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PHARMXHEALTHONE
Telehealth Consent
Effective Date: Jan 1, 2024
Last Updated: October 7, 2026
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PHARM X UNIVERSAL, LLC d/b/a PHARMXHEALTHONE
2828 South Seacrest Boulevard, Suite 216
Boynton Beach, Florida 33435
Telephone: 561-778-8121
Email: health@pharmxhealthone.com
Website: www.pharmxhealthone.com
1. PURPOSE OF THIS TELEHEALTH CONSENT
This Telehealth Consent explains the nature of telehealth services offered through PharmXHealthOne, the potential benefits and limitations of receiving healthcare through telehealth, patient responsibilities when participating in a telehealth encounter, privacy and technology considerations, circumstances in which an in-person evaluation may be required, and other information that patients should understand before agreeing to receive healthcare through telehealth.
By agreeing to receive telehealth services from PharmXHealthOne, you acknowledge that you have been given an opportunity to review this Telehealth Consent, ask questions when appropriate, and make an informed decision about whether to participate in telehealth. This consent does not replace treatment-specific informed consent when separate consent is appropriate for a medication, procedure, treatment, or other healthcare service.
2. ABOUT PHARMXHEALTHONE
PharmXHealthOne is operated by PHARM X UNIVERSAL, LLC d/b/a PHARMXHEALTHONE. PharmXHealthOne provides outpatient healthcare services through appropriately authorized healthcare professionals. Depending on the circumstances and the individual patient's needs, services may be provided in person, through telehealth, or through a combination of in-person and telehealth care. The healthcare professional participating in a telehealth encounter remains responsible for practicing within the professional's applicable scope of practice, licensure or authorization, and professional standards.
3. WHAT TELEHEALTH MEANS
Telehealth is the use of electronic communications and telecommunications technology to provide or support healthcare services when the patient and healthcare professional are not physically present in the same location. Depending on the service and technology being used, telehealth may include real-time video communication, audio communication where permitted and clinically appropriate, secure transmission or review of health information, remote consultation, patient education, monitoring, follow-up, and other legally permitted healthcare activities. Telehealth does not mean that every healthcare service can or should be provided remotely. The treating healthcare professional will determine whether telehealth is appropriate for the particular service and circumstances.
4. VOLUNTARY PARTICIPATION IN TELEHEALTH
Your participation in telehealth is voluntary, subject to the availability of another clinically appropriate method of providing the requested care.
You may ask questions about telehealth before or during your encounter.
You may decline to begin a telehealth encounter or ask to discontinue the telehealth encounter at any time. However, discontinuing telehealth does not guarantee that the requested healthcare service can be completed through another method without additional evaluation, scheduling, or cost.
A healthcare professional may also discontinue or decline to continue a telehealth encounter when the professional determines that telehealth is not clinically appropriate, that necessary information cannot be obtained remotely, that the technology is insufficient, that patient safety requires in-person evaluation, or that another healthcare setting is more appropriate.
5. PATIENT PHYSICAL LOCATION AT THE TIME OF EACH TELEHEALTH ENCOUNTER
You must accurately tell PharmXHealthOne and the treating healthcare professional your actual physical location at the time of every telehealth encounter.
Your physical location is important because healthcare licensure, professional practice authority, prescribing requirements, emergency response, and other laws may depend on where you are physically located when healthcare is provided.
Your mailing address, permanent residence, driver's-license address, or location entered during registration does not replace the requirement to provide your actual physical location at the time of the telehealth encounter. For example, if your permanent residence is in Florida but you are physically located in another state during your telehealth appointment, you must disclose the state in which you are physically located. If PharmXHealthOne or the healthcare professional is not legally or professionally authorized to provide the requested telehealth service to a patient in your location, the encounter may need to be rescheduled, modified, or discontinued. You agree not to misrepresent or conceal your physical location.
6. PATIENT IDENTITY VERIFICATION
PharmXHealthOne may take reasonable steps to verify your identity before or during a telehealth encounter. You may be asked to confirm information such as your full legal name, date of birth, address, telephone number, physical location at the time of the encounter, or other identifying information. When appropriate, PharmXHealthOne may also ask you to present a government-issued driver's license, passport, or other acceptable identification. These measures are intended to help protect patient safety, prevent unauthorized access to healthcare information, and ensure that care is being provided to the correct individual.
