TELEHEALTH INFORMED CONSENT

INFORMED CONSENT TO TELEHEALTH SERVICES

By accepting this Informed Consent, you (“Patient,” “I,” or “you”) consent to receive medical services from Black Forest MD of Florida, PLLC (the “Practice”) via telehealth technologies operated on the Practice’s behalf by Black Forest Management Services LLC (“BFMS”), a HIPAA Business Associate of the Practice.

Please read this Consent carefully. Ask any questions you have before accepting.

1. WHAT IS TELEHEALTH?

Telehealth involves the use of audio, video, and other electronic communications technology to deliver medical care between a patient and a clinician who are not in the same physical location. In this Practice, telehealth includes:

Asynchronous intake evaluation — your initial health questionnaire and any uploaded documentation are reviewed by a licensed clinician, who decides whether to approve, request more information, escalate to video, or decline treatment.
Asynchronous messaging — secure written communications for ongoing care and follow-up.
Synchronous video consultations — live video calls with your clinician where the clinician determines a video visit is clinically appropriate.
Synchronous audio consultations — live phone calls where appropriate.
Electronic transmission of medical records, prescriptions, and lab orders.

How your first visit works

Your initial encounter with the Practice will generally be conducted asynchronously: you complete a comprehensive health questionnaire and submit any required documentation, and a licensed clinician reviews your submission and either (a) approves a treatment plan, (b) requests additional information, (c) escalates you to a synchronous video visit if clinically appropriate, or (d) declines treatment if not appropriate.

Under the Florida Telehealth Practice Act (Fla. Stat. § 456.47), asynchronous evaluation is permitted in Florida provided the clinician’s evaluation meets the same standard of care as an in-person visit.

2. WHO PROVIDES YOUR CARE

Your clinician is a physician (or, where permitted, a nurse practitioner or physician assistant) licensed in Florida, practicing through Black Forest MD of Florida, PLLC. Your clinician retains full, independent professional judgment over your care. Neither BFMS nor any non-clinician affiliate directs, influences, or determines any clinical decision.

The technology platform used to deliver your care — the patient portal, secure messaging, video infrastructure, scheduling, identity verification, and patient support — is operated by BFMS on the Practice’s behalf as a HIPAA Business Associate, subject to a written Business Associate Agreement.

3. CLINICIAN IDENTIFICATION

At each telehealth encounter, your clinician will identify themselves by:

Full name
Professional designation (MD, DO, NP, or PA)
Florida medical license number, on request

You may verify your clinician’s Florida medical license at any time at www.flhealthsource.gov.

4. BENEFITS OF TELEHEALTH

Telehealth may offer benefits including:

Greater convenience and access to care
Reduced travel time and expense
Reduced exposure to in-office illness
Easier follow-up communication
Access to specialized care that may not be locally available

5. LIMITATIONS AND RISKS OF TELEHEALTH

5.1 Inability to Perform Physical Examination

Your clinician cannot perform an in-person physical examination. This may limit the clinician’s ability to fully assess your condition. The clinician may decide that telehealth is not appropriate for your particular concern and recommend in-person evaluation.

5.2 Technical Risks and What Happens If Technology Fails

Connection issues may interrupt or delay visits
Audio or video quality may be insufficient at times
Equipment failure may prevent or limit communication
Electronic data transmission carries inherent (though low) risks of interception, despite security safeguards

If a synchronous video or audio encounter is interrupted by a technology failure, your clinician will attempt to reconnect, switch to phone or secure messaging, or reschedule the visit. No prescribing decision will be made on an incomplete encounter.

5.3 Diagnostic Limitations

Some conditions cannot be safely diagnosed or treated via telehealth alone. If your clinician determines you need in-person care, you will be advised to seek it, and the Practice will assist with continuity by providing a referral to an appropriate in-person provider as required under Florida law.

5.4 Limitations of Compounded Medications

Medications prescribed through the Service are compounded medications, prepared by a licensed compounding pharmacy on a patient-specific basis, and are not FDA-approved. The risks of compounded medications are described in the separately executed Compounded Medication Acknowledgment, which you will also sign as part of your intake.

5.5 Emergency Limitations

Telehealth is not appropriate for medical emergencies. If you experience an emergency, call 911 or go to the nearest emergency room.

