Informed Consent to Telehealth Services and Essential Telemed Policies

This form describes Essential Telemed’s Telehealth treatment and payment policies and includes:

  • Your consent to receive medical treatment from Essential Telemed (and your other rights and responsibilities);
  • Your agreement to receive services using telehealth technology; and
  • Your agreement to pay in full any charges that are your responsibility.

By typing my name and clicking “I agree to Terms of Use” on the Essential Telemed telehealth portal, I understand and  agreethat I am signing this Consent electronically and that (i) I have reviewed, understand and accept the risks and benefits oftelehealth services as described below and wish to receive such services, and (ii) I agree to the remaining terms  of this Consent, including the terms of the Essential Telemed Privacy Notice described below.

If I am signing on behalf of a minor, incapacitated or otherwise legally dependent patient, I certify that I am a person
with legal authority to act on behalf of the patient, including the authority to consent to medical services, and I accept
financial responsibility for services rendered.

  1. 1. By using the Essential Telemed telehealth portal, I agree to receive telehealth service. Telehealth involves the delivery of health care services, including assessment, treatment, diagnosis, and education, using interactive audio, video, and data communications. During my visit, my Essential Telemed provider and I will be able to see and speak with each other from remote locations.


  1. 2. I understand and agree that:


  • I will not be in the same location or room as my medical provider.
  • My telemedicine provider is licensed in the state in which I am receiving services. I will report my location

accurately during registration.

  • Potential benefits of telehealth (which are not guaranteed or assured) include: (i) access to medical care if I

am unable to travel to my Essential Telemed provider’s office; (ii) more efficient medical evaluation and
management; and (iii) during the COVID-19 pandemic, reduced exposure to patients, medical staff and other
individuals at a physical location.

  • Potential risks of telehealth include: (i) limited or no availability of diagnostic laboratory, x-ray, EKG, and
    other testing, and some prescriptions, to assist my medical provider in diagnosis and treatment; (ii) my

provider’s inability to conduct a hands-on physical examination of me and my condition; and (iii) delays in
evaluation and treatment due to technical difficulties or interruptions, distortion of diagnostic images or
specimens resulting from electronic transmission issues, unauthorized access to my information, or loss of
information due to technical failures. I will not hold Essential Telemed responsible for lost information due to
technological failures.

  • I further understand that my Essential Telemed Provider’s advice, recommendations, and/or decisions may
    bebased on factors not within his/her control, including incomplete or inaccurate data provided by me. Iun-

derstand that my Essential Telemed provider relies on information provided by me before and during our
telehealth encounter and that I must provide information about my medical history, condition(s), andcur-
rent or previous medical care that is complete and accurate to the best of my ability.

  • I may discuss these risks and benefits with my Essential Telemed provider and will be given an opportunity

to askquestions about telehealth services. I have the right to withdraw this consent to telehealth services or 

endthe telehealth session at any time without affecting my right to future treatment by Essential Telemed.

  • I understand that the level of care provided by my telemedicine provider is to be the same level of care that
    is available to me through an in-person medical visit. However, if my provider believes I would be better

served by face-to-face services or another form of care, I will be referred to the nearest hospital emergency department or other appropriate health care provider.

  • I have the right to receive face-to-face medical services at any time by traveling to a Essential Telemed medical center that is convenient to me.
  • In case of an emergency, I will dial 911 or go directly to the nearest hospital emergency room.


  1. I consent to, understand and agree that:


  • I have the right to discuss the risks and benefits of all procedures and courses of treatment proposed by my health care provider(s), together with any available alternatives.
  • Essential Telemed will provide care consistent with the prevailing standards of medical practice but makes no assurances or guarantees as to the results of treatment.
  • Before prescribing any controlled substance to me, Essential Telemed may review information from the Prescription Drug Monitoring Program in my state of residence regarding my prior receipt of controlled substances.
  • My telemedicine provider will not prescribe opioids, Schedule 2 controlled substances (including stimulant medications used to treat attention deficit disorders), or new prescriptions for benzodiazepines to me during a telehealth visit.
  • I have the right to review and receive copies of my medical records, including all information obtained during a telehealth interaction, subject to Essential Telemed’s standard policies regarding request and receipt of medical records and applicable law.
  • The laws of the state in which I am located will apply to my receipt of telehealth services.

