Consent To Telehealth

Last Updated: March 1, 2019

By clicking the button titled "I Agree and Consent", you acknowledge that you understand and agree with the following:

Make sure you read all the important information below because we cover:

How our medical team consists of doctors and nurse practitioners.

How most states require you to do a video consultation with one of our doctors or nurse practitioners.

When our duty of care begins.

The benefits and risks of using our service.

The importance of reading all the information we provide.

The importance of answering all questions fully and truthfully.

The risks of accepting our treatment plan.

The risks to electronic health information.

Promo code programs from an employer, health insurer or other organization.

Only use our service if you've read this information and subsequently made an informed decision that our service is right for you. If you have any questions, please send us a message through the App or Website or call us at 424-334-9213

BACKGROUND INFORMATION

Medical services through Paloma Health are provided by independent medical groups that do business as "Paloma Health" (each, a "Medical Group"). Which Medical Group provides your care depends on the state where you are located at the time of your visit:

• Chrysalis Health of California PC, a California professional corporation — California, Colorado, Tennessee, and Arizona
• Chrysalis Health of Texas PA, a Texas professional association — Texas
• Chrysalis Health of Illinois PC, an Illinois professional corporation — Illinois
• Chrysalis Health of Florida, P.A., a Florida professional association — Florida and all other states
• Chrysalis Health of New Jersey, P.C., a New Jersey professional corporation — New Jersey, New York
• Cloud Health Medical Group: Cloud Health Medical Group, P.A., Cloud Health Medical Group of California, P.C., Cloud Health Medical Group of New Jersey, P.A., Cloud Health Medical Group of Kansas, P.C. ((collectively, “Cloud Health Medical Group”)

We will tell you which Medical Group is responsible for your care before your visit begins, and its name will appear on your visit record. If you move to a different state, a different Medical Group may become responsible for your care and you may be assigned a different provider.

Our medical team is made up of physicians and nurse practitioners licensed in the state where you are located. Whenever we use the term "doctor" or "provider" we mean both our physicians and our nurse practitioners. Paloma Health (Butterfly Health, Inc.) operates the website, app, and patient portal and provides administrative and technology support to the Medical Groups; it does not practice medicine, and no employee of Paloma Health will make decisions about your medical care.

We offer care in two ways. For some services you will have a live video or telephone visit with a provider, which allows you to ask questions and allows the provider to judge whether our online model of care is suitable for you. For other services, where permitted in your state, you may have an asynchronous visit: you complete a health questionnaire (and, where required, upload photographs), and a provider reviews it later without a live visit. Your provider may decide at any time that a live visit, or an in-person examination, is needed before treating you.

We are an online doctor's office, not a pharmacy. If your provider issues a prescription, you may fill it at any pharmacy you choose. If you ask us to have your medication delivered, we will send the prescription to an independent, licensed U.S. pharmacy that will dispense and mail it to you, and we will collect payment for the order on the pharmacy's behalf as described in our Terms of Use.

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NOT FOR EMERGENCIES

I understand that I should never use Paloma Health in a medical or psychiatric emergency. I understand that in an emergency, I should dial 911 or go to an emergency department.

WHEN OUR DUTY OF CARE BEGINS

I understand that a provider takes responsibility for my care only after (1) I have created an account and answered all required health questions, provided any required photographs, and/or completed a video or telephone visit, and (2) a provider has personally reviewed my request for treatment, my answers, and any photographs or visit information, and has determined that I am an appropriate candidate for care through this service. The provider's duty of care begins at the point the provider accepts responsibility for my care — not when I answer questions, upload photographs, start a video visit, or make any payment. Payment is not a condition of a provider reviewing my request, and making a payment does not by itself create a provider–patient relationship.

I understand that the provider has the right to decline to take responsibility for my care if, in the provider's professional judgment, I am not an appropriate candidate for this service, and that the provider may instead ask me for more information, ask me to schedule a live video or telephone visit, or recommend that I seek care elsewhere. Submitting a request for treatment, completing a questionnaire, or sending a message through the app, website, or email does not in itself create a duty of care or a provider–patient relationship.

I understand that requests for treatment and messages are reviewed during business hours and that there may be a delay of one or more business days before a provider reviews my request or responds to a message. If my condition changes or worsens while I am waiting, I should seek care elsewhere, and in an emergency I should call 911.

I understand that the only content that constitutes professional medical advice is (a) the personalized messages a provider sends me — through the app, the website, or the email address on my account — after the provider has taken responsibility for my care, (b) any content the provider links to in those messages, and (c) advice a provider gives me during a video or telephone visit. No other content in the app or on the website constitutes professional medical advice. In particular, the health questions themselves, the information about who we can and cannot treat, and any automated message telling me that I am not eligible for treatment through this service are screening tools, not medical advice or a diagnosis; if I receive such a message I should discuss my health with another health care provider.

