Vitable Health Membership Agreement

Last Updated: 01/09/2025

DO NOT USE THE SERVICES IF YOU HAVE A MEDICAL EMERGENCY. IF YOU ARE HAVING A MEDICAL EMERGENCY, PLEASE DIAL 911 OR GO IMMEDIATELY TO THE EMERGENCY ROOM.

This Membership Agreement (this “Agreement”) is a contract between you and one or more of the following entities based on the state of your primary residence and/or your physical location during treatment: Telehealth services offered by Vitable Health Service, P.A., a FL Professional Corporation; Vitable Health Service, Medical Corporation, a CA Professional Corporation;  Vitable Health Services, P.A., a KS Professional Corporation; and/or Vitable Health Service of New Jersey, P.C., a NJ Professional Corporation (collectively, “Vitable Medical Group,” “we,” “our,” or “us”). Vitable Medical Group provides virtual primary care services (the “Services”) through healthcare providers who are licensed in accordance with applicable state laws, rules, and regulations (“Providers”). This Agreement govern your use of the Services.

Please read this Agreement carefully. By clicking “I accept”, “I agree,” or similar when the option is presented to you, or by accessing or using the Services, you acknowledge that you have read, understand, and agree to this Agreement and consent to receives Services from Vitable Medical Group. If you do not agree to this Agreement, you are not allowed to use the Services.

CONSENT TO CARE AND TELEHEALTH CONSENT: YOU CONSENT TO TREATMENT AND TELEHEALTH SERVICES IN SECTION 2.

WARRANTY DISCLAIMERS AND LIABILITY LIMITATIONS: THE DISCLAIMERS AND LIMITATIONS ON OUR LIABILITY ARE EXPLAINED IN SECTION 5.

MANDATORY ARBITRATION NOTICE: SECTION 6 OF THIS AGREEMENT CONTAINS A MANDATORY ARBITRATION PROVISION THAT REQUIRES THE USE OF ARBITRATION ON AN INDIVIDUAL BASIS TO RESOLVE DISPUTES. THIS MEANS THAT YOU AND VITABLE MEDICAL GROUP ARE EACH GIVING UP RIGHTS TO BRING CLAIMS AGAINST EACH OTHER IN COURT OR IN CLASS ACTIONS OF ANY KIND.

Relationship between Vitable Medical Group and Vitable, Inc.. Vitable Medical Group works closely with Vitable, Inc., a technology company that provides technological and administrative support to Vitable Medical Group and owns and operates the Vitable website and platform (the “Platform”). You acknowledge and agree that your access to and use of the Platform is subject to the Vitable, Inc. Terms of Use and Privacy Policy. Vitable, Inc. is not a healthcare provider and does not provide medical services or medical advice.

Location and Eligibility for Services. You must be at least 18 years old and are otherwise legally qualified to enter into and form contracts under applicable law to use the Services. You will be asked for your current state of residence when registering to use the Platform. You agree to notify us and updated your state of residence in the Platform if you move. You agree that you will only use the Services while located in your state of residence. We may ask you to verify your state of residence and/or physical location to ensure compliance with applicable law relating to the licensure of our Providers. You acknowledge that you may not be able to access the Services without providing us with your physical location. We reserve the right to refuse to provide Services to you if you are in a jurisdiction that we do not serve.

Consent to Care. You consent to diagnosis, medical care and treatment that you have agreed to receive and that is considered necessary or recommended by your Providers, including treatment and services through the use of telehealth technologies. You acknowledge and agree that no guarantees have been made to you about the result of your examination, care, or treatment.

Consent to Telehealth Services. "Telehealth Services" means the delivery of Services using technology when you and your Provider are not in the same physical location, and/or the virtual delivery of healthcare services, including by a Provider or via digital or automated tools, including without limitation tools for medical or health-related diagnosis and treatment.