7. PERSONS PRESENT DURING THE TELEHEALTH ENCOUNTER
At the beginning of or during a telehealth encounter, the healthcare professional may ask who is present with you. You should identify any other person who can see, hear, or participate in the encounter. If you want a family member, caregiver, interpreter, personal representative, or another individual to participate, you should inform the healthcare professional. The healthcare professional may ask for confirmation that you consent to the person's participation. In some circumstances, the healthcare professional may request to speak with you privately for all or part of the encounter when doing so is clinically or legally appropriate.
8. PROFESSIONAL STANDARD OF CARE
Receiving healthcare through telehealth does not reduce the professional standard applicable to the healthcare professional. A PharmXHealthOne healthcare professional providing telehealth services must practice within the professional's authorized scope and according to applicable professional standards. The use of telehealth does not require a healthcare professional to diagnose, prescribe, recommend treatment, or provide a particular service when the available information is insufficient or when doing so would not be professionally appropriate. A healthcare professional may require additional information, laboratory testing, records, measurements, photographs, diagnostic testing, an in-person physical examination, or referral to another healthcare professional before making or completing a clinical decision.
9. TELEHEALTH PATIENT EVALUATION
A telehealth encounter may be used to evaluate a patient when the healthcare professional determines that the available technology and information are sufficient for the purpose of the encounter. The healthcare professional may ask questions about your medical history, symptoms, current medications, allergies, laboratory results, prior treatments, health concerns, health goals, or other information relevant to your care. You agree to answer healthcare questions truthfully and completely to the best of your knowledge. A telehealth evaluation does not guarantee that a diagnosis can be made or that treatment can be recommended remotely.
10. WHEN AN IN-PERSON EVALUATION MAY BE REQUIRED
Telehealth has limitations.
Certain physical examinations, measurements, diagnostic procedures, laboratory collections, imaging studies, body-composition assessments, vital-sign measurements, procedures, treatments, or other services cannot be adequately performed through telehealth. A healthcare professional may determine at any time that an in-person evaluation is necessary before treatment can begin or continue. An in-person evaluation may also be required if the healthcare professional cannot adequately evaluate your condition through telehealth, identifies symptoms requiring direct examination, needs testing or measurements unavailable remotely, has concerns about patient safety, or determines that an in-person encounter would better meet the applicable standard of care. You understand that agreeing to telehealth does not create a right to receive all future care remotely.
11. LABORATORY TESTING AND OTHER CLINICAL INFORMATION
Depending on your health concerns, goals, proposed treatment, and the healthcare professional's clinical judgment, laboratory testing or other clinical information may be required before a healthcare recommendation or treatment decision can be made. PharmXHealthOne may use independent laboratories such as Quest Diagnostics and Labcorp when appropriate. A telehealth consultation does not eliminate laboratory-testing requirements that the healthcare professional considers clinically necessary. If required information has not been received, is incomplete, is outdated, or requires clarification, treatment recommendations may be delayed until sufficient information is available.
12. PRESCRIPTIONS AND TREATMENT RECOMMENDATIONS
Participation in a telehealth appointment does not guarantee that a medication will be prescribed or that a particular treatment will be recommended.
Prescribing decisions are made by the treating healthcare professional based on applicable law, professional standards, the patient's medical circumstances, available records, clinical information, and the healthcare professional's independent professional judgment. Certain medications or categories of medications may be subject to additional state or federal prescribing restrictions. If the healthcare professional determines that an in-person evaluation, additional testing, additional records, consultation, or another prerequisite is necessary before prescribing, the patient must complete the required step before the prescription can be issued.
13. PATIENT-SPECIFIC TREATMENT
PharmXHealthOne does not use telehealth as a substitute for individualized healthcare decision-making. Treatment recommendations may take into account information such as your health history, health concerns, health goals, available laboratory results, medications, allergies, prior treatments, provider evaluation, and other relevant clinical information. When appropriate, SECA medical body-composition assessment or other in-person information may also form part of the overall assessment. Medications or healthcare products requiring patient-specific selection are ordered according to the applicable patient-specific process after the necessary evaluation, authorization, and payment requirements have been completed.