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BENEFITS AND RISKS OF USING OUR SERVICE

I understand that I am choosing to receive care through an online service because it is convenient and accessible, and that important differences exist between Paloma Health's model of care and traditional in-person care. By using Paloma Health I accept a greater responsibility to read and understand the information provided in the app and on the website about the limitations of this model of care, the risks of seeking care this way, and the risks and benefits of any proposed treatment.

I understand that I must read and understand this Consent to Telehealth, the Terms of Use, the Privacy Policy, the Notice of Privacy Practices, the information provided about a service before I answer health questions, the information in the health questions themselves, the messages I receive from Paloma Health and my provider, and, very importantly, any content linked in the message my provider sends me after reviewing my information and recommending a treatment plan or prescribing a medication. I understand that some of this information is shown only when I click a link or expand a section, and that if I do not do so I may miss information I need in order to give informed consent to a treatment.

I understand that I am responsible for providing full and truthful answers to all questions, for telling my provider about any change in my health, medications, pregnancy or breastfeeding status, or location, and, when requested, for providing unaltered photographs of myself taken at the time I use the service. I understand that my provider cannot independently verify the information and photographs I provide and will make a professional judgment based on them, and that inaccurate or incomplete information can lead to a wrong or unsafe treatment decision.

I understand that the care I receive through the service is limited to evaluation and treatment of the specific condition or conditions for which I request care and that a provider agrees to treat. Paloma Health does not provide primary care, and I must seek other sources of care for my other medical needs, including preventive care, screening, and any condition not being treated through the service.

I understand that when I receive care through a telehealth consultation I will not have an in-person consultation or physical examination, which might identify a medical condition that needs further investigation or immediate treatment.

I understand that some services are provided asynchronously, meaning a provider reviews my questionnaire and any photographs at a later time and I will not speak or message with a provider in real time. Other services include a live video or telephone visit with a provider.

I understand that my provider will communicate important information to me through the app, the website, and the email address on my account, and that I must check them regularly. If I do not, my care may be delayed. I understand that if I have non-urgent questions about my care I can message my provider through the app or website, and that my provider may not review or respond to my message for one or more business days. If my condition changes or worsens while I am waiting, I should seek care elsewhere.

Possible risks:

• Delays in evaluation and treatment could occur due to deficiencies or failures of equipment, software, or internet connections.
• My provider may determine that the information or photographs I have provided are of inadequate quality or are insufficient to make a safe decision, requiring additional information, a rescheduled consultation, a live visit, or a visit with a local health care provider.
• In rare events, security protocols could fail, causing a breach of the privacy of my personal medical information. Standard email and text messages are not encrypted, and messages sent to me by those means could be read by someone with access to my accounts or devices.
• Because my provider does not have access to my complete medical records and relies on the information I provide, there is a risk of adverse drug interactions, allergic reactions, or other errors in judgment.
• Some medications prescribed through the service are compounded and are not FDA-approved; their risks are described in the information provided before I consent to treatment.

If I need follow-up care, assistance in the event of an adverse reaction to treatment, or help because I am unable to communicate through the service due to a technical failure, I can contact Paloma Health at contact@palomahealth.com or (434) 248-7508.

I understand that federal and state law requires health care providers to protect the privacy and security of health information, and that Paloma Health and the Medical Groups take steps to make sure my health information is not seen by anyone who should not see it. I understand that telehealth involves electronic transmission of my personal medical information to health care practitioners and to pharmacies, laboratories, and service providers that support my care, some of which may be located in other states.

I understand that there is a risk of technical failures during a telehealth encounter beyond the control of Paloma Health, and I agree to hold Paloma Health harmless for delays in evaluation or for information lost due to such technical failures.

I understand that I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time, without affecting my right to future care or treatment, and that I may suspend or stop using the telehealth services at any time for any reason or for no reason.

I understand that if I am experiencing a medical emergency I must call 911 immediately, and that Paloma Health providers are not able to connect me directly to local emergency services.

I understand that alternatives to telehealth, such as in-person care, are available to me, and that if I choose telehealth, some parts of my care, such as laboratory tests, may be performed by others at my location or at a testing facility at the direction of my provider.

I understand that I may expect the anticipated benefits from the use of telehealth in my care, but that no results can be guaranteed or assured.

I understand that my health care information may be accessed by Paloma Health and Medical Group staff for scheduling, care coordination, and billing purposes, and by staff who operate and support the telehealth technology. If anyone other than my provider is present during a live consultation, I will be informed of their presence and may (1) ask that specific details of my medical history or examination that are personally sensitive to me be omitted, (2) ask non-medical personnel to leave the consultation, and/or (3) end the consultation at any time.

