HIPAA Authorization for Use and Disclosure of Protected Health Information

Please review this authorization carefully. By signing below, you authorize the use and disclosure of your protected health information, also known as PHI, as described in this form.

1. Patient Information

Patient full legal name:

Not provided

Date of birth:

Not provided

Phone number:

Not provided

Email address:

Not provided

Address:

Not provided

2. Person or Organization Authorized to Disclose Information

I authorize any health care provider, clinic, hospital, laboratory, pharmacy, health plan, or other health care organization that has provided, is providing, or will provide care, coverage, testing, treatment, medication, or related services to me to disclose my protected health information as described in this authorization.

This authorization also applies to the workforce members, business associates, records departments, and other personnel acting on behalf of the disclosing provider or organization, as permitted by law.

3. Person or Organization Authorized to Receive Information

I authorize my protected health information to be disclosed to and used by Provider Plexus, Inc., its workforce members, affiliated or contracted clinicians, clinical team members, administrative staff, care coordinators, and other personnel involved in my telehealth consultation, treatment coordination, or continuity of care.

Receiving organization:

Provider Plexus, Inc.

Address:

251 Little Falls Drive, Wilmington, DE 19808

Email/contact:

legal@providerplexus.com

Fax:

+1 (302) 828-8599

4. Purpose of Disclosure

The purpose of this authorization is to facilitate:

• Telehealth consultation;
• Evaluation and treatment;
• Treatment coordination;
• Continuity of care;
• Communication among providers and clinical team members involved in my care.

5. Information Authorized for Disclosure

I authorize the disclosure and use of the following protected health information relevant to my current or ongoing care:

• Medical records;
• Visit notes and clinical notes;
• Laboratory results;
• Imaging reports;
• Medication lists;
• Allergy lists;
• Diagnosis and treatment information;
• Referral information;
• Care plans;
• Records related to my current symptoms, condition, consultation, or treatment.

This authorization does not include psychotherapy notes and does not authorize disclosure of records that require separate or special authorization under applicable federal or state law.

6. Expiration

This authorization will expire one year from the date of signature unless I revoke it earlier in writing.

7. Right to Revoke

I understand that I may revoke this authorization at any time by submitting a written revocation request to:

Revocation contact/name or department:

Provider Plexus, Inc. Legal Department

Mailing address:

251 Little Falls Drive, Wilmington, DE 19808

Email:

legal@providerplexus.com

I understand that revocation will not affect any use or disclosure already made in reliance on this authorization before the revocation was received and processed.

8. Voluntary Authorization

I understand that signing this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditioned on whether I sign this authorization, except where permitted by law.

If the requested information is necessary for a telehealth consultation or care coordination, I understand that refusing to sign may limit the provider's ability to obtain or review records needed for that consultation or coordination.

9. Redisclosure Notice

I understand that information disclosed under this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal HIPAA privacy regulations. Other federal or state privacy laws may still apply.

10. Copy of Authorization

I understand that I have a right to receive a copy of this signed authorization.

11. Electronic Signature

By typing my full legal name below, I confirm that I have read and understand this HIPAA Authorization. I authorize the use and disclosure of my protected health information as described above, and I adopt my typed name as my electronic signature. If I am signing as a surrogate or designated person, I confirm that I am authorized to sign on the patient's behalf.

Patient or surrogate/designated person full legal name / electronic signature:

Not provided

Date:

Not provided

Telehealth Informed Consent

Please review this Telehealth Informed Consent carefully. By signing below, you agree to receive healthcare services through telehealth.

1. Patient Information

Patient full legal name:

Not provided

Date of birth:

Not provided

Phone number:

Not provided

Email address:

Not provided

Patient address:

Not provided

2. What Telehealth Means

I understand that telehealth involves the delivery of healthcare services using electronic communications or other technology when the provider and patient are not in the same physical location.

Telehealth may include video visits, audio communications, secure messaging, electronic transmission of health information, image sharing, remote consultation, or store-and-forward technology.

Telehealth may be used for consultation, evaluation, treatment planning, follow-up care, review of records or test results, care coordination, referrals, and other healthcare services the provider determines can be appropriately delivered through telehealth.

3. Tennessee Provider-Patient Relationship

I understand that, under Tennessee law, a telehealth provider-patient relationship may be created through mutual consent and mutual communication between the provider and patient, except in an emergency.

By signing this consent and participating in a telehealth visit, I voluntarily consent to receive healthcare services through telehealth.

I understand that the provider-patient relationship is not created merely because health information is received by a provider, unless a prior provider-patient relationship already exists.

4. Patient Identity and Location

I understand that I may be asked to confirm my identity at the beginning of a telehealth visit.

This may include confirming my full name, date of birth, phone number, current address, city, state, and emergency contact information.

I understand that confirming my location helps the provider determine whether telehealth is appropriate and helps the provider respond if an emergency occurs during the visit.

I understand that I may be required to confirm my physical location at the beginning of each telehealth visit. If I am not physically located in Tennessee at the time of the visit, the provider may be unable to provide telehealth services unless the provider is authorized to practice in the state where I am located.

Patient location at time of visit:

Confirm during visit

5. Provider Assignment and Provider Disclosures

I understand that the specific healthcare provider who will provide telehealth services to me may be assigned after I sign this consent.