14. NO GUARANTEE OF TREATMENT OR OUTCOME
Neither participation in telehealth nor execution of this consent guarantees that you will be eligible for a particular medication, procedure, service, treatment program, or healthcare product. Healthcare outcomes vary from person to person. PharmXHealthOne and its healthcare professionals do not guarantee that a particular treatment will achieve a specific result, that symptoms will improve, that weight or body composition will change by a particular amount, that laboratory values will reach a particular level, or that any other specific health outcome will occur. Treatment recommendations may change as additional information becomes available.
15. BENEFITS OF TELEHEALTH
Telehealth may provide benefits such as increased access to healthcare professionals, reduced travel requirements, increased convenience, continuity of care, easier follow-up, and the ability to communicate with a healthcare professional from another appropriate location. Telehealth may also make it easier to review certain records or discuss follow-up issues without requiring an in-person visit. These potential benefits do not mean that telehealth is appropriate for every patient, condition, or healthcare service.
16. LIMITATIONS AND RISKS OF TELEHEALTH
Telehealth has limitations and risks that may not exist to the same degree during an in-person encounter. For example, a healthcare professional may not be able to conduct the same physical examination that would be possible during an in-person visit. Technical problems may interfere with communication or prevent completion of the encounter. Information transmitted electronically may be incomplete, delayed, unavailable, or of insufficient quality. Video, audio, photographs, measurements, or other information supplied remotely may not show a condition as clearly as an in-person evaluation. There may also be risks associated with the privacy and security of electronic communications. In some circumstances, a healthcare professional may need to postpone a clinical decision until additional information or an in-person evaluation is obtained.
17. TECHNOLOGY REQUIREMENTS
You are responsible for having access to technology reasonably necessary to participate in the telehealth service being provided. Depending on the encounter, this may include a smartphone, tablet, computer, camera, microphone, speakers, internet connection, telephone connection, browser, patient portal, or other technology. You should ensure that your device is adequately charged or connected to power and that your internet or telephone connection is reasonably reliable. You should test your device or connection before the appointment when practical.
18. TECHNOLOGY FAILURE DURING THE ENCOUNTER
Telecommunications systems may fail or become unreliable. If the video, audio, internet connection, or other technology fails during your telehealth appointment, PharmXHealthOne or the healthcare professional may attempt to reconnect, contact you using another available method, continue through another permitted communication method when appropriate, or reschedule the encounter. Whether an encounter can safely continue after a technology failure is determined by the healthcare professional based on the circumstances. A failed connection does not require a healthcare professional to complete an evaluation through an inadequate communication method.
19. PRIVACY DURING TELEHEALTH
PharmXHealthOne will take reasonable steps to protect the privacy and confidentiality of healthcare information during telehealth encounters in accordance with applicable privacy requirements. Healthcare professionals should ordinarily participate from a private or appropriately controlled environment. You are also encouraged to participate from a quiet and private location where other people cannot overhear or view your healthcare discussion unless you want them to participate. Federal health privacy guidance recommends private telehealth settings and reasonable safeguards because telehealth technology can introduce privacy risks.
20. PATIENT RESPONSIBILITY FOR THE PRIVACY OF THEIR ENVIRONMENT
You are responsible for taking reasonable steps to protect privacy in the environment from which you participate. When possible, you should use a private room, avoid speakerphone where others may overhear, use headphones when appropriate, position your device so unauthorized persons cannot see the screen, and avoid discussing sensitive information where strangers or unauthorized persons are present.
You should avoid public or unsecured Wi-Fi networks when reasonably possible. You should also protect access to your device with appropriate passwords or other security measures. PharmXHealthOne cannot control or guarantee the privacy of the location, device, internet service, or network that you choose to use.
21. HIPAA AND HEALTH INFORMATION
Telehealth healthcare information is subject to applicable privacy and security requirements in substantially the same manner as information generated during an in-person healthcare encounter. PharmXHealthOne's HIPAA Notice of Privacy Practices explains how protected health information may be used, disclosed, safeguarded, and accessed and explains patient privacy rights. Applicable electronic health information, clinical notes, provider assessments, treatment recommendations, laboratory results, prescriptions, and related clinical documentation belong in PharmXHealthOne's authorized clinical record environment.
