Hello Alpha, Inc. is a technology company which provides a platform to affiliated medical practices. We collectively reference these practices and Hello Alpha as “Alpha” for ease, however all medical care is provided by, depending on your location, of Alpha Telemedicine, P.C., Alpha Telemedicine of Kansas, P.A., Alpha Telemedicine of New Jersey, P.A., Alpha Telemedicine of Alaska, P.C., and Hello Alpha Telemedicine, PA (each a “Provider” and collectively referred to herein as “Medical Practice”).
Alpha wants to make it easier and more convenient for you to get great healthcare by connecting you with clinicians via our mobile optimized website application (collectively the “Alpha App”). Providing healthcare via technology is often referred to as “telehealth.” This document describes the potential benefits and risks and asks you to consent to the use of telehealth as part of the Alpha service. While we believe the benefits of telehealth outweigh the risks, we want you to make an informed decision about your care and ask you to read this Informed Consent to Use of Telehealth (“Consent to Telehealth”) carefully. This Consent to Telehealth also incorporates Alpha’s Privacy Policy, which can be found here, and the Terms of Use, which can be found here, so please be sure to read those documents along with this Consent to Telehealth. You can also find our HIPAA Notice of Privacy Practices here.
As part of its mission to increase affordable, accessible primary care, Medical Practice also provides subcontracted medical services to patients of certain community-based organizations nationwide (each community-based organization is referred to as a “CBO”). When the Medical Practice is providing these subcontracted services via the Alpha App, the CBO is identified at the time you become a patient, on your invoice for payment, as well as on your prescription (if you choose to have this CBO fulfill your prescription) and you will be considered a patient of the CBO. For purposes of this Consent to Telehealth, the consent you are granting herein applies also to any CBO for whom Medical Practice provides services. A list of all CBOs with whom Medical Practice works, along with their contact information and links to their respective Privacy Notices and pharmacy assistance program terms, is here.
In using the Alpha App, you/your child will be consulting with a physician or other licensed healthcare provider (“Healthcare Provider” or simply your “Provider”) to receive health care services (the “Services”) solely via the use of “telehealth.” Telehealth involves the delivery of healthcare services using electronic communications, information technology or other means between a healthcare provider and a patient/patient surrogate who are not in the same physical location. Telehealth may be used for diagnosis, treatment, follow-up and/or patient education, and may include, but is not limited to:
Healthcare Provider(s) using the Alpha App will be interacting with you/your child solely via use of the Alpha App. As a result, all of the medical care and treatment received from such Healthcare Providers will be provided via telehealth, and you/your child will not be able to meet with your Healthcare Provider "in-person."
The electronic systems used in the Alpha App will incorporate network and software security protocols to protect the privacy and security of health information and imaging data, and will include measures to safeguard the data to ensure its integrity against intentional or unintentional corruption. Please see our Privacy Policy for more information.
ANTICIPATED BENEFITS: The use of telehealth by Healthcare Providers through the Alpha App may have the following benefits:
POSSIBLE RISKS: While the use of telehealth may provide numerous benefits, there are also potential risks. These risks include, but may not be limited to, the following:
ALTERNATIVE TREATMENT OPTIONS: You acknowledge that alternatives to telehealth services exist and that you have the right to pursue these alternatives instead of or in addition to the Services provided through the Alpha App. You have the right to receive in-person medical care from a healthcare provider in your area at any time. Alternative treatment options available to you include, but are not limited to:
For certain medical conditions, symptoms, or circumstances, in-person evaluation and treatment may be more appropriate, necessary, or required than telehealth services. Your Healthcare Provider may recommend alternative treatment approaches, including referral to specialists, in-person care, or other healthcare services when clinically appropriate for your specific medical needs. You are encouraged to discuss with your Healthcare Provider whether telehealth or alternative treatment options are most suitable for your particular health condition and circumstances.