I understand that the provider will disclose or make available their name, credentials, license type, primary practice location, specialty, if applicable, and other information required by Tennessee law or applicable professional rules.

I understand that the provider must be licensed or otherwise authorized to provide healthcare services to me based on my physical location at the time of the telehealth visit.

I understand that if a different provider participates in my care, that providers identity and applicable professional information may also be disclosed or made available to me.

By continuing with the telehealth visit after the provider has been identified, I consent to receive telehealth services from that provider.

6. Benefits of Telehealth

I understand that potential benefits of telehealth may include:

• Improved access to care;
• Convenience;
• Reduced travel time;
• Ability to receive care from a provider or specialist who may not be available locally;
• Improved care coordination and follow-up.

7. Risks and Limitations of Telehealth

I understand that telehealth has risks and limitations, including:

• The provider may not be able to perform a complete physical examination;
• Images, video, audio, or other information may be incomplete, unclear, delayed, or insufficient for medical decision-making;
• Technology problems may delay, interrupt, or prevent evaluation or treatment;
• Security protocols could fail, which may result in a privacy or security breach;
• Telehealth may not be appropriate for every condition;
• The provider may recommend in-person care, urgent care, emergency care, testing, imaging, referral to another provider, or additional information before making a diagnosis or treatment recommendation.

I understand that if the provider determines that the information available through telehealth is not sufficient to evaluate, diagnose, or treat me safely, the provider may decline to make a diagnosis or treatment recommendation and may request additional information, recommend an in-person examination, refer me to another provider, or recommend urgent or emergency care.

8. Standard of Care

I understand that telehealth services are subject to the same general standard of professional practice as comparable healthcare services provided in person.

I understand that the provider will determine whether telehealth is clinically appropriate based on my condition, available information, technology, and applicable professional standards.

9. Emergencies

I understand that telehealth is not intended for medical emergencies.

If I believe I am experiencing a medical emergency, I should call 911 or seek emergency medical care immediately.

If an emergency occurs during a telehealth visit, I understand that the provider or clinical team may attempt to contact emergency services or my emergency contact using the location and contact information I have provided.

Emergency contact name:

Not provided

Emergency contact phone:

Not provided

Relationship:

Not provided

10. Technology and Disconnection

I understand that telehealth depends on functioning technology, internet access, audio/video quality, and electronic communication systems.

If the telehealth connection is interrupted, I agree that the provider or clinical team may attempt to contact me using the phone number, email, patient portal, or other contact information I have provided.

Backup phone number for visit:

Not provided

11. Privacy and Security

I understand that the provider will take reasonable steps to protect the privacy and security of my health information during telehealth services.

I understand that I am responsible for choosing a private location for my telehealth visit when possible, using a secure device and internet connection when available, and telling the provider if another person can see or hear the visit.

No person should observe or participate in my telehealth visit unless I agree, except as permitted or required by law.

12. Other Participants or Facilitators

I understand that another person, such as a caregiver, interpreter, clinical staff member, parent, guardian, or other facilitator, may participate in or assist with a telehealth visit when appropriate.

If another person is present with me during the visit, I agree to identify that person to the provider. If a facilitator is used, the facilitator may be asked to confirm their identity, role, and relationship to me.

13. Recording and AI-Assisted Documentation

I understand that telehealth visits may not be recorded by me, the provider, or any other person unless permitted by applicable law and provider policy, and unless all required permissions are obtained.

I understand that my provider may use an AI-assisted documentation tool, such as an AI scribe, to help create clinical notes from the visit. Any information used for this purpose will be handled in accordance with applicable privacy laws and provider policy.

14. Medical Records

I understand that telehealth services will be documented in my medical record, including the fact that the service was provided through telehealth and the technology used, when required by applicable law or professional rules.

I understand that I may request access to medical records maintained by the provider as permitted by applicable law.

15. Prescriptions and Controlled Substances

I understand that prescriptions, including prescriptions for controlled substances or medications subject to special rules, will be provided only when clinically appropriate and permitted by applicable federal and Tennessee law.

I understand that receiving telehealth services does not guarantee that any medication will be prescribed.

16. Alternatives to Telehealth

I understand that alternatives to telehealth may include an in-person visit, urgent care, emergency care, referral to another provider, or no treatment.

I understand that I may choose to pursue in-person care at any time.

17. Costs and Insurance

I understand that telehealth services may result in charges, copayments, deductibles, coinsurance, or other patient financial responsibility, depending on my insurance coverage and the provider's billing policies.

I understand that I may contact the provider or my health plan with questions about coverage or payment.

18. Right to Withdraw Consent

I may withdraw my consent to receive telehealth services at any time.

Withdrawing consent will not affect my right to future care or treatment, but it may require that future services be provided in person or through another appropriate method.

19. Voluntary Consent

By signing below, I acknowledge that I have read and understand this Tennessee Telehealth Informed Consent.

I have had the opportunity to ask questions.

I voluntarily agree to receive healthcare services through telehealth.

20. Electronic Signature

By typing my full legal name below, I confirm that I have read and agree to this Tennessee Telehealth Informed Consent, and I adopt my typed name as my electronic signature. If I am signing as a surrogate or designated person, I confirm that I am authorized to sign on the patient's behalf.

Patient or surrogate/designated person full legal name / electronic signature:

Not provided

Date:

Not provided