22. ELATION HEALTH AND THE CLINICAL RECORD
PharmXHealthOne uses Elation Health as its clinical electronic health record. Detailed clinical information should be maintained in Elation Health or another specifically authorized clinical system when applicable. This may include medical history, diagnoses, allergies, medications, laboratory results, provider assessments, treatment recommendations, treatment plans, clinical notes, and appropriate patient-care communications. QCommand Center, Airtable, public forms, operational dashboards, event systems, and administrative workflow tools are not substitutes for the patient's clinical electronic health record. Unnecessary detailed clinical information should not be entered into general operational systems merely because a text field is available.
23. ELECTRONIC COMMUNICATIONS OUTSIDE THE TELEHEALTH ENCOUNTER
A telehealth encounter is different from general email, text messaging, website forms, event messaging, or other administrative communications.
Patients should use communication methods specifically approved by PharmXHealthOne for healthcare information.
Ordinary email, standard text messaging, public website forms, and community-event communication systems may have different privacy and security characteristics than the clinical electronic health record or telehealth platform. You should not use PHO Event & Community SMS Updates to communicate patient-specific symptoms, diagnoses, medication questions, laboratory results, treatment instructions, or other detailed clinical information. Patient-specific clinical communication should be handled through Elation Health or another communication method specifically approved by PharmXHealthOne for that purpose.
24. RECORDING TELEHEALTH ENCOUNTERS
A patient should not audio-record, video-record, photograph, livestream, broadcast, or otherwise electronically capture a telehealth encounter without prior authorization from all persons whose authorization is legally required. Likewise, PharmXHealthOne will not routinely record a telehealth encounter merely because the encounter is conducted electronically. If recording is proposed for a legitimate purpose, appropriate authorization and applicable legal requirements must be addressed before recording begins. The clinical documentation created by the healthcare professional is maintained as part of the applicable patient record according to PharmXHealthOne's record-management practices.
25. ACCURATE AND COMPLETE PATIENT INFORMATION
Telehealth depends heavily on information supplied by the patient. You agree to provide information that is accurate, complete, and truthful to the best of your knowledge. You should tell the healthcare professional about relevant health history, medications, supplements, allergies, prior reactions, current symptoms, laboratory information, diagnoses, treatment received from other healthcare professionals, and other information requested for your care.
Failure to provide important information may limit the healthcare professional's ability to safely evaluate or treat you.
26. HOME MEASUREMENTS AND PATIENT-SUPPLIED INFORMATION
A healthcare professional may ask you to provide information obtained outside the clinic, such as weight, blood pressure, pulse, temperature, glucose measurements, photographs, medication labels, or other information. Patient-supplied measurements may be useful but may also be less reliable than measurements obtained using validated equipment under controlled clinical conditions. The healthcare professional may require that a measurement be repeated or verified in person before relying on it for a clinical decision.
27. EMERGENCIES AND URGENT CONDITIONS
PharmXHealthOne is an outpatient healthcare business. PharmXHealthOne does not operate an emergency department and does not provide an after-hours or on-call emergency clinical service. Telehealth through PharmXHealthOne is not intended to replace emergency medical services. If you believe you are experiencing a medical emergency, call 911 or go to the nearest appropriate emergency department. Do not use the PharmXHealthOne website, email, text messaging, voicemail, event communication system, patient portal, or a scheduled telehealth appointment as a substitute for emergency care.
28. EMERGENCY RESPONSE DURING A TELEHEALTH ENCOUNTER
If a healthcare professional becomes concerned during a telehealth encounter that you may require urgent or emergency medical evaluation, the healthcare professional may instruct you to call 911, go to an emergency department, seek urgent in-person care, contact another healthcare professional, or take another appropriate action. Your accurate physical location is particularly important in these circumstances. If necessary and permitted by law, information may be used or disclosed for emergency treatment, patient safety, or another legally authorized purpose.