I understand that providers do not prescribe controlled substances through the service, including narcotics for pain, and that there is no guarantee that I will be given a prescription at all.

I understand that I have the right to request a copy of my medical records, which will be provided to me as described in the Notice of Privacy Practices, subject to a reasonable, cost-based fee where permitted by law.

Additional state-specific consents. The following apply to patients located in the states listed, to the extent services are available there (inclusion of a state below does not mean services are available in that state):

Arizona: I understand I am entitled to all existing confidentiality protections pursuant to A.R.S. § 12-2292. I also understand all medical reports resulting from the telemedicine consultation are part of my medical record as defined in A.R.S. § 12-2291. I also understand dissemination of any images or information identifiable to me for research or educational purposes shall not occur without my consent, unless authorized by state or federal law (A.R.S. § 36-3602).

Colorado: The patient may refuse telemedicine services at any time, without loss or withdrawal of treatment. All applicable confidentiality protections shall apply to the services. The patient shall have access to all medical information from the services, under state law (C.R.S. § 25.5-5-320).

Texas: I understand that my medical records may be sent to my primary care physician with my consent (Tex. Occ. Code § 111.005).

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IMPORTANCE OF READING ALL THE INFORMATION WE PROVIDE

I understand that Paloma Health will provide detailed information in the app, on the website, and by email to help me make an informed decision about whether to accept a proposed treatment plan. The most important information about a treatment plan is in the message my provider sends me when the provider prescribes a treatment, including any linked content and the patient guide for my medication. This information is intended to help me decide whether the benefits of the treatment plan outweigh the risks, given the alternative options available to me, which include the option of not taking any treatment.

I understand the importance of reading the information my provider gives me about adverse events, including the signs and symptoms of serious side effects and common side effects of a medication, so that I seek appropriate medical attention in a timely manner.

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IMPORTANCE OF ANSWERING ALL QUESTIONS FULLY AND TRUTHFULLY

I understand that by using Paloma Health I am entering into a relationship in which my provider relies on the information and photographs I provide to decide whether treatment is safe and appropriate for me.

I understand that my provider has no way of independently verifying the information and photographs I provide, and will treat my information as accurate, true, and complete — including my identity, age, sex, the state where I am located, and all of my answers to health questions — and will treat my photographs as being of me, taken at the time I use the service, and unaltered.

I understand that if I provide information that is not true and complete, or photographs that are altered, not of me, or not taken at the time I use the service, I will be at greater risk of adverse events from any treatment my provider prescribes, and I may receive a treatment that is not necessary, appropriate, or safe. I understand that even if the information and photographs I provide are accurate, I am still at risk of adverse events from any treatment.

I understand that it is important that I do not create more than one account. Creating more than one account makes it impossible for my provider to see the full history of my care with Paloma Health, and increases the chance that my provider will not have access to information or photographs in my medical record that could affect a clinical decision.

I understand that by using Paloma Health I give my consent for my provider to access my medication history, where available, from pharmacy and prescription-benefit records made available through Surescripts. My provider may take this information into account when making a treatment or prescribing decision, but this does not change how important it is that I provide full, true, and complete information during my visit.

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RISKS OF ACCEPTING OUR TREATMENT PLAN

I understand that all medications my provider may prescribe or recommend, including over-the-counter and "behind-the-counter" medications, can cause serious side effects and adverse events, including severe allergic reaction, permanent disability, and death.

I understand that it is my responsibility to make an informed decision whether to accept a treatment plan my provider proposes, after weighing the risks and benefits of the medication being prescribed, alternative treatment options and their risks and benefits, and the option of not seeking any treatment.

I understand the importance of reading the information that comes with a medication before I take it. For an FDA-approved medication, this is the manufacturer's leaflet. For a compounded medication, there is no manufacturer's leaflet; I should read the information the pharmacy provides with my medication and the patient guide Paloma Health provides, and I should contact my provider or the pharmacy with any questions before starting.

I understand that adverse events can be caused by a number of things, including an allergic reaction, side effects, or interactions between a medication my provider prescribes and any medical conditions I have, other prescription medications, other things I take (such as supplements, herbs, over-the-counter medications, or recreational drugs), and lifestyle factors such as smoking or drinking alcohol.

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At home blood test kit 

I understand that the test Paloma Health orders measures my thyroid hormone levels and TPO antibody levels only. A normal result means my levels for these biomarkers are normal; alone, it does not provide a comprehensive view of my overall health.