Compounded medications. Under certain circumstances, your Alpha provider may offer or recommend a compounded medication as part of your treatment plan. In these instances, please be aware that compounded medications are not FDA approved and may not have the same safety, efficacy, or purity compared to medications produced by manufacturers who adhere to FDA standards. Alpha has worked carefully to identify compounding pharmacy partners that meet our strict standards and to ensure compliance with applicable state and federal law. Please see the frequently asked questions prepared for your specific medication for a more detailed explanation of any risks associated with any compounded medication. Please note that Alpha reserves the right to refuse to send prescriptions to compounding pharmacies that do not meet our standards.
Controlled Substances: Please note that Alpha does not prescribe controlled substances through the Alpha App.
You are further consenting and agreeing to the following:
Minimum Age. By entering into this Consent to Telehealth, you represent and warrant that you are (a) at least 18 years old; (b) if less than 18 years old, you are a minimum of 13 years old and have parental consent to the extent required, depending upon regulations in the state in which you are located; or (c) you are the parent or legal guardian of the minor patient and are legally authorized to give consent on his or her behalf, as applicable. For parents or legal guardians, the terms “you, “your”, and “patient” used herein may also apply to your minor child (the patient) as appropriate based on the context.
Provider-Patient Relationship. You acknowledge and understand that NO provider-patient relationship exists between you and Medical Practice or any Healthcare Provider until a provider-patient relationship is mutually established. A provider-patient relationship is not established until you and a Healthcare Provider mutually consent through communication about your treatment. Specifically, this relationship is not created until: (1) you have requested treatment by completing your dynamic intake process; AND (2) a Healthcare Provider has reviewed your intake information and affirmatively agreed to undertake your diagnosis and treatment. By completing your intake and agreeing to this Consent to Telehealth, you are requesting to establish a provider-patient relationship, but Medical Practice and its Healthcare Providers are under no obligation to accept you as a patient until the Healthcare Provider exercises their professional judgment to do so. Reasons a Healthcare Provider may be unable to agree to treatment include, but are not limited to, a potential patient not meeting our age requirements, being located in a state in which the provider is not licensed, being unable to establish their age and identity through valid government photo identification, otherwise seeking treatment not amenable to telehealth as described in this Consent to Telehealth, or any other reason permitted by applicable law or professional or ethical guidelines. If a Healthcare Provider cannot treat you, you will be promptly notified.
Your Healthcare Provider’s Information and Credentials. Before or at the time of your treatment, you will be informed of your assigned Healthcare Provider’s name and professional credentials. They will be licensed in the state you have declared during your intake process. This information will be made available to you through the Alpha App in your patient portal and/or provided upon request by contacting us at contact@helloalpha.com. All Healthcare Providers providing services to you through the Alpha App are licensed to practice medicine in the state where you are located at the time of Treatment. You may verify your Healthcare Provider’s license and credentials by contacting the appropriate state medical board for the state in which you are receiving treatment. For California patients, additional provider disclosure information is set forth in the “Disclosure of Physician Information (CALIFORNIA PATIENTS ONLY)” section below.
Consent to Services.
DO NOT USE THE ALPHA APP FOR EMERGENCY OR URGENT MEDICAL MATTERS
For all emergency or urgent medical matters, you should call 911 or go to the nearest emergency room or urgent care facility. You may also reach the National Suicide and Crisis Lifeline by dialing 988.
Unable to Treat. Under certain limited circumstances, a Healthcare Provider may determine, in their best judgment, that they are unable to provide medical treatment and services to you, based on information received or conduct occurring during the course of your treatment; provided, however, that in no case shall a Healthcare Provider make such a determination based on a Patient’s sex, sexual orientation, gender identity, race, creed, color, national origin, disability or any other characteristic protected by applicable law.
Appropriateness of Telehealth for Your Condition. Your Healthcare Provider will evaluate whether telehealth is appropriate for your specific health condition and symptoms. If your Healthcare Provider determines that your condition is not suitable for diagnosis or treatment via telehealth, you will be promptly informed and advised to seek in-person care. This determination may be made before, during, or after your initial consultation based on the information you provide and your Healthcare Provider’s clinical judgment. You have the right to ask your Healthcare Provider whether telehealth is appropriate for your particular situation at any time during your care.
