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Telehealth Consent Notice

I understand that my health and wellness provider HealthBrew wishes me to have a telehealth consultation.

Our goal is to make it as easy as possible to access great care from a licensed healthcare provider by using our platform. Telehealth involves the delivery of healthcare using technology, when a patient is in one location and a provider is in another location (typically through a video visit). Providing healthcare through technology is called "telehealth." Below we outline the potential benefits and risks of telehealth and ask you to consent to its use. We want to provide you with information around the benefits and the risks, and we want you to make an informed decision about your care.

I understand how telehealth will be used to do such consultation and how else I will use telehealth to connect while working together, using the Healthie telehealth platform

I understand there are potential risks with this technology:

  • The video connection may not work or it may stop working during the consultation.
  • The video picture or information transmitted may not be clear enough to be useful for the consultation.
  • The technology is limited in its ability to conduct a physical exam or assess vital signs and is not suitable to identify the need for emergency care.
  • Delays in medical evaluation or treatment could occur due to unavailability of providers or failures of the technology or electronic equipment used.
  • In rare instances, security protocols or safeguards could fail, causing a breach of privacy.

The benefits of a telehealth consultation are:

  • I do not need to travel to the consult location and I am able to avoid unnecessary travel.
  • I have access to a specialist through this consultation and the services they offer.
  • I have flexibility to schedule digital communication and telehealth visits at convenient times and I am able to reduce my wait time to see a specialist.

I also understand other individuals may need to use the Healthie telehealth platform and that they will take reasonable steps to maintain confidentiality of the information obtained. I have read this document and understand the risk and benefits of the telehealth consultation and have had my questions regarding the procedure explained and I hereby consent to participate in telehealth sessions under the conditions described in this document.

Confidentiality

  • I agree to keep confidential the names of other members of HealthBrew and what is said in a group setting. As a member of this group, I agree to not disclose to anyone outside the group any information that may identify another group member. This includes, but is not limited to, names, physical descriptions, biological information, and specifics to the content of interactions with other group members.
  • I agree to indemnify and hold HealthBrew Clinic harmless for any loss or damages, including costs and attorney’s fees, incurred by HealthBrew as a result of my breach of another’s confidentiality.
  • Confidentiality of audio and video communications in individual and group counseling sessions are protected by encryption and on a secure site. I understand that efforts to keep all information confidential are made, and likewise, I will take steps to safeguard my Healthie account login information. I will not share my login with anyone or give them access to my account or virtual sessions.
  • I agree not to record any audio or visual communication transmitted via the site or app including telehealth services, without the express consent of all communicating parties. 
  • I agree not to use unsecured public wi-fi or other unsecured electronic communication.

Additional Agreements:

  • I give permission to HealthBrew Clinic to care for me. I may withdraw this consent at any time by no longer seeking services from HealthBrew Clinic.
  • I understand that the problem I am seeking care for may not be resolved and I may need to seek care with a different provider or possibly an in-person clinic. 
  • I understand that my primary doctor is not HealthBrew Clinic. Instead I am seeking specialty care for the services they do provide as specialists. 
  • I understand that it is up to me if I want to share my treatment plan with my primary doctor to review.
  • I understand that this is a cash only practice and I do not expect a refund for services already paid for.
  • I agree to try my best and stay consistent with the treatment plan in order to achieve the best possible result for my health.
  • I understand that if I have an emergency health issue of any nature, I should call my local emergency medical number, visit an urgent care, call my primary doctor, or if the situation is truly an emergency, call 911. 
  • I agree to show up on time to my telehealth appointment and understand that visits are time-limited and there may be another member scheduled for their visit right after mine. 
  • Lastly, I consent and understand that my anonymous data such as biomarker results or survey results might be used in an anonymous observational study to help offer the FDA and other regulating bodies evidence of the benefits of off label use of a non FDA approved medication. This is also known as 'real world evidence' which is in contrast to a sponsored clinical trial. 

Pharmacies we send our prescriptions to: We utilize an e-prescribing platform (DoseSpot) to send prescriptions to National Association of Boards of Pharmacy accredited and/or legitscript certified pharmacies. Presently, we send our prescriptions to TMC [200 Moore Dr, Nicholasville, KY 40356, Phone: (859) 887-0013]. We may in rare instances. and for commercially available medication, send an electronic prescription to CVS [1 CVS Drive, Woonsocket, RI, 02895, (800) 746-7287] a nationally recognized retail pharmacy which is NABP accredited but is not legitscript certified. In those rare instances, your medication may not be delivered to you depending on the location and service of the retail location and may require coordination for pickup.