29. REFERRAL TO ANOTHER HEALTHCARE PROFESSIONAL OR FACILITY
Telehealth does not guarantee that all of your healthcare needs can be addressed by PharmXHealthOne. A healthcare professional may recommend or require referral to another healthcare professional, specialist, hospital, urgent care facility, diagnostic provider, laboratory, imaging center, emergency department, or other healthcare resource. A referral does not necessarily mean that PharmXHealthOne controls, employs, or is responsible for the independent provider. Separate charges may apply for services provided by independent organizations.
30. PHARMACY AND MEDICATION FULFILLMENT
When medication is prescribed, dispensing and fulfillment may involve an independent pharmacy or compounding pharmacy. The pharmacy may have its own patient requirements, policies, shipping procedures, verification requirements, storage instructions, pricing, or other requirements. A telehealth consultation does not guarantee that an independent pharmacy will fill or dispense a prescription. Pharmacy decisions remain subject to applicable law, pharmacy requirements, availability, professional judgment, and the specific prescription.
31. PHARMXHEALTHONE'S CASH-PAY MODEL
PharmXHealthOne is cash-pay only for PharmXHealthOne healthcare services. PharmXHealthOne does not accept or bill Medicare Part B, Medicaid, or commercial health insurance for PharmXHealthOne services, including PharmXHealthOne telehealth services. Patients are responsible for applicable PharmXHealthOne charges. The fact that a healthcare service is provided through telehealth does not change PharmXHealthOne's cash-pay operating model.
32. QUEST DIAGNOSTICS AND LABCORP
PharmXHealthOne may use independent laboratories, including Quest Diagnostics and Labcorp. Those laboratories are separate organizations and may accept or bill a patient's health insurance for eligible laboratory services according to their own network, eligibility, coverage, medical-necessity, deductible, copayment, coinsurance, authorization, and billing rules. This does not mean PharmXHealthOne accepts insurance. An insurance card may be requested or copied when necessary for outside laboratory processing without converting PharmXHealthOne services into insured services.
33. TELEHEALTH FEES AND PATIENT FINANCIAL RESPONSIBILITY
You are responsible for applicable telehealth consultation fees and other PharmXHealthOne charges communicated to you. Additional charges may apply if subsequent laboratory testing, assessments, in-person evaluations, treatments, medications, procedures, products, or follow-up services are recommended and you choose to proceed. Whenever required by applicable law, eligible uninsured or self-pay patients may have rights relating to a Good Faith Estimate of expected healthcare charges. The PharmXHealthOne Good Faith Estimate & No Surprises Act Notice provides additional information regarding those rights.
34. CANCELLATION, RESCHEDULING, AND MISSED TELEHEALTH APPOINTMENTS
Telehealth appointments are subject to PharmXHealthOne's applicable scheduling, cancellation, rescheduling, and no-show policies. You are responsible for joining the scheduled telehealth appointment at the designated time using the instructions provided. Technology problems should be reported as soon as reasonably possible. A patient-caused technology problem or failure to join the encounter does not automatically require a refund or waive an otherwise applicable cancellation or no-show policy. Any exception required by law or expressly approved by PharmXHealthOne will be addressed separately.
35. FINAL SALE AND NO REFUND POLICY
PharmXHealthOne's applicable Final Sale / No Refund policy remains in effect for telehealth-related services and purchases. Medications and healthcare products ordered for a patient are not returnable and are not voluntarily refundable after purchase. Consultations, assessments, procedures, treatments, and other healthcare services that have already been partially or fully provided are not voluntarily refundable. This policy reflects patient-specific ordering, pharmacy and supplier costs, compounding or preparation costs where applicable, fulfillment, shipping, storage and temperature requirements, sterility, chain of custody, product-integrity concerns, professional time, clinical review, staffing, administrative processing, and other nonrecoverable costs. Nothing in the policy eliminates remedies that cannot legally be waived, including appropriate correction of unauthorized transactions, duplicate charges, established billing errors, or another remedy required by applicable law.
36. PATIENT CHOICE TO DISCONTINUE TELEHEALTH
You may tell the healthcare professional that you no longer wish to continue the telehealth encounter. Ending the encounter does not require a healthcare professional to issue a diagnosis, prescription, treatment recommendation, or other clinical determination when adequate evaluation has not been completed. If you decide that you prefer in-person care, you may ask whether an appropriate in-person option is available. Scheduling, availability, additional assessments, and applicable fees may apply.
