Informed Consent Regarding Use of Telehealth
Effective Date: January 4, 2025
Contact: info@nubalance.health | 678-313-5106
Address: NuBalance Health LLC
1. Introduction and Purpose
NuBalance Health LLC (“NuBalance Health,” “we,” “our,” or “us”) is committed to delivering high-quality medical care in a manner that accommodates the evolving needs of our patients. In keeping with this commitment, we offer the option of receiving care through telehealth services, which utilize electronic communications to enable healthcare professionals to consult, diagnose, treat, educate, and monitor patients remotely.
This Informed Consent Regarding Use of Telehealth (“Consent Form”) is designed to inform you (“patient,” “you,” or “your”) about the nature, benefits, risks, limitations, and your rights associated with telehealth services. It is important that you read this consent carefully and understand it fully before agreeing to receive telehealth services.
Your signature or digital acceptance of this form indicates that you understand and consent to receive healthcare services through telehealth technologies as provided by NuBalance Health and its licensed professionals.
2. Definition of Telehealth
Telehealth is defined as the use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health, and health administration. Technologies may include:
Real-time video conferencing (two-way interactive communication)
Store-and-forward technology (transmission of medical data for evaluation at a later time)
Remote patient monitoring (use of connected devices to gather patient data)
Secure messaging and emails
Mobile health applications and portals
Telehealth is not a product or a separate form of treatment; rather, it is a means of delivering healthcare services. The services provided via telehealth may include, but are not limited to:
Initial consultations
Follow-up appointments
Mental health counseling
Medication management
Hormone replacement therapy consultations
Weight loss program follow-ups
Wellness coaching
Diagnostic assessments and health education
3. Scope of Telehealth Services
The scope of telehealth services offered by NuBalance Health includes, but is not limited to:
Evaluation and management of chronic conditions
Preventive health assessments
Medication prescriptions or renewals
Laboratory result reviews and interpretations
Lifestyle and behavioral coaching
Post-treatment follow-ups
Discussion of treatment options and shared decision-making
Ongoing monitoring and management of health outcomes
You may receive services from physicians, nurse practitioners, physician assistants, licensed therapists, registered dietitians, or other qualified healthcare professionals operating within their scope of licensure and credentials.
4. Benefits of Telehealth
There are several recognized benefits to receiving healthcare via telehealth:
Convenience and Accessibility: Access care from the comfort of your home, workplace, or other location, avoiding travel time and associated expenses.
Continuity of Care: Maintain consistent communication with healthcare providers, especially for those in rural or underserved areas.
Reduced Risk of Infection: Telehealth limits the need for physical contact, thus reducing the transmission risk of communicable diseases such as COVID-19.
Time Efficiency: Appointments are generally more efficient and flexible for both the patient and provider.
Increased Patient Engagement: Virtual visits can encourage more frequent check-ins and proactive participation in health management.
5. Risks and Limitations of Telehealth
While telehealth offers significant benefits, The potential risks associated with the use of telemedicine are rare but include delays in medical evaluation and treatment due to equipment failures or information transmission deficiencies (such as poor image resolution); breach of privacy of protected health information due to security breaches or failures; and adverse drug interactions, allergic reactions, complications, or other errors due to patient’s failure to provide complete medical information or records. There are also limitations and risks that you must understand:
5.1. Technical Risks
Connectivity Issues: Internet or software malfunctions may disrupt or limit your session.
Data Breach Risk: While we use encryption and HIPAA-compliant platforms, any transmission over the internet carries a residual risk of unauthorized access.
Equipment Failure: Your or our devices may malfunction or fail, impacting communication or documentation.
5.2. Clinical Limitations
Lack of Physical Exam: In certain situations, a hands-on physical examination may be necessary for accurate diagnosis or treatment.
Delayed Treatment: If technology fails or if a condition is complex, diagnosis or treatment may be delayed until an in-person visit is possible.
Limited Sensory Input: Visual, tactile, or auditory diagnostic cues may be limited compared to in-person exams.
5.3. Regulatory and Legal Limitations
Licensure Restrictions: Our providers may only deliver care if they are licensed in your state.
Medication Prescribing Limitations: Some controlled substances may not be prescribed via telehealth under federal or state regulations.
6. Confidentiality and Security
NuBalance Health complies with the Health Insurance Portability and Accountability Act (HIPAA) and relevant state privacy laws. All telehealth sessions are conducted via encrypted, HIPAA-compliant platforms designed to ensure confidentiality and data integrity.
We use the following safeguards:
End-to-end encryption for video/audio
Secure cloud storage
Access control systems
Regular cybersecurity risk assessments
Password-protected interfaces
Despite these safeguards, no system is completely immune from breaches. By agreeing to use telehealth, you acknowledge the residual risk associated with data transmission.
7. Your Rights Under This Consent
As a patient, Your Privacy Rights
NuBalance Health uses network and software security protocols to protect the confidentiality of your patient health information, including for example your medical record, EMR, imaging, and personal financial data. These protocols are designed to safeguard the data and to ensure its integrity against corruption. Personal information that identifies you or contains protected health information will not be disclosed to any third party without your consent, except as authorized by law for the purposes of consultation, treatment, payment/billing, and certain administrative purposes, or as otherwise set forth in NuBalance Health Privacy Polices.
