Consent to Telehealth

Agreeing to this Consent

Selecting “I Agree,” checking an acceptance box, or otherwise confirming consent means you have read this Telehealth Informed Consent (“Consent”) and accept it. If you do not, do not open an account or use the Service. Anyone who accepts for you is authorized to bind you to this Consent.

A digital copy of this Consent is available via email at support@archiehealth.org or through the Service. This form will be placed in your medical records.

If this is an emergency

If you are experiencing a medical emergency or life-threatening situation, call 9-1-1 immediately. Do not attempt to contact Archie Health or your Provider through the Service for emergency care. After receiving emergency treatment, follow up with your local primary care provider.

Purpose

This Consent informs you (“patient,” “you,” or “your”) about telehealth, including its methods, risks, and limitations, and obtains your informed consent to receive healthcare services from physicians or other healthcare providers (“Providers”) through Archie Health’s online platform (the “Service”). Archie Health provides administrative and management services and does not itself provide medical services. This Consent should be read together with the Service’s Terms of Use.

How telehealth works

Telehealth involves delivering healthcare using electronic communications, information technology, or other means between a Provider and a patient not in the same physical location. It may include:

• Electronic transmission of medical records, images, or health data;
• Audio, video, or text-based interactions (e.g. messaging, email);
• Use of data from medical devices, sound, or video files;
• Medical intake forms, prescription refills, or consultation reports.

Telehealth may be used for diagnosis, treatment, follow-up, or patient education. You understand that telehealth may have limitations compared to in-person care, such as the inability to perform physical examinations, potential technical failures, and differences in communication. Alternative care options, such as in-person visits with a local healthcare provider, are available outside the Service, and you may choose an alternative at any time after discussing with your Provider. You may withdraw consent to telehealth at any time, but this may result in Providers discontinuing care.

Expected Benefits

Telehealth may offer:

• Improved access to care from your preferred location;
• Convenient follow-up care (contact your Provider via the Archie Health messaging portal for non-emergent needs or support@archiehealth.org for non-clinical issues);
• Efficient evaluation and management (clinical questions typically answered within 48 hours, Monday through Friday, excluding holidays).

Possible Risks

Telehealth involves risks, including:

• Delays due to equipment, technology failures, or Provider availability;
• Inadequate data quality affecting diagnosis or treatment;
• Rare instances where Providers require rescheduling or in-person visits due to poor data quality;
• Potential privacy breaches if security protocols fail;
• Incomplete medical records leading to adverse drug interactions, allergic reactions, or clinical errors;
• Technology errors (e.g., bugs, data corruption) limiting functionality or producing incorrect results;
• Inability to perform in-person tests or assess vital signs, potentially preventing diagnosis or identifying emergencies;
• Regulatory limits on prescriptions or treatment options;
• Missed visual, auditory or other cues compared to in-person visits;
• Patient withholding of key medical information;
• Possible information loss due to technical failures.

You accept that telehealth consultations, including any “physical exam” (e.g. via photos, video or questionnaires), may involve uncertainty or inaccuracy compared to in-person exams. Report adverse side effects to your Provider, local doctor, or seek emergency care if needed.

Limits of the services

Providers accessible through the Service may offer consultations, diagnoses, treatment recommendations, prescriptions, or referrals to in-person care when clinically appropriate. Each Provider must be appropriately licensed or otherwise authorized to practice where the patient is located and will establish a provider-patient relationship for the specific services provided.

These services do not replace primary care or emergency care. Providers are not your general or specialized healthcare providers, and their role is limited to the service engaged. Responsibility for your overall care remains with your local primary care provider, if you have one, and you are encouraged to establish one if you do not. Providers may deny care for potential misuse or if deemed medically or ethically inappropriate.

Coaching Disclaimer — No Professional Licensure

Our coaches are not licensed healthcare professionals. They are not dietitians, nutritionists, physicians, or other state-regulated healthcare professionals. All information, suggestions, and support they provide are general wellness and behavioral-change coaching only. The coaching does not diagnose, treat, cure, or prevent any disease, does not constitute “medical nutrition therapy,” and does not replace individualized advice from a licensed healthcare provider. Always seek the guidance of a licensed physician or registered dietitian for questions about a medical condition or before making major dietary changes. By enrolling in this program you acknowledge and agree to these limitations.

You agree to inform Providers of any conditions affecting your ability to receive services and to follow up with your primary care provider for any issues arising during or related to the services. Providers do not guarantee the accuracy, completeness or adequacy of services.