37. PROVIDER'S RIGHT TO REQUIRE A DIFFERENT METHOD OF CARE
A PharmXHealthOne healthcare professional may determine that telehealth is not the appropriate method for providing or continuing care. The professional may require an in-person encounter or another evaluation when necessary to obtain adequate clinical information, satisfy professional standards, protect patient safety, comply with law, satisfy prescribing requirements, or appropriately address the patient's needs. The healthcare professional's decision to require an in-person assessment is a clinical or professional decision and does not guarantee that the patient will ultimately qualify for a particular treatment.
38. TELEHEALTH ACROSS STATE LINES
Healthcare practice authority may depend on the state or jurisdiction where the patient is physically located at the time healthcare is provided.
PharmXHealthOne may therefore determine whether the treating professional is appropriately authorized to provide care to a patient in the patient's current location.
If you travel or temporarily relocate, you must disclose your location before receiving telehealth care. A previously established relationship with PharmXHealthOne does not automatically authorize a healthcare professional to provide telehealth services to you in every state or jurisdiction.
39. MINORS AND PERSONAL REPRESENTATIVES
When a patient is a minor or another person is legally authorized to act for the patient, telehealth participation, consent, access to information, and decision-making will be handled in accordance with applicable law and the person's legal authority. PharmXHealthOne may request documentation establishing the authority of a parent, guardian, personal representative, healthcare surrogate, or other legally authorized person when appropriate. Nothing in this Telehealth Consent expands a person's authority beyond what applicable law permits.
40. ACCESSIBILITY AND COMMUNICATION NEEDS
If you have a disability, communication limitation, hearing or vision limitation, language need, or another circumstance that affects your ability to participate effectively in telehealth, notify PharmXHealthOne as early as reasonably possible. PharmXHealthOne will evaluate reasonable communication or accessibility measures as required by applicable law and available under the circumstances. A different communication method or in-person appointment may sometimes be necessary when a telehealth format cannot adequately meet the patient's needs.
41. TELEHEALTH AND INFORMED CONSENT FOR SPECIFIC TREATMENTS
This Telehealth Consent authorizes participation in the telehealth method of healthcare delivery. It does not replace informed consent for a specific medication, treatment, procedure, therapy, medical device, or clinical intervention when separate informed consent is appropriate.
Treatment-specific informed consent may address matters such as potential benefits, material risks, side effects, alternatives, contraindications, medication-specific information, follow-up requirements, or circumstances in which treatment should be stopped or modified. You may be required to review and sign additional consent documents before a particular treatment is provided.
42. TELEHEALTH AND THE HIPAA NOTICE OF PRIVACY PRACTICES
This Telehealth Consent should be read together with PharmXHealthOne's HIPAA Notice of Privacy Practices. The HIPAA Notice of Privacy Practices explains in greater detail how PharmXHealthOne may use and disclose protected health information, patient privacy rights, restrictions, access and amendment rights, complaint procedures, legally permitted disclosures, and PharmXHealthOne's privacy obligations. Signing or accepting this Telehealth Consent does not waive your rights under HIPAA or other applicable privacy laws.
43. TELEHEALTH AND THE PHARMXHEALTHONE PRIVACY POLICY
PharmXHealthOne's Legal Notice, Privacy Policy & Cookie Notice separately governs matters involving the public website, online information collection, cookies and tracking technologies, public forms, privacy requests, security, and other website-related privacy practices. This Telehealth Consent should therefore not be interpreted as replacing PharmXHealthOne's broader website privacy documentation.
44. TELEHEALTH AND PHARMXHEALTHONE TERMS AND CONDITIONS
Use of PharmXHealthOne's website, portals, online systems, and other applicable services may also be governed by PharmXHealthOne's Terms and Conditions. When there is a treatment-specific clinical issue, the applicable healthcare consent and professional requirements control the clinical decision rather than general website language. Nothing in the Terms and Conditions or this Telehealth Consent is intended to eliminate a patient right that cannot lawfully be waived.
