Draft, pending review by counsel. Not yet in effect. Highlighted fields are still being completed.
This is a reference copy. You review and accept this consent, together with the treatment-specific consent for the treatment you choose, inside the secure intake before checkout. You can download the version you accepted.
This Telehealth and Medical Consent (this “Consent”) explains what telehealth is, its potential benefits, risks, and limitations, and your rights as a patient, so that you can make an informed decision about receiving healthcare services through telehealth. This Consent is between you and the independent, physician-owned professional entities affiliated with Swell Healthcare (the “Medical Group”), and the licensed healthcare professionals who provide care through the Medical Group (each, a “Provider”). Your Provider may be a physician, nurse practitioner, or physician assistant, will be licensed, certified, or otherwise authorized to practice in the state where you are located at the time of your visit, and your Provider’s name and credentials will be made available to you in connection with your visit. By accepting this Consent, you acknowledge that your treating Provider may be a nurse practitioner or physician assistant rather than a physician, and you agree to be treated by such non-physician Providers where applicable. The Services are available only to individuals who are eighteen (18) years of age or older, and by accepting this Consent you represent that you are at least eighteen (18) and are consenting for yourself.
Jellyphysh and CareValidate, Inc. (“CareValidate”) are not parties to your provider-patient relationship. They provide the website, technology platform, and non-clinical administrative and support services only; they do not practice medicine, do not provide medical advice, diagnosis, or treatment, and do not influence any clinical decision. All healthcare services are provided solely by the Medical Group and your Provider. This Consent is incorporated into and forms part of the Terms of Service available at https://jellyphysh.com/terms-of-service, and it controls with respect to the healthcare services it covers.
Telehealth is the delivery of healthcare services using electronic communications and technology, where the patient and Provider are not in the same physical location. Depending on your state, your condition, and your Provider’s clinical judgment, your care may involve one or more of the following: live, interactive video visits; telephone or other audio visits; asynchronous (store-and-forward) review, in which your Provider reviews your health questionnaire, medical history, images, and other records and responds without a real-time interaction; secure messaging with your Provider or care team; electronic transmission of medical records, images, and health data; and remote evaluation and management of your treatment, including prescribing where clinically appropriate and permitted by law. The modality used for your care will comply with the laws of the state where you are located, and certain states may require a specific modality, such as a synchronous video visit, before certain treatments may be prescribed. By accepting this Consent, you expressly consent to receiving healthcare services through both synchronous modalities (real-time audio or audio-video interactions) and asynchronous modalities (store-and-forward review of your information without a real-time interaction), in each case as determined clinically appropriate by your Provider and as permitted by the law of the state where you are located.
Telehealth can improve access to care by allowing you to be evaluated and treated without traveling to a medical office, at times that may be more convenient for you, and can allow your Provider to consult efficiently regarding your ongoing treatment, including follow-up care, dose adjustments, and monitoring.
As with any healthcare service, there are potential risks associated with telehealth. These include, without limitation:
(a) your Provider cannot conduct a hands-on physical examination, and in some cases information sufficient for your Provider to exercise clinical judgment may not be available through telehealth, including because of limitations of the technology or the information you provide;
(b) delays in evaluation or treatment may occur due to failures or limitations of equipment, software, or internet connections, and a visit may need to be interrupted, rescheduled, or completed by another means; either you or your Provider may discontinue a visit if the technical connection is not adequate;
(c) in rare circumstances, security protocols could fail and the privacy of your medical information could be compromised despite the safeguards used;
(d) a lack of access to your complete medical records could result in adverse drug interactions, allergic reactions, or other errors, which is why it is essential that you provide complete and accurate health information, including all medications, supplements, allergies, and conditions;
(e) regulatory requirements in certain states may limit the diagnoses that can be made or the treatments and prescriptions that can be provided through telehealth, and your Provider may determine that telehealth is not appropriate for your condition, in which case you will be advised to seek in-person care and no treatment or prescription will be provided through the platform; and
(f) telehealth is not appropriate for emergencies, as described in Section 9 below.