Payment for Services.
You agree to pay all fees or charges to the account you created through the Alpha App (your “Account”) for the treatment provided to you (or to a minor on whose behalf you are consenting to this Consent to Telehealth) in accordance with the fees, charges, and billing terms in effect at the time a fee or charge is due and payable (the “Service Fees”). By providing Alpha with your credit card number and associated payment information, or by connecting your PayPal account, you agree that Alpha is authorized to immediately invoice your account for all fees and charges due and payable to Medical Practice (or to the CBO, Pharmacy or other provider identified on your invoice) and that no additional notice or consent is required. The third party services provider who manages the processing of your credit card payments may impose terms and conditions on you, which are independent of this Agreement, and you agree to comply with such terms. Medical Practice reserves the right to modify or implement a new pricing structure at any time prior to billing you for your initial payment or for future payments due. Medical Practice further reserves the right to correct any billing error or mistakes even if payment has already been requested or received.
Accuracy of Information. It is imperative that you provide accurate and truthful information about the identity and health and physical conditions of the patient, parent or guardian, and relevant family members during the registration process and to the Healthcare Providers. You represent and warrant to Medical Practice that all of the personal information you provide during this process is true and correct. Medical Practice and the Healthcare Providers reserve the right to refuse to provide services if Medical Practice determines you have not provided complete or accurate health or identifying information. You also agree to keep your Account information current and accurate. If you move to a new address, or if any medical conditions or treatments change, you should update the information through the Alpha App.
Email, Texts and Electronic Communications. By agreeing to this Consent to Telehealth, you consent to the use of unsecured email, mobile phone text messages, or other electronic methods of communication (“E-messages”) between you and Medical Practice and the Healthcare Providers for purposes of:
You understand that E-messages are typically a non-confidential means of communication and that there is a reasonable chance that a third-party may be able to intercept and see these messages (including people in your home or work who can access or view your phone, computer, or other devices, and/or third parties on the Internet such as server administrators and others who monitor Internet traffic). You have been informed of the risks, including but not limited to the risk with respect to the confidentiality of your treatment, of transmitting your Protected Health Information by an unsecured means.
Communication through Alpha App. By agreeing to this Consent to Telehealth, you are agreeing to contact your Healthcare Provider through the Alpha App. You acknowledge that Healthcare Providers have no obligation to communicate with you via telephone or otherwise via personal social media accounts, and you agree not to attempt to contact your Healthcare Provider via their personal phone numbers, email accounts or social media.
Recording of Telehealth Sessions. Medical Practice does not routinely record telehealth consultations. However, if Medical Practice or your Healthcare Provider determines that recording a session is medically necessary or beneficial to your care, you will be notified at the time of the consultation and asked to provide explicit verbal consent before any recording begins. You have the right to refuse to be recorded, and such refusal will not affect your ability to receive care through the Alpha App, though it may affect the modality of care delivery. If you consent to recording, the recording will become part of your medical record, will be stored securely in compliance with HIPAA and applicable state laws, and will only be accessible to Healthcare Providers directly involved in your care and as otherwise permitted or required by law. For California patients: California law requires the consent of all parties before recording any confidential communication. You will receive clear notice and must affirmatively consent before any recording of your telehealth session occurs.
Communication through telephone services/during real-time visits. By agreeing to this Consent to Telehealth, if you are located in a state requiring synchronous/real-time communications or otherwise request to speak to your provider by phone, whether by VOIP services or by mobile, wired or landline services, you are agreeing your Healthcare Provider may communicate with you via these technologies and disclose your PHI and other personal information on this call. Should you choose to allow any third party in the same room during any call, you are authorizing us to communicate information to you, including PHI, in the presence of this third party. We recommend that you complete calls from a private location.