Essential Telemed Notice of Privacy Practices (“Privacy Notice”)

Essential Telemed will protect the privacy of my health information and will not use or disclose it except as permitted by law. Essential Telemed’s privacy policies are more fully described in the Privacy Notice, which is available for review and download here: By signing this Consent, I acknowledge receipt of the Privacy Notice and consent to Essential Telemed’s use and disclosure of my health information in accordance with its terms. I understand that all existing confidentiality protections that apply to in-person treatment apply to telehealth services.

Florida patients only: By signing this consent electronically, I authorize Essential Telemed to disclose information

related to HIV/AIDS for treatment, payment, health care operations, and other purposes consistent with the Privacy

Notice. I may revoke consent by sending written notice as required by the Privacy Notice. Revocation will be

effective upon receipt, except to the extent that Essential Telemed has already taken action in reliance on my


Payment Policy

I acknowledge, understand and agree that:

  1. It is my responsibility to determine whether Essential Telemed’s services are covered by my insurer. I will pay the cost of any service that is not covered by my health plan for any reason or are covered but applied to a deductible.
  2. I will pay at time of service any required co-payments, co-insurance and deductibles, as well as charges for

services not covered by insurance, outstanding balances and delinquent accounts.

  1. I assign to Essential Telemed all health care benefits to which I am entitled under any insurance policy or benefit plan and authorize payment of benefits directly to Essential Telemed.
  2. If I have health care benefits, Essential Telemed will submit a claim to my insurer and allow 60 days for a

response. If my insurer does not respond within 60 days, Essential Telemed will assume that the visit is not covered and will, to the extent permitted by law, bill me for the visit charges.

  1. By providing my credit card information and receiving telehealth services, I (i) authorize Essential Telemed to charge my credit card for any and all unpaid amounts that Essential Telemed or my insurer determines are my responsibility, and (ii) agree to pay all amounts charged pursuant to this consent and authorization in accordance with the issuing bank cardholder agreement. I agree that Essential Telemed may charge my credit card for such amounts at the end of my telehealth visit or at a later date.
  2. I will be billed for all unpaid balances deemed by Essential Telemed or my insurer to be my responsibility and agree to pay such amounts in full. Essential Telemed will charge late fees of 1.5% per month on unpaid balances starting 30 days after the first statement, as well as a $30 fee for returned checks. Delinquent accounts may be turned over to a collection agency at which time I am responsible for a $40 collections charge and all associated legal fees in addition to the amount owed.
  3. Essential Telemed reserves the right to deny non-emergency services if my account is delinquent.

I understand that I may access and print a copy of this Consent here:

Terms of Use

Terms of Use 31 January 2021.USE OF THE WEBSITE. Essential Telemed, LLC (“we “, “us”, or “our “, “Essential”, “Telemed”), operates this Essential Telemed mobile website(the “website. Through the website we offer a self-pay online telehealth service (the “Service “) that lets people get a telemedicine consultation. Our nurse practitioners are licensed to practice in your state. If appropriate, our nurse practitioners will send a prescription to a pharmacy licensed in your state, you agree to these Terms of Use, the Consent to Telehealth, and the Privacy Policy that appear on the Website. If you do not wish to be bound by these Terms of Use, you may not use the Website. Essential Telemed, LLC does not provide any medical services. Essential Telemed, LLC can store a request for medical services and forward that request to a licensed medical provider in your state. After you make a request through the Website, Essential Telemed will nominate one or more nurse practitioners to work on your request. Those nurse practitioners are third-party beneficiaries of this Agreement. 2. ‘JAILBREAKING’ THE MOBILE OPERATING SYSTEM. The Website is intended for use only on a mobile phone that runs an unmodified manufacturer approved operating system. Using the Website on a mobile phone with a modified operating system may undermine security features that are intended to protect your protected health information from unauthorized or unintended disclosure. You may compromise your protected health information if you use the Website on a mobile phone that has been modified. Use of the Website on a mobile phone with a modified operating system is a material breach of these Terms of Use. 3. WEBSITE CONTENT. Other than the personalized content we send you through an in-website message, you should not consider content on the Website to be medical advice . 4. USER ACCOUNTS. When you register on the Website, you need to create an account (“Account “) by entering your name, email address, password, and certain other information we collect. You may not transfer or share your Account password with anyone, or create more than one Account. You are responsible for maintaining the confidentiality of your Account password and for all activities that occur under your Account. You are responsible for changing your password promptly if you think it has been compromised. To change your password go into ‘Account’ within the Website. We reserve the right to take any and all action, as it deems necessary or reasonable, regarding the security of the Website and your Account. You may not use anyone else’s account at any time. 5. ACCESS RIGHTS. We hereby grant to you a limited, non-exclusive, non-transferable right to access the Website from a mobile phone located in the Essential Telemed service area and to use the Service solely for your personal non-commercial use and only as permitted under these Terms of Use, Consent to Telehealth, and the Privacy Policy. We reserve the right, in our sole discretion, to deny or suspend use of the Website to anyone for any reason. You agree that you will not, and will not attempt to: (a) impersonate any person or entity or otherwise misrepresent your affiliation with a person or entity; (b) use the Website to violate any local, state, national or international law; (c) reverse engineer, disassemble, decompile, or translate any software or other components of the Website; (d) distribute viruses or other harmful computer code through the Websiteor (e) otherwise use the Websitein any manner that exceeds the scope of use granted above . 6. OWNERSHIP. The Website and its entire contents, features and functionality (including but not limited to all information, software, text, displays, images, video and audio, and the design, selection, and arrangement thereof), are owned or used under license by Essential Telemed and are protected by United States and international copyright, trademark, trade secret, and other intellectual property or proprietary rights laws. These Terms of Use permit you to use the Website for your personal, non-commercial use only. You must not reproduce, distribute, modify, create derivative works of, publicly display, publicly perform, republish, download, store or transmit any of the material on our Website except as generally and ordinarily permitted through the Website according to these Terms of Use. You must not access or use for any commercial purposes any part of the Website. 7. TRADEMARKS. Certain names, logos, and other materials displayed on the Website may constitute trademarks, trade names, service marks or logos (“Marks “) of Essential Telemed or other entities. You are not authorized to use any such Marks without the express written permission of Essential Telemed. Ownership of all such Marks and the goodwill associated therewith remains with us. 8. TERMINATION. Essential Telemed may suspend or terminate your use of the Website for any reason at any time. Subject to applicable law, Essential Telemed reserves the right to maintain, delete or destroy all communications and materials posted or uploaded to the Website pursuant to its internal record retention and/or content destruction policies. After such termination, Essential Telemed will have no further obligation to provide the Service, except to the extent we are obligated to provide you access to your health records or we are required to provide you with continuing care under our applicable legal, ethical and professional obligations to you. 9. RIGHT TO MODIFY. We may at our sole discretion change, add, or We may at our sole discretion change, add, or delete portions of these Terms of Use at any time on a going-forward basis. Continued use of the Website following notice of any such changes will indicate your acknowledgments of such changes and agreement to be bound by the revised Terms of Use, inclusive of such changes. 10. DISCLAIMER OF WARRANTIES. YOU EXPRESSLY AGREE THAT USE OF THE WEBSITE IS AT YOUR SOLE RISK. WE PROVIDE THE WEBSITE ON AN “AS IS” AND “AS AVAILABLE” BASIS. Essential Telemed EXPRESSLY DISCLAIMS ALL WARRANTIES OF ANY KIND, WHETHER EXPRESS OR IMPLIED, INCLUDING, BUT NOT LIMITED TO ANY WARRANTIES OF MERCHANT ABILITY, FITNESS FOR A PARTICULAR USE OR PURPOSE, NON.INFRINGEMENT, TITLE, OPERABILITY, CONDITION, QUIET ENJOYMENT, VALUE, ACCURACY OF DATA, AND SYSTEM INTEGRATION . 