You may withhold or withdraw your consent to the telemedicine health service at any time before or during the consult without affecting the right to future care or treatment. You may also withdraw consent to extra personnel participating in telemedicine health services. You may also revoke your consent to allow NuBalance Health to store and use the video images and audio recordings. The request to revoke consent must be in writing and received by NuBalance Health. If you revoke your consent, the video images and audio recordings will be destroyed and no longer used by NuBalance Health. Any uses of the video made with your permission prior to NuBalance Health’s receipt of your revocation cannot be changed or undone. To revoke your consent to NuBalance Health’s storage and use of video images and audio recordings of your telemedicine health service, please send a written statement to NuBalance Health and state that you are revoking your consent for Nubalance Health’s to store and use video images and audio recordings of your telemedicine health service. You have the following rights when receiving telehealth services:
Right to Informed Consent: You have the right to understand the nature of telehealth, ask questions, and withdraw your consent at any time.
Right to Refuse Care: You may refuse or request in-person care without affecting your access to future treatment or benefits.
Right to Confidentiality: All personal and medical data shared via telehealth will be kept confidential as required by law.
Right to Access Records: You may request access to your health records at any time.
Right to File Complaints: If you feel your rights were violated, you may contact NuBalance Health or your state medical board to report concerns.
8. Your Responsibilities
When participating in telehealth, you agree to:
Ensure a Private Environment: Choose a quiet, private setting for your session to ensure confidentiality.
Use a Reliable Internet Connection: Maintain a stable internet connection to support clear communication.
Accurate Information: Provide complete and honest medical information, including history, symptoms, and current medications.
Follow Instructions: Adhere to treatment plans and post-consultation guidance provided by your healthcare provider.
Respect Scheduled Times: Be available at the agreed time, or give advance notice to reschedule if needed.
9. Emergency Situations
Telehealth is not suitable for all types of care. Do not use telehealth in the case of a medical emergency. If you are experiencing a life-threatening emergency or symptoms that require urgent intervention, call 911 or go to the nearest emergency department.
10. Fees and Insurance
Fees for telehealth services may vary based on provider type, session length, and service provided. You may be responsible for:
Co-payments or deductibles
Non-covered services
Out-of-network charges (if applicable)
We recommend that you confirm coverage with your insurance provider. By participating in telehealth, you authorize NuBalance Health to bill your insurer (where applicable) and acknowledge your financial responsibility for any uncovered costs.
11. Consent to Telehealth Services
BY SIGNING THIS FORM, YOU AGREE TO AND UNDERSTAND THE FOLLOWING:
Telemedicine is the use of electronic information and communication technologies by a health care provider to deliver services to an individual when he/she is located at a different site than the provider. I understand that I need to provide a full and accurate medical history, including any pre-existing conditions, to my telemedicine provider so that my provider can accurately determine what services I need. I further understand that my provider will determine whether telemedicine is appropriate for me at this time, based on the condition being diagnosed and/or treated. I understand that I may benefit from telemedicine, but that results cannot be guaranteed. My provider will inform me who will be present at the provider’s location during the telemedicine service, and I have the right to exclude anyone from being present, if I so choose. I further understand that I have the right to object to the use of a telemedicine service without prejudice to any future care or treatment and without risking the loss or withdrawal of any health benefits to which I am entitled. If there are costs to me associated with my telemedicine encounter, a health care professional will discuss those costs with me prior to the start of my session. Further, I understand and agree that I must pay the full amount of the costs associated with this telemedicine service, including any prescription I may receive, and I will not attempt to submit a claim to Medicare, any other federal payor, or any state or private insurer. I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine, and I agree that NuBalance Health may provide my confidential personal health information to other medical providers who may be located in other areas, including on rare occasions to providers outside the State, as necessary. I have the right to inspect and obtain copies of all information received and recorded during any telemedicine session, subject to the policies of the physicians, physician assistants, nurse practitioners and facilities involved in my care. I may be charged a fee for copies of my records in accordance with applicable State rules. I have read and understand the information above, and all of my questions have been answered to my satisfaction.
I consent to a physician, physician assistant, or nurse practitioner to provide services to me via telemedicine.
By clicking or signing “I Agree” below, I understand and consent to the foregoing acknowledgements and disclosures, including but not limited to NuBalance Health’s Terms and Conditions and which are incorporated herein by reference. NuBalance Health has a financial relationship with the Provider. You are, however, free to obtain your medical examination from another healthcare provider that is not associated with in Nubalance Health. NuBalance Health will use its pharmacy partner to fulfill your order directly to your door. You are, however, free to obtain your prescription from any pharmacy of your choice by contacting Nubalance Health. Further, for purposes of this informed consent, MY ACT OF CLICKING “I Agree” SHALL CONSTITUTE AND IS MY ELECTRONIC SIGNATURE. You acknowledge and agree that:
You understand what telehealth is and how it works.
You have had the opportunity to ask questions.
You understand and accept the risks and limitations of telehealth.
You consent to the use of electronic communications in your healthcare.
You understand that NuBalance Health uses HIPAA-compliant systems to protect your information.
You understand you may stop telehealth services at any time by notifying us.
12. Acknowledgment and Agreement
By signing this form, you confirm that you:
Have read and understood the information provided above.
Have had the opportunity to ask questions and receive answers.
Voluntarily consent to receiving healthcare services through telehealth from NuBalance Health.
Understand that this consent will remain in effect unless revoked in writing.
Signature of Patient (or Legal Representative): will be signed on new patient intake form
13. Contact Information for Questions or Concerns
If you have any questions regarding this informed consent form or the telehealth services offered, please contact:
NuBalance Health LLC
Info@nubalance.health
678-313-5106