The Telehealth Services may be used for diagnosis, treatment, care, follow-up and/or patient education, and include the following: electronic transmission of patient medical records, medical images, and/or other patient data or information; synchronous (i.e., "real time") and asynchronous (i.e., non-"real time") interactions via audio, video, text, and/or data or other electronic communications; automated, electronic or digital tools or services for diagnosis, care, treatment and/or communication pertaining to healthcare or medical matters; and output, transmission or exchange of data from medical devices, sound and video files.

You acknowledge and agree that:

• Vitable Medical Group provides Telehealth Services that are not intended as a substitute for routine or ongoing medical care or advice for acute or chronic conditions or illnesses.
• You will be assigned to a Provider licensed to provide Services in your state prior to the consult, including a review of the Provider’s credentials.
• You are prohibited from recording or taking pictures of your interactions with a Provider or other care team member without your Provider’s and Vitable Medical Group’s prior written consent.
• There are various benefits associated with Telehealth Services, including improved access to care by enabling you to remain in your home while the Provider consults with you, more efficient care evaluation and management, and obtaining expertise of a specialist located some distance away.
• Possible risks to Telehealth Services include delays in evaluation and treatment due to deficiencies or failures of the equipment and technologies.
• You are responsible for providing accurate medical information to your Provider. It is up to your Provider to determine whether your specific needs are appropriate for Telehealth Services.
• Telehealth Services using video conferencing technology and messaging-based communications will not be the same as a direct client/therapist visit because you will not be in the same room as your therapist. Alternatives to Telehealth Services, such as in-person services, are available to you.
• Information transmitted through the Telehealth Services may not be sufficient quality to allow for appropriate medical decision making, thus necessitating a rescheduled telehealth encounter or a meeting with your local healthcare provider.
• You or your Provider may discontinue any Telehealth Services encounter if you or the Provider determine that the telehealth technology used for the encounter is not adequate for the situation.
• You will not be prescribed any controlled substances and we do not guarantee that you will receive a prescription at all.
• You may withhold or withdraw your consent to the use of Telehealth Services in the course of your care at any time. However, if you withdraw your consent, we will not be able to provide Services to you.
• The state in which you reside or are located at the time you use the Services may require us to provide additional notices to you or obtain additional consents from you regarding the Telehealth Services. You can review the additional disclosures and consents applicable to you, if any, here. These disclosures and consents are incorporated into this Agreement.

Subscriptions. The Services are offered on a subscription basis through the Platform, and you agree to pay all fees for the Services. For more information about your subscription and cancellation options, please review the Vitable, Inc. Terms of Use.

Excluded Services. Your subscription does not cover (i) any ancillary services; (ii) unless otherwise specified by us in writing, any services provided by third parties; (iii) hospital services, emergency room visits, or urgent care facility visits; (iv) appointments with other providers or specialists you are referred to (whether by Vitable Medical Group or otherwise); (v) conditions that Vitable Medical Group advises are out of scope; (vi) complex chronic conditions; (vii) complex mental health; or (viii) any services not expressly listed as included in your applicable Subscription (collectively, the “Excluded Services”). Vitable Medical Group is not responsible for any medical bills incurred for any Excluded Services, even if Vitable Medical Group has referred you for such services.

No Insurance Accepted. At this time, the Providers do not accept commercial health insurance plans, are not in-network with any commercial health insurance plans and are not enrolled with federal or state healthcare programs, such as Medicare and Medicaid. By choosing to use the Services, you are specifically choosing to obtain products and services offered by the Providers on a cash-pay basis outside of any commercial health insurance plan or federal or state healthcare program. You agree that you are solely responsible for the costs of any services or products provided to you. The Services may be eligible for reimbursement from a flexible spending account (FSA) or health savings account (HSA), subject to the terms of the FSA or HSA, and you are responsible for meeting any requirements that may be required to obtain such reimbursement. You may check with your FSA plan administrator or HSA trustee or custodian for details. If you are covered by a government health plan, please consult with a provider who participates in such plans. You agree that you will not submit a claim for reimbursement to any government healthcare program or commercial health insurance plan for the costs of the services and products provided to you through the Services.