I understand that if any result is outside the normal range, it is my responsibility to seek further evaluation from a provider, in person if my provider recommends it.

I understand that hypothyroidism is not the only cause of high or low thyroid hormone levels, and that the test Paloma Health orders cannot tell me the cause of an abnormal result.

I understand that I cannot use insurance to pay for the test Paloma Health orders, and that if I have insurance, it might pay for a similar test if I saw a provider in person.

I understand that if I have symptoms of hypothyroidism, a family history of hypothyroidism, am 40 or over and overweight or obese, or have hypothyroidism or subclinical hypothyroidism, generally accepted medical opinion is that I can benefit from an at-home thyroid blood test. I understand that if I do not fall into these groups, there is not sufficient data to show whether the benefits of the test outweigh the potential harms, which can include "false-positive" results (a result that says a condition exists when it does not) and overtreatment (treating abnormal thyroid hormone levels that may return to normal on their own and would never have caused health problems).

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PROMO CODE PROGRAMS

I understand that if I received a promo code for Paloma Health's services from a third party such as my employer, health insurer, or other organization ('Promo-Code-Provider'), I assume all risks associated with my use of the promo code. I understand and agree to fully release, waive, and forever discharge the Promo-Code-Provider from any and all losses, rights, liabilities, claims, demands, legal actions or right of action that I may have now or in the future, known or unknown, for any damages or personal injury that may occur during my use of a promo code for Paloma Health. I understand that by consenting to these terms and using the Paloma Health service, I forfeit any and all right to bring a suit against the Promo-Code-Provider arising from my use of the coupon. This release applies even if the injury or damage is caused in whole or in part by the negligence or fault of the Promo-Code-Provider, however, I understand that the forgoing release does not apply to gross negligence or willful misconduct by the Promo-Code-Provider.

I understand that in the event that Paloma Health, or any of its affiliates (including business associates and vendors) unintentionally discloses or disseminates my personal health information, my only recourse is against Paloma Health and its affiliates, and not against Promo-Code-Provider.

RISKS TO ELECTRONIC HEALTH INFORMATION

I understand that although Paloma Health and the Medical Groups implement administrative, physical, and technical safeguards to protect my health information and comply with HIPAA and applicable state law, they cannot guarantee the privacy and confidentiality of my health information. For details about how my health information is protected, used, and disclosed, see the Notice of Privacy Practices and the Privacy Policy.

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SURESCRIPTS

Authorization to obtain my medication history

In accordance with state law and the HIPAA Privacy Rule, I authorize the following:

1. Paloma Health and the Medical Groups use Surescripts, a prescription network that allows prescriptions and related information to be exchanged between my providers and pharmacies. Through Surescripts, my provider may obtain my medication history, which may include prescription medications I am currently taking or have taken in the past, as reported by pharmacies and prescription-benefit managers. This information will be used by my provider to evaluate and treat me.
2. This authorization may include disclosure of prescription information related to alcohol or drug abuse treatment, mental health treatment, and/or HIV-related information.
3. I have the right to revoke this authorization at any time by writing to Paloma Health at privacy@palomahealth.com, except to the extent that action has already been taken in reliance on it.
4. Signing this authorization is voluntary. My treatment will not be conditioned on it; however, without it my provider will rely solely on the medication information I provide.
5. Information disclosed under this authorization may be re-disclosed by the recipient and may no longer be protected by federal privacy law.
6. This authorization expires [two years] from the date I accept it, or earlier if I revoke it or my care with Paloma Health ends.
7. This authorization does not authorize Paloma Health or the Medical Groups to discuss my health information or medical care with anyone other than those permitted under applicable law.

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Use of Non–FDA Approved or Off-Label Treatments

I understand that my provider may recommend treatments that have not been approved by the U.S. Food and Drug Administration (FDA) for my condition. These may include: medications that are FDA-approved for other conditions but are being prescribed for a different use ("off-label" use); compounded medications, which are prepared for me individually by a licensed compounding pharmacy according to my provider's prescription and are not FDA-approved or tested by the FDA for safety, effectiveness, or quality; and vitamins or dietary supplements, which are not reviewed by the FDA. These recommendations are made because my provider believes they may help me, based on research, clinical guidelines, or clinical experience. Because the FDA has not evaluated these options for my condition, some risks, side effects, or long-term outcomes may not be fully known, and supplements can interact with prescription medications. My provider prescribes a compounded medication only when the provider concludes that a commercially available product is not appropriate for me. The Terms of Use list the compounded and off-label medications currently offered.

I understand that the treatments recommended to me may not be FDA-approved or fully studied; that I have had the opportunity to ask my provider questions through the app or website before starting; and that I am choosing to proceed voluntarily.

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