Translation. As noted above, our services are not eligible for Medicare, Medicaid or other government-funded plans, nor are we able or required to provide translation services. We take pains to communicate this information in advance of you scheduling a visit so that you may make an informed choice of whether to proceed. Should you decide to continue the visit with the assistance of a friend/family member translating during synchronous/real-time calls/visits, you are authorizing the Provider to share your information with this individual. We nonetheless reserve the right to end/cancel any visit in which we determine your friend/family member is unable to effectively translate or if we believe it is in your best interest, according to our best judgment, to terminate the call.
Privacy Policy and Terms of Use. By agreeing to this Consent to Telehealth, you are consenting to the terms of, and acknowledge that you have reviewed Alpha’s Privacy Policy, which can be found here, and the Terms of Use, which can be found here. As set forth in the Privacy Policy and accompanying Notice of Privacy Practices, Medical Practice maintains the confidentiality of all patient records and other patient information in accordance with legal and professional standards, including, without limitation, the Health Insurance Portability and Accountability Act, as amended, and regulations promulgated thereunder, and applicable state privacy laws. For patients receiving services through a CBO once your patient records are provided to the CBO to fulfill prescriptions or otherwise coordinate care, those records are subject to the CBO’s Notice of Privacy Practices available here. By agreeing to this Consent to Telehealth, you acknowledge that you have been provided access to each of the Medical Practice’s Notice of Privacy Practices and the CBO’s Notice of Privacy Practices, you consent to be bound by these entities’ respective privacy practices with respect to your records for the purposes of fulfilling prescriptions and coordinating your care.
Electronic Prescribing. Alpha uses electronic prescribing technology to send prescriptions securely to your pharmacy. This system helps prevent medication errors and provides your Provider with the following important information to safely prescribe:
You consent to your Healthcare Provider accessing this information through secure pharmacy and insurance networks to support your care. This access is protected by HIPAA privacy rules.
Pharmacy Choice. If your Provider recommends a prescription medication, you have the right to select the medication be filled by the pharmacy of your choice. In addition, under certain circumstances, there may be a generic version of a prescription medication available, and you have the right to select between brand and generic versions. Your choice may affect the price you pay, and neither Hello Alpha nor your Provider are responsible for drug pricing. Your Provider will work with you to send the prescription to a mail order Pharmacy integrated with Hello Alpha, a pharmacy affilaited with your chosen financial assistance or hardship assistance program, or a local pharmacy that accepts electronic prescribing. Please communicate your choice as early as possible to avoid delays associated with cancelling and re-transmitting prescriptions to alternate pharmacies.
Access to Records (for parents or guardians providing consent for patients under 18 years old). By agreeing to this Consent to Telehealth, you acknowledge that either parent may access the patient’s Alpha account and medical records and make treatment decisions for the patient, with exceptions under state laws. If either parent has limited rights to make medical decisions on behalf of the patient, you agree to disclose such limitations to Medical Practice prior to treatment and provide Medical Practice with the legal documents stating so. In no event will Medical Practice or Hello Alpha be held liable for damages or liabilities of any kind arising out of your failure to disclose any such limitations on parental rights to Medical Practice prior to treatment, and such damages or liabilities shall be subject to indemnification below.
If you would like Alpha to send a copy of your telehealth treatment records to another provider, please contact support@helloalpha.com or include the name and complete contact information in a message to your Healthcare Provider.
Indemnification. By agreeing to this Consent to Telehealth, you acknowledge and agree that you shall be liable for, and shall indemnify, defend and hold harmless Medical Practice and Alpha from any and all liability, loss, claim, lawsuit, injury, cost, damage or expense whatsoever (including reasonable attorneys’ fees and court costs) arising out of, incident to or in any manner occasioned by your performance or nonperformance of any of your duties or responsibilities under this Agreement, but only to the extent, and only in such amount, that such liability, loss, claim, lawsuit, injury, cost, damage or expense is not covered and paid by third party insurance.
