Telehealth Authorization

The purpose of this form is to provide you with information about telehealth and to obtain your informed consent for a telehealth consultation. If you so consent, Ezra Health will use telehealth technology in connection with your screening or assessment.This service is not to be used for urgent or emergency consults. Nor is it a replacement for primary care. Your screening or assessment will not involve diagnosis or treatment. Similarly, if you are seeking a consultation in connection with Covid-19 antibody testing, such test results may provide information about prior exposure and your provider may help you develop a wellness plan or other treatment protocol based on your test results, but Ezra does not provide Covid-19 treatment and the antibody testing services are not a replacement for primary care.

Telehealth is the use of electronic information and communication technologies to enable a healthcare provider and a patient at different locations to share medical information, including, for example, for the purpose of evaluation and consultation regarding certain healthcare screening results. The delivery of healthcare via telehealth allows the patient and provider to establish a relationship, much as they would during a traditional face-to-face appointment. For example, your telehealth encounter may include interaction through and with the use of some of the following: synchronous video (e.g. videoconferencing) and/or asynchronous technology, such as store-and-forward technology to exchange medical data and secure messaging portal communication.

The benefits of telehealth include improved access to health services and care, including the expertise of specialists and consultants that may not otherwise be available to you. There are potential risks to using telehealth technology, including interruptions to the connection, images and other information transmitted may not be clear enough to be useful for the consultation, unauthorized access, and technical difficulties. However, either the healthcare provider or you can discontinue your telehealth visit if the telehealth technologies are not adequate for the situation, if the information obtained via telehealth was not sufficient or if telehealth is inappropriate for any reason. Other potential risks to using telehealth services include breach of privacy of protected health information due to security breaches or failures, as well as adverse drug interactions, allergic reactions, complications, or other errors due to a patient’s failure to provide complete medical information or records.

Alternative methods of care, such as in-person services, may be available to you. You may choose an alternative at any time.

Ezra Health does not provide primary care, and does not treat any medical conditions (e.g.  Ezra Health’s healthcare providers do not prescribe medication in connection with the screening, testing, or assessment services, or in connection with any diagnosis or treatment provided).

However, if a technical failure prevents you from communicating with the Ezra Health telehealth provider, or if you believe telehealth will not provide sufficient safety and quality, you should contact us as indicated below. In the event of an urgent health issue or concern, you must seek care in-person, at a facility or provider equipped to deliver urgent or emergent care. IF THE SITUATION IS AN EMERGENCY, YOU MUST CALL 911.

Phone: 888-402-3972

Hours of Operation: Monday to Friday, 9am – 5pm (except federal Holidays)

By signing this form, I understand that telehealth involves the use of electronic information and communication technologies by a healthcare provider to deliver services to a patient when the patient is located at a different site than the provider, and I hereby consent to Ezra Health providers delivering services to me via telehealth.

I understand that telehealth technology will be used in connection with my screening or assessment, and have been given the opportunity to ask questions regarding the technology. I understand that this visit will not be the same as an in-person visit due to the fact that I will not be in the same physical location as the healthcare provider at the distant site. I further understand that the provider will determine whether telehealth is appropriate for me at this time. I understand that I may benefit from telehealth, but that results cannot be guaranteed. I further understand that my telehealth visit will involve review of my medical data for screening or assessment purposes, and that I am responsible for any follow-up with my primary care provider or another specialist regarding any results, concerns, or abnormalities that may be identified based on my screening or assessment. If my visit results in a diagnosis or plan of care related to Covid-19, I agree to seek appropriate follow-up treatment, including with my primary care provider.

The provider will inform me who will be present at the provider’s location during the telehealth service and I have the right to exclude anyone from being present, if I so choose. I understand that the laws that protect privacy and the confidentiality of medical information also apply to telehealth. In addition, a summary of my visit may also be sent to my primary care provider of record in order to facilitate continuing care. I understand that I have the right to inspect and obtain copies of all information received and recorded during any telehealth session, subject to the policies of the providers involved in my care. I may be charged a fee for copies of records in accordance with applicable State rules.

I understand that I have the right to withhold or withdraw my consent to the use of telehealth at any time, without affecting my right to future care. I may revoke my consent orally or in writing at any time by contacting Ezra Health.

For purposes of this informed consent, I understand and agree that accepting THE TERMS OF SERVICE SHALL CONSTITUTE AND IS MY ELECTRONIC SIGNATURE.

• I understand that Ezra Health has a financial relationship with Ezra AI, Inc. and that I am free to obtain a consultation elsewhere.

• I further understand that I will be responsible for any payments that apply to my telehealth visit. I agree that I will not submit the bills for these services to any commercial health insurance plan or governmental health insurance plan, including but not limited to Medicare, Medicaid or Tricare. I further understand that neither Ezra Health, Ezra AI, nor any facility through which I obtain any imaging, lab work, or testing will submit or facilitate the submission of any claims to my health insurer or other medical benefit plan.

• I have read and understand the information above and all of my questions have been answered to my satisfaction.

• I have read, understand, and agree to the terms of the Ezra Privacy Policy and Terms of Service.

The Practice may communicate with me, including about my personal medical information, using the  methods outlined in the Terms of Service, including without limitation, by email, by leaving me a voicemail message, and by texting me at the mobile number I have provided.

I understand that the above methods of unencrypted communication will be used to communicate with me about Ezra services, for my own convenience, and I accept all risks associated with them (including, without limitation, risks of improper exposure of my medical information). I have read the Terms of Service and Privacy Policy.