45. NO WAIVER OF PROFESSIONAL RESPONSIBILITIES
Your consent to telehealth does not release a healthcare professional from the professional responsibilities applicable to the healthcare services being provided. It does not authorize care that would otherwise violate applicable professional standards, scope-of-practice requirements, prescribing requirements, privacy obligations, or other applicable law. It also does not constitute a waiver of claims or rights that cannot lawfully be waived.
46. QUESTIONS BEFORE CONSENTING
You have the right to ask questions about telehealth before consenting.
Questions may include how the encounter will work, what technology will be used, whether an in-person visit may be required, what information will be needed, how privacy is protected, what fees apply, or what alternatives may be available.
You should ask questions before proceeding if there is anything in this Telehealth Consent that you do not understand.
47. PATIENT ACKNOWLEDGMENTS
By signing, electronically accepting, or otherwise providing legally valid consent to this Telehealth Consent, you acknowledge that:
You have reviewed or have been given the opportunity to review this Telehealth Consent before participating in telehealth.
You understand that telehealth involves healthcare delivered through telecommunications technology while the patient and healthcare professional are in different locations.
You understand the potential benefits, limitations, privacy considerations, and technology risks associated with telehealth.
You understand that you must accurately disclose your actual physical location at the beginning of each telehealth encounter.
You understand that the healthcare professional may determine that telehealth is insufficient and may require an in-person evaluation, additional records, laboratory testing, diagnostic testing, or referral.
You understand that participating in telehealth does not guarantee a diagnosis, prescription, medication, treatment recommendation, or particular outcome.
You understand that PharmXHealthOne does not provide emergency medical services and that you should call 911 or seek appropriate emergency care for a medical emergency.
You understand that PharmXHealthOne is cash-pay only for PharmXHealthOne healthcare services.
You understand that independent laboratories, pharmacies, and other third-party providers may have separate charges, billing practices, requirements, and responsibilities.
You understand that telehealth-related clinical information may become part of your healthcare record. You understand that this Telehealth Consent does not replace a separate treatment-specific informed consent when one is appropriate. You understand that you may ask questions before or during the telehealth process.
48. CONSENT TO RECEIVE TELEHEALTH SERVICES
By providing your signature or other legally valid electronic acknowledgment below, you voluntarily consent to receiving healthcare services through telehealth from an appropriately authorized PharmXHealthOne healthcare professional when telehealth is determined to be an appropriate method of delivering the applicable service.
You authorize the healthcare professional to conduct the telehealth encounter, obtain and review information reasonably necessary for your care, document the encounter in the appropriate clinical record, and use or disclose healthcare information as permitted by applicable law and PharmXHealthOne's HIPAA Notice of Privacy Practices.
You understand that you may withdraw your consent to continue a telehealth encounter, subject to the limitations and consequences described in this Telehealth Consent.
49. PATIENT CONSENT RECORD
Patient Full Legal Name: ______________________________________
Date of Birth: _______________________________________________
Patient Telephone Number: ____________________________________
Patient's Physical Location at Time Consent Is Executed:
Patient Signature: ___________________________________________
Date: _______________________________________________________
If signed by a Parent, Guardian, Personal Representative, or Other Legally Authorized Person:
Name: ______________________________________________________
Relationship/Authority: ______________________________________
Signature: __________________________________________________
Date: _______________________________________________________
50. PHARMXHEALTHONE CONTACT INFORMATION
Questions concerning telehealth services or this Telehealth Consent may be directed to:
PharmXHealthOne
PHARM X UNIVERSAL, LLC d/b/a PHARMXHEALTHONE
2828 South Seacrest Boulevard, Suite 216
Boynton Beach, Florida 33435
Telephone: 561-778-8121
Email: health@pharmxhealthone.com
Questions specifically concerning privacy matters may be directed to:
PharmXHealthOne Privacy Officer
Michael Gempel, Executive Director
PHARM X UNIVERSAL, LLC d/b/a PHARMXHEALTHONE
2828 South Seacrest Boulevard, Suite 216
Boynton Beach, Florida 33435
Telephone: 561-778-8121
Email: mgempel@pharmxhealthone.com
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