Informed Consent to Use of Telehealth
Hello Alpha, Inc. (f/k/a Alpha Medical Group, Inc.) is a technology company which provides a platform to affiliated medical practices. We reference those practices and Alpha collectively as “Alpha” for ease, however all medical care is provided by, depending on your location, of Alpha Telemedicine, P.C. (f/k/a Clarity Health, P.C.), Alpha Telemedicine of Kansas, P.A. (f/k/a Clarity Health of Kansas, P.A.), Alpha Telemedicine of New Jersey, P.A. (f/k/a Clarity Health of New Jersey, P.A.), Alpha Telemedicine of Alaska, P.C. (f/k/a Clarity Health of Alaska, P.C.) (each a “Provider” and collectively referred to herein as “Medical Practice”).
In using the Alpha Platform, you/your child will be consulting with a physician or other licensed healthcare provider (“Healthcare 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:
Electronic transmission of medical records, photo images, personal health information or other data between you and/or your child and a Healthcare Provider.
Interactions between you and/or your child and a Healthcare Provider via audio, video and/or data communications.
Use of output data from medical devices, sound and video files.
Healthcare Provider(s) using the Alpha Platform will be interacting with you/your child solely via use of the Alpha Platform. 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."
ANTICIPATED BENEFITS: The use of telehealth by Healthcare Providers through the Alpha Platform may have the following benefits:
Making it easier and more efficient for you/your child to access medical care for the conditions treated by Healthcare Providers.
Reducing wait times for diagnosis, treatment, and appropriate prescriptions.
Allowing you/your child to obtain medical care and treatment by Healthcare Providers at times that are convenient for you.
Avoiding unnecessary travel and allowing you/your child to obtain medical care from the comfort and privacy of your home.
Enabling ongoing care and follow-up communication with Healthcare Providers on your/your child’s terms and without travel or missed work/school.
Care for you/your child has an additional layer of privacy, as all care is delivered through messaging with no requirement for video visit.
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:
The information transmitted to your Healthcare Provider(s) may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision-making by the Healthcare Provider(s).
The inability of your Healthcare Provider(s) to conduct certain tests, examine a patient, or assess vital signs in-person may in some cases prevent the Healthcare Provider(s) from providing a diagnosis or treatment or from identifying the need for emergency care.
Your Healthcare Provider may not be able to provide medical treatment for your/your child’s particular condition, and you/your child may be required to seek alternative healthcare or emergency care services.
Delays in medical evaluation/treatment could occur due to unavailability of Healthcare Providers, patient volume, or the possibility of deficiencies or failures of the technology or electronic equipment used. In rare instances, security protocols or safeguards could fail, causing a breach of privacy.
Given regulatory requirements in certain jurisdictions, your Healthcare Provider(s) treatment options, especially pertaining to certain prescriptions, may be limited.
In rare cases, a lack of access to all of your medical records may result in adverse drug interactions or allergic reactions or other judgment errors.
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.
Alpha App. Medical Practice contracts with an independent third party, Alpha Medical Group, Inc., dba Alpha (“Hello Alpha”) to provide management, administrative, and other non-medical services, including without limitation billing and collection of Service Fees (as defined below). To facilitate your Treatment, Medical Practice licenses access to a web-based and mobile application (the “Alpha App”) that is owned by Hello Alpha. The use of the Alpha App alone does not create a patient relationship with Medical Practice.
Provider-Patient Relationship. You acknowledge that a provider-patient relationship is not established until you and a Healthcare Provider mutually consent through asynchronous communication about your Treatment. In other words, this relationship is not created until you have requested treatment by completing your dynamic intake process and a Healthcare Provider has had the opportunity to review your intake and agree to undertake your diagnosis and treatment. 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.
Consent to Services.
By agreeing to this Consent to Telehealth, you agree that you have requested to receive medical treatment and Services in exchange for payment to Medical Practice. You consent to the rendering of medical treatment and Services as considered necessary and appropriate by your Healthcare Provider at the time of Treatment. You have the right to decline treatment and Services at any time during the course of Treatment but you may be responsible for any Service Fees (as defined below) already paid.
You acknowledge and understand that the Services are not covered by Medicare or Medicaid. You are responsible for paying for the Services and our services are not eligible for subsequent reimbursement by Medicare, Medicaid or any other government-funded program.
You acknowledge that no assurances or guarantees have been made to you by Medical Practice or the Healthcare Providers concerning the outcome and/or results of any medical treatment or Services.
You acknowledge that no assurances or guarantees have been made to you by Medical Practice or the Healthcare Providers concerning response time to any message, and that any projected response time provided via the Alpha App or on the Alpha Website is an estimate only, and may be impacted at any time by patient or message volume or the possibility of deficiencies or failures of the technology or electronic equipment used.
You acknowledge that some medications, including medications which treat anxiety and depression, if stopped abruptly, can cause a relapse of your medical condition and/or withdrawal symptoms.
During the course of Treatment, the Healthcare Providers may discuss the details of your or the patient’s medical or health history or personal health information. You may also be asked for proof of identity with a valid driver’s license, government-issued photo ID, or other legal documents. If you are a parent or guardian, you agree to provide evidence of your authority to consent on behalf of the patient upon our request.
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.
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, you agree that Alpha is authorized to immediately invoice your account for all fees and charges due and payable to Medical Practice hereunder 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:
notifying you of the availability of messages on our platform; or
otherwise for discussing personal information, including Protected Health Information (“PHI”) relevant to the patient’s Treatment or health records.
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.
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.
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 email@example.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, ALPHA MEDICAL GROUP, INC., 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 firstname.lastname@example.org. 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.
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: email@example.com or write to us at:
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:
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 firstname.lastname@example.org, 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)
Acknowledgement of Consent
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 Platform, and give my informed consent to the use of telehealth by Providers using the Alpha Platform.
Last updated on 09/07/2023