Vitable Medical Group is not an insurer and the subscription does NOT provide comprehensive health insurance coverage. It provides only the health care services specifically described. The amounts you pay to Vitable Medical Group for the subscription are NOT insurance premiums. If you desire any type of health or other insurance, you will need to purchase such insurance separately. The subscription is NOT a health insurance plan, a Medicare Insurance Supplement, a health discount plan, or a prescription discount plan. We do not meet any individual health insurance mandate that may be required by federal law. The fees for the subscription shall only cover the rendering of medical care by Vitable Medical Group and related healthcare providers that fall within the definition of the Services, and, unless otherwise specified by Vitable Medical Group in writing, shall not cover the cost of anything else, such as medications, diagnostics, medical devices, specialty medical care rendered by any third party, or any other referral made by Vitable Medical Group to a third party.

The subscription is not health insurance, and Vitable Medical Group will not file any claims against your health insurance policy or plan for reimbursement of any health care services covered by the subscription. The subscription does not qualify as minimum essential coverage to satisfy the individual shared responsibility provision of the Patient Protection and Affordable Care Act, 26 U.S.C. Section 5000A. The subscription is not workers’ compensation insurance and does not replace an employer’s obligations under Chapter 440.

Consent to Use and Disclose Health Information. You agree and consent to Vitable Medical Group using, disclosing, and/or releasing your information, including your “sensitive health information”, as permitted by law for purposes of treatment, payment, or health care operations of Vitable Medical Group, such as with your other health care providers in connection with your treatment, with Vitable, Inc. or other contractors and/or affiliates of Vitable Medical Group for scheduling, billing and other administrative purposes, with any person or entity liable for payment on your behalf in order to verify coverage or payment questions, or for any other purpose related to benefit coverage and payment. “Sensitive health information” includes information about psychiatric treatment, mental health or illness, or developmental or intellectual disability, substance use disorder treatment, and any other type of information that is given special privacy protection under state or federal laws.

Consent to Confidential Telephone and Electronic Communications. You authorize Vitable Medical Group (and Vitable, Inc. on behalf of Vitable Medical Group) to send confidential communications, including calls, text messages, and emails, to the phone numbers and email addresses we have on file for you and to leave voice messages regarding your health information at such numbers. You further authorize Vitable Medical Group to communicate with you through chat features available on the Platform. You acknowledge that the content of these communications may include, but is not limited to, health information, preventative care, treatment recommendations, outstanding balances, and requests from Vitable Medical Group for user feedback as part of your relationship with us. You acknowledge that text messages and emails may be unencrypted and carry some risk that the information in the messages could be read by an unauthorized person, and that we cannot guarantee the security and confidentiality of the text, email, or other electronic messages that we send to you, and we are not responsible for any unauthorized access that occurs during or after the transmission of any text messages or emails to you.

The Services are intended for use only within certain states in the United States and its territories. We make no representation that the Services are appropriate or are available for use in states where we do not currently operate or outside the United States.

TO THE MAXIMUM EXTENT PERMITTED BY LAW, IN NO EVENT WILL VITABLE MEDICAL GROUP, OUR AFFILIATES, AND OUR AND THEIR OFFICERS, DIRECTORS, EMPLOYEES, PROVIDERS OR AGENTS BE LIABLE FOR ANY CONSEQUENTIAL, EXEMPLARY, INCIDENTAL, SPECIAL,  PUNITIVE, OR OTHER INDIRECT DAMAGES, INCLUDING WITHOUT LIMITATION THOSE RELATING TO LOST PROFITS OR THE COST OF SUBSTITUTE PRODUCTS OR SERVICES ARISING OUT OF OR IN CONNECTION WITH THE SERVICES OR YOUR  USE OF OR INABILITY TO USE THE SERVICES, WHETHER BASED ON CONTRACT, WARRANTY, PRODUCT LIABILITY, TORT OR OTHER LEGAL THEORY AND EVEN IF WE HAVE BEEN INFORMED OF THE POSSIBILITY OF SUCH DAMAGES.

