Informed Consent for Telehealth Services
Last Updated: November 3, 2025
DO NOT USE VIDA IF YOU’RE HAVING A MEDICAL EMERGENCY. In case of an emergency, please call 911, go to the nearest emergency room, or call or text the free 988 Suicide & Crisis Lifeline at 988 or 800-273-8255.
Vida Medical, PC, a California professional corporation, Vida Medical, P.A., a Kansas professional association, Vida Medical, New Jersey, P.C., a New Jersey professional corporation, and Vida Medical, P.A., a Delaware professional corporation (collectively, the “Affiliated Practices” or “Vida Medical”)”, “we”, “us”, or “our”)provides Telehealth Services (as defined below). This document is intended to inform you of what you can expect of your Clinician in terms of his or her credentials and in connection with your treatment via telehealth. After you have carefully read this document and had an opportunity to have your questions answered, certain state laws mandate that you must acknowledge and attest to receipt of this consent before commencing Telehealth Services. Capitalized terms not defined in this Agreement shall have the meanings ascribed to them in the Terms of Use.
THIS AGREEMENT APPLIES TO EACH OF THE VIDA PROGRAMS. EACH PROGRAM HAS ITS OWN PROGRAM DESCRIPTION, EXPECTATIONS, AND RISKS ASSOCIATED WITH YOUR PARTICIPATION IN THE PROGRAM, DEFINED AND DETAILED BELOW, YOU INDICATE THAT YOU HAVE REVIEWED THE APPLICABLE PROGRAM INFORMATION AND UNDERSTAND THE RISKS ASSOCIATED WITH YOUR PARTICIPATION.
YOUR TELEHEALTH PROVIDER’S CREDENTIALS. Your Provider’s credentials were made available to you before your Encounter (defined below). If you have any questions about these credentials, please direct them to your Provider. For those states that require it, you can find an explanation of the levels of regulation applicable to Providers (defined below) under the STATE REGULATIONS section of this document.
IMPORTANT INFORMATION REGARDING YOUR TREATMENT BY TELEHEALTH HEALTH PROVIDERS, INCLUDING POTENTIAL RISKS AND BENEFITS. Vida Medical offers treatment by various types of healthcare Providers via telecommunications technology (“Telehealth”) via virtual appointments and interactions (collectively “Encounters”), enabling patients to receive care from Providers without being in the same physical location. Our Providers include physicians, nurses, mental health therapists, registered dietitians, and equivalent licensed professionals (collectively “Clinicians), as well as certain unlicensed professionals, such as health coaches (together, “Providers”). Our “Telehealth Services” include, but are not limited to, advanced medical services, asthma management, care navigation, health assessments, CHF management, COPD management, diabetes prevention, nutrition-based health coaching, exercise health coaching, exercise counseling, heart failure management, weight loss care, mental health coaching, smoking cessation, behavior modification, sleep health coaching, mental health therapy, and cardiometabolic medication management and treatment (together, “Program” or “Programs”). The Telehealth Services provided may also include the development of an individualized plan of care for each patient (“Care Plan”), chart review, remote medication management and prescribing, Encounter scheduling, refill reminders, health information sharing, and non-clinical support, such as patient education. The electronic communication systems we use will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption. There are various benefits associated with Services, including improved access to care by enabling you to remain in your residence while receiving Services, more efficient care evaluation and management, and obtaining access to the expertise of a specialist as appropriate. Possible risks include delays in evaluation and treatment could occur due to deficiencies or failures of the equipment and technologies, and in rare events, our Provider may determine that the transmitted information is of inadequate quality, thus necessitating a rescheduled Encounter or a meeting with your local primary care physician.
You specifically understand and agree to the following for each Program, as applicable to your care:
| Program | Description |
|---|---|
| Advanced Medical Service | You’ll participate in clinical care for cardiovascular condition management, which may include one or more of the following conditions: prediabetes, type 2 diabetes, high blood pressure, high cholesterol, overweight/obesity, congestive heart failure, and chronic obstructive pulmonary disease. Vida Medical physicians and nurse practitioners will evaluate and may recommend changes to your Care Plan. They may order new lab tests and prescribe certain medicines to treat the targeted health conditions. They’ll meet with you for follow-up care. You’ll still need a primary care physician for in-person exams, illness, and injury care. |
| Asthma Management | Vida Medical health coach will support you in following your asthma wellness plan from your primary care physician. You’ll learn about and practice skills in using inhalers and other asthma medicines as prescribed by your primary care physician or non-Vida specialist, managing triggers of breathing flare-ups, exercising safely, and reducing stress. If you smoke, you also can choose to work on a quit plan. |
| Care Navigation | The Care Navigation Program offers mental health screenings and referrals conducted by a licensed mental health expert. This may include discussing your mental health symptoms, mental health history, and any past or current treatments. You’ll learn more about mental health benefits and resources. Those may include referrals to Vida programs, benefits covered by your health plan, and referrals to outside services. |
| Condition Control (CHF/COPD) | This program supports management of congestive heart failure (CHF) and/or chronic obstructive pulmonary disease (COPD) in order to improve health and well-being and avoid unnecessary emergency room visits and hospital stays. You’ll work with a health coach on learning about your condition, taking medicine as directed, healthy habits, and coping with stress. If you smoke, you also can choose to work on a quit plan. Vida Medical physicians and nurse practitioners will evaluate and may recommend changes to your treatment plan to address breathing flare-ups, low energy, swelling from water retention, and sleep troubles caused by CHF and/or COPD. They will help you monitor any symptoms and flare-ups. They may order new lab tests and prescribe certain ongoing or emergency pack medicines to treat the targeted health conditions. You’ll still need a primary care physician or non-Vida specialist for in-person exams, illness, and injury care. |