Limitation of Liability. TO THE MAXIMUM EXTENT ALLOWED BY LAW, IN NO EVENT WILL MEDICAL PRACTICE, ITS HEALTH CARE PROVIDERS, HELLO ALPHA, INC., THE CBOs, OR ITS OR THEIR AFFILIATES, EMPLOYEES, OFFICERS, DIRECTORS OR AGENTS BE LIABLE FOR ANY CONSEQUENTIAL, EXEMPLARY, INCIDENTAL, SPECIAL OR PUNITIVE DAMAGES, INCLUDING WITHOUT LIMITATION THOSE RELATING TO LOST PROFITS OR THE COST OF SUBSTITUTE PRODUCTS OR SERVICES ARISING OUT OF OR IN CONNECTION WITH YOUR TREATMENT, OR YOUR INABILITY TO OBTAIN THE TREATMENT, WHETHER BASED ON CONTRACT, WARRANTY, PRODUCT LIABILITY, TORT OR OTHER LEGAL THEORY, EVEN IF MEDICAL PRACTICE HAS BEEN INFORMED OF THE POSSIBILITY OF SUCH DAMAGES. SOME JURISDICTIONS DO NOT ALLOW THE LIMITATION OF LIABILITY FOR CONSEQUENTIAL OR INCIDENTAL DAMAGES, SO THE ABOVE LIMITATION MAY NOT APPLY TO YOU.
Disputes. Any dispute or claim relating in any way to your use of any Service provided by Alpha must be adjudicated on an individual basis and not on a class basis, meaning only individual relief is available and claims of more than one individual cannot be arbitrated or consolidated with those of any other individual or patient. We each waive any right to a jury trial.
Severability. The provisions of this Agreement shall be deemed severable and if any portion is held invalid, illegal or unenforceable for any reason, the remainder of this Agreement shall be effective and binding upon the parties.
Entire Agreement. This Agreement, including all corresponding attachments and exhibits represent the entire agreement between you and Medical Practice, and no other agreements, oral or written, have been entered into with respect to my treatment and Services provided by Medical Practice. This Agreement supersedes all prior agreements and communications of whatever type, whether written or oral, regarding your treatment and Services provided by Medical Practice. The execution of this Agreement by any electronic means or by other affirmative electronic acceptance shall constitute effective execution and delivery of this Agreement for any purposes whatsoever.
Notice of Amendment. This Agreement may be amended or modified by Medical Practice at any time. If Medical Practice makes changes, we will notify you of any changes by posting the revised Consent to Telehealth on our Website, making it available on the Alpha App, and updating the “Last Update” date to reflect the date of the changes. We will also notify you, either through a user interface on the Alpha App, in an E-Message, or through other reasonable means. You may request a copy of any current or previous Consent to Telehealth by visiting the link at the bottom of our website, available in the Alpha App, or contacting us at contact@helloalpha.com. By continuing to use our Alpha App and the Services after we post such changes, you agree to the terms of this Consent to Telehealth, as modified.
Waiver. No delay or omission by either party to exercise any right or remedy under this Agreement shall be construed to be either acquiescence or waiver of the ability to exercise any right or remedy in the future. Any waiver of any terms and conditions hereof must be in writing, and signed by the parties hereto. A waiver of any term or condition hereof shall not be construed as a future waiver of the same or any other term or condition hereof.
Governing Law. This Agreement shall be governed by and construed in accordance with the laws of the State of Delaware, without giving effect to any principles that provide for the application of the law of another jurisdiction.
Disclosure of Physician Information (CALIFORNIA PATIENTS ONLY). By entering this Agreement you acknowledge that you have received information regarding the applicable Medical Practice Physician’s name and license number, license status, highest level of academic degree, and board certification. Each Medical Practice Physician providing services in California is licensed to practice medicine in the state of California and may be a board certified physician or a licensed physician in his/her final year of residency who is not yet board-certified. You are encouraged to contact the Medical Board of California per the below contact information should you have any questions or concerns.
NOTICE
Medical doctors are licensed and regulated
by the Medical Board of California
(800) 633-2322
webmaster@mbc.ca.gov
No Surprises Billing.