Privacy and security of telehealth

The Service uses administrative, technical, and physical safeguards designed to protect patient information and handles protected health information in accordance with the Health Insurance Portability and Accountability Act (HIPAA), where applicable. Your identity will be verified, and your Provider’s credentials are available upon request. Personal or protected health information will not be disclosed without your consent except as permitted or required by law, including for treatment, payment, healthcare operations, or as described in the applicable Notice of Privacy Practices.

Email or text communications may involve your health information and may be less secure than other channels, creating a risk of unauthorized access. By using these methods, you acknowledge and accept these risks. Telehealth sessions may not be recorded by you or your Provider without appropriate authorization. Patient-identifiable images or information will not be used for research or education without your affirmative consent unless otherwise permitted by law. No system is completely risk-free, and technical failures may result in information loss.

Additional service limits

Telehealth cannot replicate direct physical contact, so some clinical needs may require in-person care, as determined by your Provider. The Service does not provide emergency care or operate in-person clinics. If you require urgent or emergency care, seek treatment at an emergency room or other appropriate facility. For non-urgent issues, use the Service’s secure messaging portal. For technical assistance, contact support@archiehealth.org.

You must provide truthful, accurate and complete information, including updates to your medical or mental health status and emergency contact details for local providers. Medical records are stored in a secure database with reasonable safeguards, but some information may be shared for scheduling or billing purposes.

Prescriptions

Prescriptions are not guaranteed. Your plan price includes the clinician review, medication if prescribed, supplies, and shipping. Archie Health does not bill insurance. You must review risks, side effects and drug interactions with your Provider, local doctor, or pharmacist. Report adverse effects immediately and seek emergency care if needed. Prescriptions are issued by Dr. Robert Vichich, M.D., an independently licensed physician in the USHWN network. Medication is filled by GoGoMeds, a U.S.-licensed pharmacy.

Where care is provided

You must provide accurate information about your physical location at each telehealth encounter. Archie Health will connect you with a Provider who is licensed or otherwise authorized to practice where you are located, as required by applicable law. If your location changes, notify your Provider immediately.

Open Payments (Sunshine Act) notice

The federal Open Payments database (Open Payments) provides information on payments above a small annually adjusted threshold (see openpaymentsdata.cms.gov) from drug, device or biologic manufacturers to physicians and teaching hospitals, as required by the Physician Payments Sunshine Act.

What you acknowledge

By consenting, you agree to the following:

1. Services are provided via telehealth by an independently licensed physician, Dr. Robert Vichich, M.D., in the USHWN network, and do not replace your primary care provider.
2. You understand the benefits and risks of telehealth, as outlined above, and that alternatives (e.g. in-person care) are available.
3. You may withdraw consent to telehealth at any time without affecting your right to future care, although doing so may end the telehealth services offered by your Provider.
4. You have the right to review your Provider’s credentials, which are listed on our Medical Team & Licensing page.
5. Technical failures may disrupt services or cause delays or data loss. You agree to follow instructions for obtaining alternative care when necessary.
6. Technology may contain defects or errors impacting care quality, accuracy or effectiveness.
7. You will provide complete, accurate and current medical history and updates via the Patient Portal.
8. No benefits, results, or prescriptions are guaranteed, and your condition may not improve or may worsen.
9. Providers may deny care if deemed inappropriate, and you agree to their medical assessment for telehealth services.
10. You accept risks of unsecure communication methods (e.g. email, text) and will not hold Archie Health liable for unauthorized access.
11. Your medical records are confidential under federal and state laws, accessible via the Patient Portal at a reasonable cost.
12. Others (e.g. technical staff) may be present during consultations to operate technology, and you may request their exclusion or omit sensitive details.
13. Archie Health may have administrative or commercial arrangements with independent Providers, pharmacies, and service vendors. You may instead seek care from a provider or pharmacy outside Archie Health.
14. You will pay all costs of the Service, which are shown before checkout. Archie Health does not bill insurance, Medicare or Medicaid, and you will not submit claims for the Service to Medicare, other federal payors, or insurers.
15. You understand that consent may be required annually or per encounter, depending on state requirements.
16. Your Provider will determine whether telehealth is appropriate for your care.

If you have concerns about a Provider, contact your state’s Medical Board (list available at Federation of State Medical Boards).