SOME JURISDICTIONS DO NOT ALLOW CERTAIN EXCLUSIONS OR LIMITATIONS OF LIABILITY, SO THE ABOVE EXCLUSIONS AND LIMITATIONS MAY NOT APPLY TO YOU.

PLEASE READ THIS SECTION CAREFULLY BECAUSE IT REQUIRES YOU AND VITABLE MEDICAL GROUP TO RESOLVE ALL DISPUTES BETWEEN US THROUGH BINDING INDIVIDUAL ARBITRATION AND LIMITS THE MANNER IN WHICH YOU CAN SEEK RELIEF FROM VITABLE MEDICAL GROUP. YOU UNDERSTAND AND AGREE THAT, BY ENTERING INTO THIS AGREEMENT, YOU AND VITABLE MEDICAL GROUP ARE EACH WAIVING THE RIGHT TO A TRIAL BY JURY AND THE RIGHT TO PARTICIPATE IN A CLASS ACTION.

We want to address your concerns without needing a formal legal case, so we have included a tiered dispute resolution process. This Dispute Resolution section may be modified by written agreement between you and Vitable Medical Group.

You and Vitable Medical Group agree that any dispute, claim, or controversy arising out of or relating in any way to this Agreement or your use of the Platform, including products and Services ordered or purchased through the Platform, shall be determined by binding arbitration instead of in courts of general jurisdiction. Arbitration is more informal than bringing a lawsuit in court. Arbitration uses a neutral arbitrator instead of a judge or jury, and is subject to very limited review by courts. Arbitration allows for more limited discovery than in court, however, we agree to cooperate with each other to agree to reasonable discovery in light of the issues involved and amount of the claim. Arbitrators can award the same damages and relief that a court can award, but in so doing, the arbitrator shall apply substantive law regarding damages as if the matter had been brought in court, including without limitation, the law on punitive damages as applied by the United States Supreme Court. You agree that, by agreeing to this Agreement, the U.S. Federal Arbitration Act governs the interpretation and enforcement of this provision, and that you and Vitable Medical Group are each waiving the right to a trial by jury or to participate in a class action. This arbitration provision shall survive termination of this Agreement and any other contractual relationship between you and Vitable Medical Group.

If you desire to assert a claim against Vitable Medical Group, and you therefore elect to seek arbitration, you must first send to Vitable Medical Group, by certified mail, a written notice of your claim ("Notice"). The Notice to Vitable should be addressed to: Vitable Medical Group, Attn: LEGAL NOTICE, 215 Bullens Lane, Woodlyn, PA 19094 ("Notice Address"). If Vitable Medical Group desires to assert a claim against you and therefore elects to seek arbitration, it will send, by certified mail, a written Notice to the most recent address we have on file or otherwise in our records for you. A Notice, whether sent by you or by Vitable Medical Group, must (a) describe the nature and basis of the claim or dispute; and (b) set forth the specific relief sought ("Demand"). If Vitable Medical Group and you do not reach an agreement to resolve the claim within 30 days after the Notice is received, you or Vitable Medical Group may commence an arbitration proceeding or file a claim in small claims court. During the arbitration, the amount of any settlement offer made by Vitable Medical Group or you shall not be disclosed to the arbitrator. You may download or copy a form Notice and a form to initiate arbitration from the American Arbitration Association at www.adr.org. If you are required to pay a filing fee, after Vitable Medical Group receives notice at the Notice Address that you have commenced arbitration, it will promptly reimburse you for your payment of the filing fee, unless your claim is for more than US $10,000. The arbitration will be governed by the Commercial Arbitration Rules and the Supplementary Procedures for Consumer Related Disputes (collectively, "AAA Rules") of the American Arbitration Association ("AAA"), as modified by this Agreement, and will be administered by the AAA. The AAA Rules and Forms are available online at www.adr.org, by calling the AAA at 1-800-778-7879, or by requesting them from us by writing to us at the Notice Address. The arbitrator is bound by the terms of this Agreement. All issues are for the arbitrator to decide, including issues relating to the scope and enforceability of this Agreement, including this arbitration agreement. Unless Vitable Medical Group and you agree otherwise, any arbitration hearings will take place in the county (or parish) of your billing address. (If you reside outside of the United States, any arbitration hearings will take place in your country of residence at a location reasonably convenient to you, but will remain subject to the AAA Rules including the AAA rules regarding the selection of an arbitrator). If your claim is for US $10,000 or less, we agree that you may choose whether the arbitration will be conducted solely on the basis of documents submitted to the arbitrator, through a telephonic hearing, or by an in-person hearing as established by the AAA Rules. If your claim exceeds US $10,000, the right to a hearing will be determined by the AAA Rules. Regardless of the manner in which the arbitration is conducted, the arbitrator shall issue a reasoned written decision sufficient to explain the essential findings and conclusions on which the award is based. If the arbitrator issues you an award that is greater than the value of Vitable Medical Group’s last written settlement offer made before an arbitrator was selected (or if Vitable Medical Group did not make a settlement offer before an arbitrator was selected), then Vitable Medical Group will pay you the amount of the award or US $1,000, whichever is greater. Except as expressly set forth herein, the payment of all filing, administration and arbitrator fees will be governed by the AAA Rules. Each party shall pay for its own costs and attorneys' fees, if any. However, if any party prevails on a statutory claim that affords the prevailing party attorneys' fees, or if there is a written agreement providing for payment or recovery attorneys’ fees, the arbitrator may award reasonable fees to the prevailing party, under the standards for fee shifting provided by law.