Alpha believes the amount you pay for medical services should be understandable. If you subscribe to an Alpha Membership, your membership costs are displayed to you, on-screen. If you complete a single visit with Alpha, before you are asked to pay for any services, you will see displayed for you a good faith estimate of the costs of items and services that are reasonably expected for your health care needs for an item or service. The estimate is based on information known at the time you complete your intake forms and request a visit. This good faith estimate is not a contract and does not require you to obtain the items or services from any of the providers listed in the good faith estimate. The good faith estimate does not include final prescription drug costs (as those are not known unless and until a provider prescribes a given prescription and whether or not any applicable insurance may cover this prescription drug cost), or any unknown or unexpected costs that may arise during treatment.
You could be charged more if complications or special circumstances occur. If this happens, and your bill is $400 or more for any provider or facility than your Good Faith Estimate for that provider or facility, federal law allows you to dispute the bill.
Federal law provides that if you are billed $400 or more for any provider or facility than your good faith estimate for that provider or facility, you may dispute the bill, by contacting the health care provider or facility, or you may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). The initiation of the dispute resolution process will not adversely affect the quality of healthcare services furnished to you.
If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill. There is a $25 fee to use the dispute process.
To learn more and get a form to start the process, go to: www.cms.gov/nosurprises/consumers or call 1-800-985-3059.
For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises/consumers, email FederalPPDRQuestions@cms.hhs.gov, or call 1-800-985-3059.
California Open Payments Notice
The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. It can be found at https://openpaymentsdata.cms.gov.
How to Contact Us at Alpha to Use your Rights
For general inquiries or to request a physical copy of your/your minor child’s medical record, please e-mail us at: contact@helloalpha.com or write to us at:
Alpha
555 Bryant St, Suite 814
Palo Alto, CA 94301
How to Submit a Complaint to Alpha:
To submit a complaint to Alpha please submit your complaint in writing to:
Alpha
Attn: Privacy Office
555 Bryant St, Suite 814
Palo Alto, CA 94301
NOTICE TO CALIFORNIA PATIENTS:
Medical doctors are licensed and regulated by the Medical Board of California. To check up on a license or to file a complaint go to www.mbc.ca.gov, email licensecheck@mbc.ca.gov, or call (800) 632-2322. Physician assistants are licensed and regulated by the Physician Assistant Board of California, www.pab.ca.gov or (916) 561-8780.
For patients located in any other state, formal complaints may also be submitted to your state officials. To learn where and how to submit a complaint within your state please visit our FAQ page or you may find a list of contacts here.
In addition you can submit your complaint to: Secretary of the U.S. Department of Health and Human Services Attention: Regional Manager 50 United Nations Plaza, Room 322 San Francisco, California 94102 For additional information, call (800) 368-1019 or U.S. Office of Civil Rights (866) 627-7748 (Voice) or (866) 788-4989 (TTY)
Health Information Exchange (HIE) Consent
Medical Practice participates in one or more health information exchange networks (each an “HIE”), which allow secure electronic sharing of your health information among participating healthcare providers, hospitals, labs, and other entities involved in your care. Participation in an HIE helps your Provider access important health information from other providers to deliver safer, more coordinated care.
By default, your Provider will both send and receive your health information through these networks. You have the right to opt out of HIE participation at any time. If you opt out, we will disable access to your health information through HIE networks, except as permitted or required by law (such as for public health reporting or court orders). Please see the Notice of Privacy Practices for information on how to opt out. If you are receiving services through a CBO partner, that organization may participate in additional health information exchange networks as described in their Notice of Privacy Practices. To find those documents, please see our Community Partners page Here.
Informed Consent for At-Home Tests From Ash Wellness
Depending on the condition for which you seek treatment, you may receive access to an at-home test kit provided by Ash Wellness and processed by its third-party laboratory partner. This section provides information to help you understand the purpose, procedures, risks, benefits, and alternatives of the test so that you can make an informed decision about whether to participate. Please read this consent form carefully and ask any questions you may have before agreeing to participate.
Purpose of the test: Your Alpha Provider will review with you the specific purpose of the test kit and the conditions or health metrics for which it screens. Ash Wellness or its third-party lab partner will transmit results back to your Alpha Provider.