Consents that vary by state

The following consents apply to users accessing the Service for the purposes of participating in a telehealth consultation as required by the states listed below:

• Alaska: I understand my primary care provider may obtain a copy of my records of my telehealth encounter. (AK Stat. 08.64.364).
• Arizona: I understand I am entitled to all existing confidentiality protections pursuant to A.R.S. § 12-2292. I also understand all medical reports resulting from the telemedicine consultation are part of my medical record as defined in A.R.S. § 12-2291. I also understand dissemination of any images or information identifiable to me for research or educational purposes shall not occur without my consent, unless authorized by state or federal law. (A.R.S. § 36-3602).
• California: Physicians and midwives and other practitioners are licensed and regulated by the Medical Board of California. To confirm a license or file a complaint, go to www.mbc.ca.gov or call (800) 633-2322.
• Connecticut: I understand that my primary care provider may obtain a copy of my records of my telehealth encounter. (C.G.S.A. § 19a-906).
• D.C.: I have been informed of alternate forms of communication between me and a physician for urgent matters. (17 DCMR § 4618.10).
• Idaho: I acknowledge that my identity has been verified, and I have been informed about my Provider’s credentials. I understand the security measures in place to protect my health information and have been informed about the possibility of information loss due to technical failures.
• Kentucky: If I am a Medicaid recipient, I recognize I have the option to refuse the telehealth consultation at any time without affecting the right to future care or treatment and without risking the loss or withdrawal of a Medicaid benefit to which I am entitled. I understand that I have the right to be informed of any party who will be present at the site during the telehealth consult and I have the right to exclude anyone from being present. I also understand that I have the right to object to the videotaping of the telehealth consultation. (KY Admin. Regs. Tit. 907, 3:170).
• Louisiana: I understand the role of other healthcare providers who may be present during the consultation in addition to my Provider. I further understand that I may decline to receive medical services via telemedicine and may withdraw from such care at any time. (46 La. Admin. Code Pt. XLV, § 7511).
• Maryland: I understand that dissemination of image or information identifiable to me shall not be disseminated to other entities without my consent, unless there is an emergency preventing the practitioner from obtaining such consent. (Code of MD Reg. 10.09.49.09).
• Nebraska: If I am a Medicaid recipient, I retain the option to refuse the telehealth consultation at any time without affecting my right to future care or treatment and without risking the loss or withdrawal of any program benefits to which the patient would otherwise be entitled. All existing confidentiality protections shall apply to the telehealth consultation. I shall have access to all medical information resulting from the telehealth consultation as provided by law for access to my medical records. Dissemination of any patient identifiable images or information from the telehealth consultation to researchers or other entities shall not occur without my written consent. I understand that I have the right to request an in-person consult immediately after the telehealth consult and I will be informed if such consult is not available. (NE Revised Stat.71-8505; NE Admin. Code Tit. 471, Ch. 1).
• Nevada: I consent to the forwarding of my medical records to my primary care provider or other designated healthcare providers.
• New Hampshire: I understand that my Provider may forward my medical records to my primary care or treating provider. (N.H. Rev. Stat. § 329:1-d).
• New Jersey: I understand I have the right to request a copy of my medical information and I understand 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. (NJ Rev. Stat. §45:1-62).
• Ohio: I understand that technical failures may cause delays or disruptions in service and may require alternative methods of care.
• Rhode Island: If I use email or text-based technology to communicate with my Provider, I understand the types of transmissions that are permitted and the circumstances in which alternate forms of communication or in-person visits should be used. I have also discussed security measures, such as data encryption, password-protected screen savers and data files, or other reliable authentication techniques, as well as potential privacy risks. I acknowledge that failure to comply with these requirements may result in my Provider ending email or text-based communications. (Rhode Island Medical Board Guidelines).
• South Carolina: I understand my medical records may be distributed in accordance with applicable law and regulation to other treating health care practitioners. (S.C. Code 1976 §40-47-37).
• Tennessee: I understand that I may request an in-person assessment before receiving a telehealth assessment if I am a Medicaid recipient.
• Texas: I acknowledge that for telehealth services in Texas, consent must be obtained prior to each encounter or annually. I understand there are no fees beyond my plan price, which is shown before checkout.
• Vermont: I understand that I have the right to receive a consultation with a distant-site Provider and will receive one upon request immediately or within a reasonable time after the results of the initial consultation. (Vt. Stat. Ann. tit. 8, § 9361). If receiving audio-only services, I understand the availability of alternative delivery methods and the insurance implications.
• Wisconsin: I confirm that my identity and my Provider’s credentials have been verified, the technology used has been explained, and that telehealth is appropriate for my care, with security measures in place.

State-law compliance

This Telehealth Informed Consent is intended to address generally applicable telehealth consent requirements. Additional state-specific disclosures or consents may be presented when required by applicable law.

Specific Benefits and Risks of the Services You Are Receiving

To learn more about the specific benefits and risks of the Services you are seeking, please select from the offered Services below:

• Weight Loss