Telehealth Consent & Patient Rights

Effective Date: September 2026  |  Last Updated: September 8, 2026

About This Notice

This page provides general information about telehealth. It does not by itself create a Provider-patient relationship or replace the informed-consent process conducted by your treating Provider. Before care is delivered, a licensed Provider will complete your patient appointment through the secure patient portal and will obtain and document any consent required for the service and the state where you are physically located.

Nature of Telehealth Services

Telehealth uses electronic communications to allow a patient and a licensed healthcare Provider in different locations to communicate and exchange information. Depending on the service and the Provider's judgment, this may include:

• Secure portal messaging, telephone, or video communication
• Review of your medical history, medications, symptoms, photographs, or other submitted information
• A clinical evaluation and discussion of treatment options
• Electronic prescribing when the Provider determines that it is clinically and legally appropriate
• Follow-up care, monitoring, referral, or a recommendation for in-person evaluation

Completing an intake does not guarantee that a prescription will be issued. All diagnosis, treatment, and prescribing decisions are made by the independent licensed Provider.

Potential Benefits

Potential benefits may include more convenient access to a Provider, reduced travel, and remote follow-up.

These are potential benefits only. Telehealth may not be appropriate for every person, condition, or treatment, and no particular clinical or service outcome is guaranteed.

Material Risks and Limitations

• A remote evaluation may provide less information than an in-person physical examination.
• The information you submit may be incomplete, inaccurate, delayed, or insufficient for a decision.
• Technology, connectivity, equipment, or platform failures may interrupt or delay the encounter.
• Electronic communications may present privacy or security risks despite reasonable safeguards.
• The Provider may determine that telehealth is not appropriate and recommend local or in-person care.
• Delays in seeking emergency or in-person care may worsen a medical condition.

Your Rights

• Know the identity, credentials, professional entity, and state licensure of the treating Provider.
• Ask questions about telehealth, the proposed treatment, material risks, benefits, and alternatives.
• Decline or withdraw consent to telehealth before or during an encounter, subject to applicable law.
• Refuse a recommended treatment and seek an independent opinion.
• Access or request a copy of your medical record as permitted by applicable law.
• Be told when another person will participate in or observe the encounter.
• Seek local in-person care at any time. Fifty 410 does not promise that it can provide in-person care.
• Request reasonable communication assistance or an accommodation for the telehealth process.

Your Responsibilities

• Confirm your identity and physical location at the time of each telehealth encounter.
• Provide complete and accurate health, medication, allergy, and contact information.
• Tell the Provider if another person is present or assisting you.
• Use a reasonably private location, secure device, and reliable connection when possible.
• Follow the Provider's instructions for follow-up, laboratory testing, monitoring, or in-person care.
• Contact the treating Provider about adverse effects or a worsening condition and seek urgent care when needed.

Emergency and Technology-Failure Plan

TELEHEALTH THROUGH FIFTY 410 IS NOT AN EMERGENCY SERVICE. CALL 911 OR GO TO THE NEAREST EMERGENCY DEPARTMENT IF YOU MAY BE EXPERIENCING A MEDICAL EMERGENCY.

If technology fails during an encounter, follow the instructions in the patient portal and use the contact information provided by the treating Provider. If the Provider cannot safely complete the evaluation remotely, the encounter may be stopped and you may be directed to local in-person care.

State-Specific Requirements

Telehealth requirements vary based on the patient's physical location, the Provider's profession, and the service being delivered. Services are available only when the treating Provider is licensed or otherwise authorized to practice in the state where the patient is located.

Any additional state-specific disclosure or consent required for your encounter will be presented through the patient portal by the treating Provider or professional entity. If a state-specific requirement conflicts with this general notice, the state-specific requirement controls.

Questions or complaints about clinical care should be directed first to the treating Provider or professional entity using the contact information supplied in the portal. You may also contact the Provider's licensing board in the state where you received care.

Privacy, Communications, and Records

Clinical information should be submitted through the designated patient portal. Standard email and SMS are not guaranteed to be encrypted or private, so do not use them for sensitive medical information unless instructed by your Provider.

Read the Practice's HIPAA Notice of Privacy Practices for information about its clinical records. Other treating Providers and dispensing pharmacies may issue their own notices during the patient-care process. Fifty 410's separate Privacy Policy describes its general website and platform practices.

The treating Provider or professional entity is responsible for maintaining the clinical record, including documentation of the encounter and informed consent where required.

Consent Acknowledgment

When telehealth consent is required, the patient portal will present an affirmative acknowledgment tied to the applicable patient, Provider, service, date, location, and version of the consent. You will have an opportunity to ask the treating Provider questions before care is delivered.

Withdrawing consent does not affect care already provided or records already created, and it does not require deletion of records that must be retained by law.

Questions or Concerns

For questions about this consent, privacy, or legal matters, email [email protected].

For platform or administrative questions, email [email protected]. For clinical questions, use the contact method provided by your treating Provider in the patient portal.