YOU AND VITABLE MEDICAL GROUP AGREE THAT EACH MAY BRING CLAIMS AGAINST THE OTHER ONLY IN YOUR OR ITS INDIVIDUAL CAPACITY, AND NOT AS A PLAINTIFF OR CLASS MEMBER IN ANY PURPORTED CLASS OR REPRESENTATIVE PROCEEDING. Further, unless both you and Vitable Medical Group agree otherwise, the arbitrator may not consolidate more than one person's claims with your claims, and may not otherwise preside over any form of a representative or class proceeding. The arbitrator may award declaratory or injunctive relief only in favor of the individual party seeking relief and only to the extent necessary to provide relief warranted by that party's individual claim.

If this Agreement to Arbitrate provision is found to be unenforceable, then (a) the entirety of this arbitration provision shall be null and void, but the remaining provisions of this Agreement shall remain in full force and effect; and (b) exclusive jurisdiction and venue for any claims will be in state or federal courts located in and for Philadelphia County, Pennsylvania. Both Vitable Medical Group and you agree to waive any and all rights to a jury trial in the event this agreement to arbitrate is found to be unenforceable.

Changes. Notwithstanding anything to the contrary in this Agreement, if we change this “Dispute Resolution” section after the date you accepted this Agreement or access our Services, you may reject any such change by sending us written notice (including by email to corporate@vitablehealth.com) within 30 days of the date such change became effective, as indicated in the “Last Updated” date listed at the beginning of this Agreement or in the date of our email to you notifying you of such change. By rejecting any change, you are agreeing that you will arbitrate any dispute between you and us in accordance with the provisions of this “Dispute Resolution” section as of the date you accepted this this Agreement or accessed our Services.

No Class Actions. YOU AND WE AGREE THAT EACH MAY BRING CLAIMS AGAINST THE OTHER ONLY IN YOUR OR ITS INDIVIDUAL CAPACITY AND NOT AS A PLAINTIFF OR CLASS MEMBER IN ANY PURPORTED CLASS OR REPRESENTATIVE PROCEEDING. Further, unless both you and we agree otherwise in writing, the arbitrator may not consolidate more than one person's claims and may not otherwise preside over any form of a representative or class proceeding.

Entire Agreement. This Agreement are the entire and exclusive understanding and agreement between Vitable Medical Group and you regarding the Services and other subject matter herein, and supersedes and replaces all previous communications, representations, understandings, and agreements, either oral or written, between the parties with respect to said subject matter, excluding any other agreements that you may have entered into with Vitable Medical Group, provided, however, that you shall remain bound by all terms and conditions set forth in Vitable, Inc.’s Terms of Use and Privacy Policy.

