota, Minnesota, and Delaware. You agree to accurately disclose your physical location at the time of each telehealth encounter. Care cannot be provided if you are located outside of these states at the time of your visit, even if you have previously received care from Altru while located elsewhere.

Any prescriptions will be issued solely at the clinical discretion of your provider based on the information available during your telehealth visit, and only where appropriate and permitted under applicable state and federal law. Certain medications may not be prescribed via telehealth without an in-person evaluation, depending on state and federal requirements.

Information disclosed during your telehealth visit is confidential and protected under HIPAA to the same extent as information disclosed during an in-person visit, as described in our Privacy Policy and Notice of Privacy Practices.

By proceeding with a telehealth visit, you acknowledge that you have read and understood this consent, that your questions about telehealth have been answered to your satisfaction, and that you voluntarily agree to receive care through telehealth with Altru Telehealth, LLC. You understand that you may withdraw consent to telehealth at any time without affecting your right to future care.

If you have questions about this consent or telehealth services generally, please contact us through the channels provided on our website.