6. WHEN TELEHEALTH IS NOT APPROPRIATE

You should NOT use telehealth (and should seek in-person care or emergency services) for:

Chest pain, difficulty breathing, sudden severe headache, or signs of stroke
Severe abdominal pain
Suspected fracture or significant trauma
Suicidal thoughts or psychiatric emergency
Loss of consciousness
Severe allergic reactions
Severe bleeding
Any condition you believe is a medical emergency

7. YOUR DUTY TO PROVIDE ACCURATE INFORMATION AND VERIFY YOUR IDENTITY

The safety of telehealth depends substantially on the accuracy and completeness of the information you provide. You acknowledge and agree that:

You will provide accurate, complete, and current information about your medical history, medications, allergies, symptoms, and treatment goals.
You will update that information whenever it changes.
You will verify your identity through the Practice’s identity-verification process at intake and again at any later point the clinician requests verification. You authorize the Practice and BFMS to collect, process, and verify your government-issued photo identification, selfie image (where required), date of birth, and address.
You will confirm your physical location in Florida at the time of each encounter. Misrepresenting your physical location is a violation of this Consent and is grounds for the clinician to decline to prescribe and to terminate your account.

The Practice and your clinician are not liable for adverse outcomes resulting from undisclosed, inaccurate, or out-of-date health or identity information that you provided.

8. PRIVACY AND CONFIDENTIALITY

Your telehealth encounters are subject to the same confidentiality protections as in-person visits, under HIPAA, Florida law, and the Practice’s privacy policies. See:

HIPAA Notice of Privacy Practices — describes how the Practice uses and discloses your Protected Health Information (“PHI”) and your rights under HIPAA and Florida law (including Fla. Stat. § 456.057).
Privacy Policy — describes the broader information practices of the Site.
Cookie and Tracking Disclosure — describes the marketing-zone vs. patient-zone separation of tracking technologies.

8.1 No Recording Without Two-Party Consent

Florida is a two-party-consent state for the recording of communications under Fla. Stat. § 934.03. Neither you nor your clinician may record (audio or video) a telehealth encounter without the other party’s express written consent. The Practice does not record visits in the ordinary course. If recording is contemplated for clinical or quality-assurance reasons, you will be informed in advance and asked for separate written consent.

8.2 Notes Are Part of Your Record

Your clinician may take written notes during the visit; those notes become part of your medical record and are stored in the Practice’s electronic health record system (Canvas Medical) under a Business Associate Agreement.

8.3 Privacy on Your End

You are responsible for taking your telehealth encounter in a private location where household members, coworkers, or others cannot overhear or view your screen. If your environment is not private and your clinician is concerned about confidentiality, the encounter may be rescheduled.

8.4 Medical Record Retention

Records are retained per the requirements of HIPAA and Fla. Stat. § 456.057 — generally a minimum of five years from the last patient encounter for adult patients, longer for minors. The full retention policy is set out in the HIPAA Notice of Privacy Practices.

9. USE OF AI AND AUTOMATED TOOLS

The Practice and BFMS may use artificial intelligence and machine-learning technologies (“AI”) to improve customer support and the efficiency of clinical workflows — for example, to help draft replies that a licensed clinician then reviews, to triage non-clinical support tickets, or to summarize information for your care team.

No AI tool makes clinical decisions. All clinical messages, prescriptions, and treatment decisions are reviewed and approved by a licensed clinician, who remains fully responsible for your care.

10. RIGHT TO REFUSE OR WITHDRAW

You have the right to:

Refuse telehealth services without affecting your right to seek care elsewhere
Withdraw consent to telehealth at any time, by notifying the Practice at [email protected] (withdrawal does not affect treatment already provided)
Terminate any encounter at any time, with no further obligation to continue
Request an in-person provider — the Practice does not offer in-person care, but will provide a referral to an in-person provider where clinically appropriate

11. ALTERNATIVE OPTIONS

You may also receive care through:

In-person consultation with your primary care physician
Hospital emergency departments (for emergencies)
Urgent care centers
Other telehealth providers

12. PRESCRIPTION POLICY

Your clinician will only prescribe medications they believe are medically appropriate based on your individualized evaluation
Not all conditions or requests result in a prescription; the clinician’s professional judgment is final
Compounded medications prescribed will be filled by a Florida-licensed compounding pharmacy designated by the Practice, or by another pharmacy of your choice where clinically appropriate
The Practice does not prescribe controlled substances through the Service. Specific state-law restrictions on telehealth controlled-substance prescribing (including Fla. Stat. § 456.44) are not addressed in this Consent because they do not apply to the care you will receive.