Alternatives to telehealth are available to you, including in-person evaluation and treatment by a physician or other licensed healthcare professional of your choosing, and you may choose an alternative at any time, because the Medical Group for which you are consenting to treatment with only provides telemedicine visits. Your participation in telehealth is entirely voluntary. You have the right to withhold or withdraw this Consent at any time, without affecting your right to future care or treatment; to ask questions about telehealth, your treatment, and its alternatives, risks, and benefits, and to have those questions answered before proceeding; to request an in-person referral or to seek care outside the platform at any time; and to access your medical records as provided by applicable law. A withdrawal of this Consent is effective upon receipt of your written notice, does not affect actions taken by the Medical Group or your Provider in reasonable reliance on this Consent before receipt, and may mean that services can no longer be provided to you through the platform, because Providers practicing through the platform do not offer in-person visits.
Completing a health assessment or visit does not guarantee that any treatment or prescription will be provided. All treatment and prescribing decisions are made solely by your Provider in the exercise of independent professional judgment, based on your individual clinical presentation, history, and applicable clinical standards, and only where your Provider determines that a valid provider-patient relationship has been established and that treatment is medically appropriate. As with any medical care, no specific result, health outcome, or therapeutic effect can be promised or guaranteed; your condition may not improve and in some cases may worsen. If your care may involve a compounded medication, additional disclosures and a separate compounding consent will be provided to you; compounded medications are not FDA-approved.
The Medical Group is a healthcare provider subject to the Health Insurance Portability and Accountability Act (“HIPAA”) and applicable state privacy laws, and the laws that protect the privacy and security of health information delivered in person also apply to telehealth. Your medical records are maintained by the Medical Group, which will provide you access to or copies of your records in accordance with applicable law upon request. You consent to the Medical Group and your Provider obtaining, importing, and reviewing your available medical records and medication history, including prescription records, in connection with your care. The Medical Group’s affiliated entities may share your health information among themselves and Jellyphysh, CareValidate, and the Pharmacies as needed for treatment, payment, and healthcare operations, as described in the Medical Group’s Notice of Privacy Practices, which is available through the patient portal and which you should review. Your health information will not be disclosed to third parties except as authorized by you or as permitted or required by law. To protect your privacy, you agree to participate in visits from a private location; your Provider will do the same, and if any other individual is present on the Provider’s side (for example, for technical or interpretation assistance), you will be informed of that individual’s presence and role and given the opportunity to consent. Electronic communications such as email and text messages may not be secure, and neither the Medical Group nor any other party can guarantee the security of communications services you choose to use; use the patient portal for sensitive clinical communications where possible.
Your care may involve the use of clinical documentation and support technologies, which may include artificial intelligence tools, for purposes such as transcription or summarization of visits, documentation assistance, analysis of medical information, clinical decision support, and quality assurance. Any such tools are used to support, and never to replace, the professional judgment of your Provider, and your Provider reviews any technology-assisted output before making clinical decisions. Information processed by these technologies is protected in accordance with applicable privacy laws and the Medical Group’s policies. You have the right to ask what technologies are used in your care and how your information is processed, and to request that such tools not be used in aspects of your care where feasible. If a visit will be recorded (audio or video) or if ambient documentation technology will be active during a visit, you will be notified before or at the start of the visit and given the opportunity to object; recordings, where made, are retained and made available to you in accordance with applicable law and the Medical Group’s policies. Visits will not otherwise be recorded, by you or by your Provider, without consent.
TELEHEALTH IS NOT FOR EMERGENCIES. IF YOU BELIEVE YOU ARE EXPERIENCING A MEDICAL EMERGENCY, INCLUDING CHEST PAIN, DIFFICULTY BREATHING, SEVERE ALLERGIC REACTION, SIGNS OF STROKE, UNCONTROLLED BLEEDING, OR LOSS OF CONSCIOUSNESS, CALL 9-1-1 OR GO TO THE NEAREST EMERGENCY DEPARTMENT IMMEDIATELY. IF YOU ARE EXPERIENCING SUICIDAL THOUGHTS OR A MENTAL HEALTH CRISIS, CALL OR TEXT THE 988 SUICIDE AND CRISIS LIFELINE AT 988, OR CALL 9-1-1. DO NOT WAIT FOR A RESPONSE THROUGH THE PLATFORM.
Providers may not respond immediately to messages submitted through the platform. If a technical failure prevents you from reaching your Provider or care team through the platform for a non-emergency matter, contact support at (833) 453-7493 or support@jellyphysh.com. To facilitate care in an emergency, you agree to provide and keep current your physical location and an emergency contact, and if your Provider believes you are experiencing an emergency, your Provider may contact emergency services, your emergency contact, or both.