Test Kit: You will receive an at-home test kit that includes all necessary materials and instructions.
Sample Collection: Follow the instructions provided in the kit to collect a sample. This typically involves using a lancet to prick your finger and collect in a provided container.
Sample Return: Once the sample is collected, use the pre-paid shipping materials to return the sample to the laboratory for analysis.
Results: You will receive your test results via your Alpha Patient Portal or if you agree, via email from Ash Wellness.
Risks and Discomforts: This test involves a dried blood spot card which will require a capillary sample extracted via a lancet. It may be uncomfortable, painful, or potentially cause mild abrasion or bleeding. No long-lasting side effects from testing are expected. Receiving test results may cause anxiety or stress. In addition, although Ash Wellness takes extensive measures to protect your privacy, there is a small risk that your personal health information could be inadvertently disclosed. In addition, please note that Ash Wellness’ partner labs have infectious disease reporting responsibilities under applicable governmental regulations and, depending on the test and result, may report your testing information per these regulations.
Benefits include greater health insight, in that the test may provide valuable information about your health status or lead to your Alpha Provider making recommendations to improve your health or treatment outcome. In addition, early detection of certain conditions may lead to more effective treatment options.
Alternatives: You have the option to decline this at-home test. Alternatives include: visiting a healthcare provider for in-person testing, or utilizing other at-home testing services.
Confidentiality and HIPAA Authorization: Your test results and personal information will be kept confidential and will only be shared with authorized personnel involved in the testing process. Your information may also be shared with Ash Wellness, its third-party laboratory, the assigned provider or your designated provider, if requested, or as required by law. By agreeing to this Consent to Telehealth and requesting an Ash Wellness home test kit, you authorize Alpha, Ash Wellness, its third-party laboratory, the assigned Alpha Provider or your designated provider, to use and disclose your protected health information (PHI) for the purposes described in this consent form. This authorization is voluntary, and you may revoke it at any time by notifying Alpha in writing, except to the extent that action has already been taken in reliance on your authorization.
Voluntary Participation: Your participation in this at-home test is entirely voluntary. You have the right to refuse or withdraw your consent at any time without penalty or loss of benefits to which you are otherwise entitled.
Acknowledgement of Consent
BY CHECKING THE BOX CORRESPONDING TO THIS CONSENT TO TELEHEALTH, I UNDERSTAND AND AGREE TO THE FOLLOWING: All medical care and treatment I or my child receive from Providers using the Alpha App will be provided using telehealth and my Providers will not be able to provide any medical care and treatment to me/my child without the use of telehealth. The delivery of healthcare services via telehealth is an evolving field and the use of telehealth in my/my child’s medical care and treatment from Providers may include uses of technology not specifically described in this Consent to Telehealth. While the use of telehealth may provide potential benefits to me, as with any medical care service (in-person or using telehealth technology) no such benefits or specific results can be guaranteed. There are certain potential risks to me in the use of telehealth, including but not limited to the risks described in this Consent to Telehealth. I have the right to withhold or withdraw my consent to the use of telehealth at any time by terminating my use of the Alpha App. I understand I may request a physical copy of my/my child’s medical record at any time. In certain instances, I understand that Alpha may be unable to provide me with a minor child’s medical records due to state or federal law. I have read the Privacy Policy on the Alpha App and to the extent applicable on the CBO’s website, and I understand that my medical information is subject to all applicable laws regarding the confidentiality of healthcare information. I am responsible for providing all information relevant to my medical care, including all relevant information to my/my child’s Provider. My Provider may determine in his or her sole discretion that my/my child’s condition is not suitable for treatment using the Alpha App and that I/my child may need to seek medical care and treatment from a specialist or other healthcare provider outside of the Alpha App.
I represent that I have read this Consent to Telehealth carefully, understand the benefits and risks of the use of telehealth in the medical care and treatment provided to me/my child by Providers using the Alpha App, and give my informed consent to the use of telehealth by Providers using the Alpha App.
Last updated on November 04, 2025