Governing Law. This Agreement shall be governed by the laws of the State of New York without reference to its conflict of laws provisions.

Severability. If any provision of this Agreement are determined to be invalid, illegal, or unenforceable, the remaining provisions of this Agreement remain in full force, provided that the essential terms and conditions remain valid, binding, and enforceable and the economic and legal substance of the transactions contemplated by this Agreement are materially preserved.

Survival. Any provision of this Agreement that by its nature should survive termination will survive such termination.

Contact Us. If you have any questions about this Agreement and/or any other documents referenced in this Agreement, please feel free to contact us at corporate@vitablehealth.com.

‍

VITABLE MEDICAL GROUP:

VITABLE HEALTH GROUP, P.A., ON BEHALF OF VITABLE MEDICAL GROUP

By:
Name:
Title:  

MEMBER:

Name:

STATE DISCLOSURES

Alaska: You understand your primary care provider may obtain a copy of your records of your telehealth encounter. (Alaska Stat. § 08.64.364).

Arizona: You understand that all medical records resulting from a telemedicine consultation are part of your medical record. (A.R.S. § 12-2291.)

Colorado: You are informed that if you want to register a formal complaint about a provider, you should file at https://dpo.colorado.gov/FileComplaint.

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 your and a physician for urgent matters. (D.C. Mun. Regs. tit. 17, § 4618.10).

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)).

Iowa: 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://medicalboard.iowa.gov/consumers/filing-complaint

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/

Illinois: You have been informed that if you want to register a formal complaint about a provider, you should visit the Illinois Division of Professional Regulation at https://idfpr.illinois.gov/admin/dpr/complaint.html

Indiana: 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://inoag.my.salesforce-sites.com/ConsumerComplaintForm

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). You understand that the complaint process may be found here: http://www.ksbha.org/complaints.shtml

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/grievances/Pages/default.aspx

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

Maryland: Telehealth services may not be provided based solely on an online questionnaire. 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.mbp.state.md.us/forms/complaint.pdf.

Nebraska: All existing confidentiality protections shall apply to the telehealth consultation. You shall have access to all medical information resulting from the telehealth consultation as provided by law for access to your medical records. Dissemination of any patient identifiable images or information from the telehealth consultation to researchers or other entities shall not occur without your written consent. You understand that you have the right to request an in-person consult immediately after the telehealth consult and you will be informed if such consult is not available. (Neb. Rev. Stat. Ann. § 71-8505; 471 Neb. Admin. Code § 1-006.05). You have been informed that if you want to register a formal complaint about a provider, you should visit: https://dhhs.ne.gov/Pages/Complaints.aspx

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 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. (N.J. Rev. Stat. Ann. § 45:1-62).

Ohio: You understand that the telehealth provider may forward your medical records to your primary care or treating provider. Ohio Admin. Code 4731-11-09(C).

Oklahoma: 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.okmedicalboard.org/complaint. Board of Osteopathic Examiners can be found at: https://www.ok.gov/osboe/faqs.html

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. (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. (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 cirugia, 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 understand (i) any additional fees charged for telehealth services, if any, and how payment is to be made for those additional fees, if the fees are charged separately from any fees for face-to-face services provided in combination with the telehealth services; (ii) to whom your health information may be disclosed and for what purpose, and have received information on any consent governing release of your patient-identifiable information to a third-party; (iii) your rights with respect to patient health information; (iv) appropriate uses and limitations of the site, including emergency health situations. You understand that the telehealth services meets industry security and privacy standards, and comply with all laws referenced in Subsection 26-60-102(8)(b)(ii). You were warned of potential risks to privacy notwithstanding the security measures and that information may be lost due to technical failures, and you agree to hold the provider harmless for such loss. You have been provided with the location of telehealth company’s website and contact information. You were able to select your provider of choice, to the extent possible. You were able to select your pharmacy of choice. You are able to a (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. 156-1-603).

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 Vitable Medical Group and your Provider 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 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/osteopathic-physicians/