You agree to: provide complete, accurate, and current information about your identity, physical location, health history, symptoms, medications, supplements, and allergies, and to update that information if it changes; confirm your physical location at the time of each visit, because your Provider must be authorized to practice where you are located; participate in follow-up care, monitoring, and laboratory testing as recommended by your Provider, and take medications only as prescribed; maintain a relationship with a primary care provider where possible, inform your other healthcare providers of the treatment you receive through the platform, and share relevant results and records with them, since coordination of care is important to your safety; and use a private, secure location and device for your visits to protect your own privacy.
The services provided by the Medical Group through the platform are offered on a cash-pay basis, outside of Medicare, Medicaid, and other federal, state, or private payor healthcare programs, as further described in the Terms of Service. Neither you nor the Medical Group will submit a claim for reimbursement to any such program for services provided through the platform, and you are solely financially responsible for the services you receive.
You understand that Jellyphysh and CareValidate have commercial relationships with the Medical Group, under which they provide non-clinical technology, administrative, and support services and with the pharmacies and laboratories accessible through the platform. These arrangements do not affect, and are not permitted to influence, your Provider’s clinical judgment. You are free to obtain your medical evaluation from any healthcare provider not associated with the platform, to have any prescription filled at any pharmacy of your choice, and to use any laboratory of your preference; contact support to direct a prescription to your preferred pharmacy.
If your care includes laboratory testing, tests will be ordered by your Provider where determined clinically appropriate, and may be performed using an at-home collection kit or an in-person blood draw at a collection site. Risks of blood draws include discomfort, bruising, redness or swelling at the site, bleeding, lightheadedness, and, rarely, infection. Laboratory tests are performed by independent licensed laboratories, and no laboratory test is perfectly accurate: tests can produce false negative, false positive, or inconclusive results, which could affect your Provider’s ability to diagnose or treat you. Test results are confidential and will be shared among your Provider, the Medical Group, and the performing laboratory as needed for your care, and will not otherwise be disclosed except as authorized by you or permitted or required by law. Where permitted, you elect to exercise your right of direct access to your test results under federal law and to receive results when the report is complete, and you understand some states may require a delay so your Provider can review results with you. Laboratory testing is voluntary, and questions about specimen retention should be directed to the performing laboratory.
Some states impose additional telehealth requirements, including per-encounter consent, specific consent language, modality restrictions, or additional disclosures. Where the state in which you are located requires additional consents or disclosures beyond those in this Consent, they will be presented to you before or during your visit, are incorporated into this Consent, and control to the extent they impose additional requirements. This Consent is intended to satisfy the informed consent requirements of the state in which you are located and will be interpreted consistently with that state’s law.
If your care involves a specific medication, product, or service, a treatment-specific medical consent for that treatment is presented to you together with this Consent and is incorporated into and forms part of this Consent. The applicable treatment-specific medical consent is determined by the medication, product, or service you select; describes the nature, benefits, material risks, and alternatives of that treatment; and is set forth immediately below. Your acceptance in the following section applies both to this telehealth consent and to the treatment-specific medical consent set forth in this Section.
[TREATMENT-SPECIFIC MEDICAL CONSENT: TO BE POPULATED BASED ON THE MEDICATION, PRODUCT, OR SERVICE SELECTED]
By checking the acceptance box, clicking “I Agree” or a similar button, signing electronically, or proceeding with a visit, you acknowledge and agree that: you have read and understand this Consent, or have had it explained to you; you have had the opportunity to submit any questions in writing or through a video consultation to your Provider before proceeding, and all of your questions have been answered to your satisfaction; you understand the potential benefits, risks, and limitations of telehealth and the available alternatives, including in-person care; you understand that your participation is voluntary and that you may withdraw this Consent at any time as described in Section 5; you understand that all healthcare services are provided by the Medical Group and your Provider, and not by Jellyphysh or CareValidate; you understand that no treatment, prescription, or outcome is guaranteed; you agree to receive care through synchronous or asynchronous telehealth visits as described in Section 2; the information you have provided and will provide is true, accurate, and complete; and you voluntarily consent to receive healthcare services from the Medical Group and its Providers through telehealth. Your electronic acceptance constitutes your signature and has the same effect as a handwritten signature. If you have questions about this Consent, contact support@jellyphysh.com for non-clinical questions or ask your Provider through the patient portal for clinical questions. You may request a copy of this Consent for your records.