13. FLORIDA-SPECIFIC PROVISIONS (Fla. Stat. § 456.47)

13.1 Compliance with the Florida Telehealth Practice Act

Your care is provided pursuant to the Florida Telehealth Practice Act (Fla. Stat. § 456.47). The Practice and your clinician affirm that:

Your clinician will conduct a patient evaluation sufficient to diagnose and treat you, at the same standard of care as would apply in an in-person encounter
Your clinician will document the evaluation, your medical history, and the basis for any treatment decision in your medical record
Your clinician will verify your identity and physical location at the time of the encounter
Your clinician will maintain professional responsibility for your care, including any prescribed compounded medication
Your clinician will have the ability to refer you for in-person care when clinically necessary

13.2 Provider Identification

Your treating clinician is licensed by the Florida Board of Medicine or the Florida Board of Osteopathic Medicine (as applicable). License verification is available at www.flhealthsource.gov.

13.3 Asynchronous Evaluation Acceptable in Florida

Florida law permits a telehealth encounter to be conducted via asynchronous (non-real-time) means, including via a comprehensive health questionnaire reviewed by a licensed clinician, provided that the clinician’s evaluation meets the standard of care described above. Your initial encounter with the Practice will generally be conducted asynchronously. The clinician may escalate to a synchronous video visit if the clinician determines, in clinical judgment, that a synchronous evaluation is necessary.

13.4 Florida Medical Records Access

Pursuant to Fla. Stat. § 456.057, you have the right to obtain a copy of your medical records upon written request. The Practice will provide records within a reasonable time and may charge a reasonable cost-based fee for copying.

13.5 Florida Pharmacy

Your prescription will be filled by a Florida-licensed compounding pharmacy that holds the appropriate state and (where applicable) federal registrations under Fla. Stat. Ch. 465.

13.6 Florida Complaints

You may file a complaint about telehealth services with the Florida Department of Health:

Online: www.flhealthsource.gov
Phone: 850-245-4444

14. NO GUARANTEE OF OUTCOME

No specific medical outcome or result can be guaranteed. Your clinician will provide care to the applicable standard of medical practice. Individual results vary.

15. CONTINUITY OF CARE AND TRANSFER BETWEEN AFFILIATES

If your state of residence or physical location changes, and the Practice does not serve your new state, your care through the Service may need to be transferred or terminated. You consent to the transfer of your medical record between the Practice and any state-affiliated medical entity associated with Black Forest MD, as necessary to continue your care.

If the Service is terminated by the Practice (for any reason other than your own request), the Practice will provide a reasonable transition period and appropriate referrals consistent with Florida’s standards on patient abandonment under the Board of Medicine rules.

16. LANGUAGES AND ACCESSIBILITY

This Consent is available in English. Upon request, the Practice will provide a Spanish-language version and, where reasonably available, other languages. Patients with limited English proficiency or with disabilities affecting reading, vision, or comprehension may request language assistance services or reasonable accommodation at no cost by emailing [email protected].

17. RELATIONSHIP TO OTHER DOCUMENTS

This Consent is intended to be read together with, and is supplemented by:

Terms of Service — the contractual terms governing your use of the platform
Privacy Policy — the information practices of the Site
HIPAA Notice of Privacy Practices — your HIPAA rights and how the Practice uses your PHI
Compounded Medication Acknowledgment — risks and acknowledgments specific to compounded medications
Cookie and Tracking Disclosure — tracking technologies and the patient-zone separation

If a conflict arises between this Consent and any of those documents on a matter of clinical consent specifically, this Consent governs.

18. ACKNOWLEDGMENT AND CONSENT

By accepting this Consent (by electronic signature, click-through acceptance), you acknowledge that:

You have read and understood this Informed Consent
You have had the opportunity to ask questions
You understand the benefits, limitations, and risks of telehealth
You understand that telehealth is not appropriate for emergencies
You consent to receive medical care via telehealth from a Florida-licensed clinician of the Practice
You consent to the use of the BFMS-operated technology platform to deliver that care, including secure messaging, video, scheduling, and electronic record-keeping under a HIPAA Business Associate Agreement
You consent to identity verification by the Practice and its vendors, including review of government-issued photo identification and a selfie image where required
You represent and warrant that you are physically located in Florida at the time of each encounter, and you will update your physical location promptly if it changes
You consent to the electronic transmission, storage, and use of your medical information as described in the Privacy Policy and HIPAA Notice of Privacy Practices
You consent to the use of AI-supported tools in non-clinical support workflows and clinician-reviewed drafting, as described in Section 9
You acknowledge that neither you nor your clinician may record any encounter without the other party’s express written consent (Section 8.1)
You are at least 18 years of age
You will provide accurate and complete health information and update it as it changes