11.LIMITATION OF LIABILITY. YOU UNDERSTAND THAT TO THE EXTENT PERMITTED UNDER APPLICABLE LAW, IN NO EVENT WILL Essential Telemed OR ITS OFFICERS, EMPLOYEES, DIRECTORS, PARENTS, SUBSIDIARIES, AFFILIATES, AGENTS OR LICENSORS BE LIABLE FOR ANY INDIRECT, INCIDENTAL, SPECIAL, CONSEQUENTIAL OR EXEMPLARY DAMAGES, INCLUDING BUT NOT LIMITED TO, DAMAGES FOR LOSS OF REVENUES, PROFITS, GOODWILL, USE, DATA OR OTHER INTANGIBLE LOSSES ARISING OUT OF OR RELATED TO YOUR USE OF THE SITE OF THE WEBSITE, REGARDLESS OF WHETHER SUCH DAMAGES ARE BASED ON CONTRACT, TORT (INCLUDING NEGLIGENCE AND STRICT LIABILITY), WARRANTY, STATUTE OR OTHERWISE. To the extent that we may not, as a matter of applicable law, disclaim any implied warranty or limit its liabilities, the scope and duration of such warranty and the extent of our liability will be the minimum permitted under such applicable law . 12.INDEMNIFICATION. You agree to indemnify, defend, and hold harmless Essential Telemed, its officers, directors, employees, agents, subsidiaries, affiliates, licensors, and suppliers, harmless from and against any claim, actions, demands, liabilities, and settlements, including, without limitation, reasonable legal and accounting fees (“Claims”), resulting from, or alleged to result from, your violation of these Terms of Use. 14.MISCELLANEOUS. These Terms of Use and your use of the Website shall be governed by the laws of the State of Florida, without giving effect to the principles of conflict of laws. Any dispute arising under or relating in any way to these Terms of Use will be resolved exclusively by final and binding arbitration in Florida under the rules of the American Arbitration Association, except that either party may bring a claim related to intellectual property rights, or seek temporary and preliminary specific performance and injunctive relief, in any court of competent jurisdiction, without the posting of bond or other security. The parties agree to the personal and subject matter jurisdiction and venue of the courts located in Florida, for any action related to these Terms of Use. You understand that by checking the “agree” box for these Terms of Use and/or any other forms presented to you on the Site you are forms presented to you on the Site you are agreeing to these Terms of Use and that such action constitutes a legal signature. No waiver by Essential Telemed of any term or condition set forth in these Terms of Use shall be deemed a further or continuing waiver of such term or condition or a waiver of any other term or condition, and any failure of Essential Telemed to assert a right or provision under these Terms of Use shall not constitute a waiver of such right or provision. If any provision of these Terms of Use is held by a court or other tribunal of competent jurisdiction to be invalid, illegal or unenforceable for any reason, such provision shall be eliminated or limited to the minimum extent such that the remaining provisions of the Terms of Use will continue in full force and effect. The Digital Millennium Copyright Act of 1998 (the “DMCA “) provides recourse for copyright owners who believe that material appearing on the Internet infringes their rights under U.S. copyright law. If you believe in good faith that materials appearing on the Website infringe your copyright, you (or your agent) may send us a notice requesting that the material be removed, or access to it blocked. In addition, if you believe in good faith that a notice of copyright infringement has been wrongly filed against you, the DMCA permits you to send us a counter-notice. Notices and counter-notices the Internet infringes their rights under U.S. copyright law. If you believe in good faith that materials appearing on the Website infringe your copyright, you (or your agent) may send us a notice requesting that the material be removed, or access to it blocked. In addition, if you believe in good faith that a notice of copyright infringement has been wrongly filed against you, the DMCA permits you to send us a counter-notice. Notices and counter-notices must meet statutory requirements imposed by the DMCA. One place to find more information is the U.S. Copyright Office Website, currently located at Any written Notification of Claimed infringement should comply with Title 17, United States Code, Section 512(c)(3)(A) and should be provided in writing to Essential Telemed, LLC, or by email to Consent To Telehealth Before you give your consent, please make sure you understand how using Essential Telemed, referred to as “Essential Telemed”, both the native app, and the mobile web experience, to obtain care differs from the traditional doctor’s office. The service is provided by Essential Telemed, LLC. Essential Telemed does not provide any medical services. Essential Telemed partners with local nurse practitioners to give them the infrastructure to practice telemedicine. Our nurse practitioners are third-party beneficiaries of this Agreement. NOT FOR EMERGENCIES I understand that I should never use the Website in an emergency. I understand that in an emergency, I should dial 911 or go to an emergency department. NURSE PRACTITIONER-PATIENT RELATIONSHIP I understand that the nurse practitioner has the right to refuse to take responsibility for my care if the nurse practitioner makes a professional judgment that I am not a good candidate for this service. I understand that making a request for treatment (by completing a visit and making payment) or sending a message through the Website does not in and of itself create a duty of care or create a nurse practitioner-patient relationship. I understand that the nurse practitioner will take responsibility for my care only after the nurse practitioner has reviewed my request for treatment, reviewed all my information, and then subsequently determined that I am a good candidate for the telehealth services. I understand that there may be a delay until a nurse practitioner reviews and responds to any messages I send. RISKS TO ELECTRONIC HEALTH INFORMATION I understand that the electronic nature of the Website means that there’s a greater risk to the privacy of my health information compared to visiting a traditional nurse practitioner’s office. I understand that although Essemtial Telemed implements a wide range of administrative, physical, and technical safeguards to protect my health information, Essential Telemed cannot guarantee the privacy and confidentiality of my health information. For more details about how Essential Telemed protects your health information, see our Privacy Policy.