| Core Medical Service | You’ll participate in Telehealth clinical assessments, health assessments, lab test ordering, and health device prescribing. Vida Medical physicians and nurse practitioners will assess you for certain health risks, order basic cardiometabolic lab tests, and may prescribe diabetes devices if you are eligible. |
| COPD Management | Vida Medical’s health coach will support you in following your chronic obstructive pulmonary disease (COPD) wellness plan from your primary care physician or non-Vida specialist. You’ll learn about and practice skills in using inhalers and other medicines as prescribed by your primary care physician or non-Vida specialist, managing triggers of breathing flare-ups, exercising safely, and reducing stress. If you smoke, you also can choose to work on a quit plan. |
| Diabetes Prevention | You’ll do in-app lessons, track weight and exercise minutes weekly, and meet weekly with a Vida Medical health coach to help you lose weight, improve nutrition, boost exercise, and reduce your risk for developing type 2 diabetes. This 12-month program is recognized by the Centers for Disease Control and Prevention. |
| Eating Better (Nutrition) | Vida Medical’s health coach can help you improve your nutrition knowledge and habits based on your health situation and goals through nutrition-based coaching. You’ll learn about and practice skills in choosing foods within your budget, planning meals, social eating, and keeping track of what you eat and drink. |
| Exercise | Vida Medical’s health coach will support you in learning about and improving planned exercise and being more active in daily life based on your lifestyle and abilities through exercise coaching. You’ll learn about and practice skills in making exercise and activity habits that work for you. |
| Heart Failure Focus | You’ll work with a Vida Medical health coach to learn about your heart health, monitor any symptoms of congestive heart failure, and build healthy habits. You’ll learn about and practice skills in eating healthy, self-monitoring your weight and heart symptoms, medication management, and coping with stress. |
| Medical Prescribing Service | You’ll participate in clinical care for anxiety and/or depression. Vida Medical physicians and nurse practitioners will evaluate and may recommend changes to your treatment plan. They may prescribe certain medicines to treat the targeted health conditions and will meet with you for follow-up care. You’ll still need a primary care physician or non-Vida specialist for in-person exams, illness, and injury care. |
| Medical Weight Loss | You’ll participate in clinically-supervised treatment of overweight/obesity and related conditions such as high blood pressure, high blood sugar, and high cholesterol. You’ll work with a registered dietitian on an eating plan for weight loss. You’ll also have a health coach to support helpful lifestyle activities such as exercise and activity, using a scale, stress management, learning about why you eat, and sleep. Dietary changes and related activities support your weight loss efforts. You will also provide lab results and meet with a physician or nurse practitioner on intake to review your medical and weight history, and design a treatment plan for you. You’ll have follow-up Encounter(s) with the clinical Provider to make sure your body is responding and losing weight. |
| Mental Health Coaching | You’ll work with a Vida Medical health coach to learn and practice helpful ways to manage everyday stress symptoms. You’ll practice and use skills such as deep breathing and slowly relaxing parts of your body that feel tense or tight. You’ll also learn and practice realistic ways of thinking and solving problems. This can help you worry less. |
| Back Pain Relief [MSK] | Vida Medical’s health coach will support you as you learn skills and set up habits for easing back pain. You’ll be supported with exercise videos designed by licensed Doctors of Physical Therapy. These videos guide you through a personalized exercise plan for your back-pain symptoms. As needed, you may meet with a physical therapist to screen you for symptoms and refer you to care outside of Vida Medical. |
| Quit Smoking | Vida Medical’s health coach can help you set up and support your smoking cessation plan. You’ll learn about and practice skills to prepare for your quit date, consider quit aids and nicotine replacement available from your primary care physician, manage smoking triggers, and cope with cravings. Your health coach will support you up to, during, and after your quit date as you work to be and stay smoking free. |
| Resilience | You’ll work with a Vida Medical health coach to learn and practice helpful ways to handle everyday stress symptoms. You’ll practice and use skills such as mindful moments, deep breathing, and slowly relaxing parts of your body that feel tense or tight. You’ll focus on your unique strengths and values to be flexible in thinking, responding to hard times, and finding meaning and purpose in life. |
| Sleep Health | You’ll work with Vida Medical’s health coach to learn about and practice skills in setting up for good sleep, making a bedtime routine, reducing noise and other distractions, and other sleep health habits. The goal is to improve the amount of good quality sleep that you get. |
| Stress Management | You’ll work with Vida Medical’s health coach to learn and practice mindfulness-based ways to handle everyday stress symptoms. You’ll practice and use skills such as focusing on your senses, being in the moment, deep breathing, and slowly relaxing parts of your body that feel tense or tight. |
| Therapy | You’ll work with a licensed mental health therapist to help you learn new skills for improving your thoughts, increasing positive behaviors, and learning how to manage difficult emotions. The program is based on Cognitive Behavioral Therapy (CBT), which has been shown to be an effective tool for addressing symptoms. |
| Weight Loss+ | Vida Medical’s health coach will help you target healthful weight loss and how to maintain a healthful weight. You’ll learn about and practice skills in eating healthy, being active, getting exercise, managing feelings about food, getting good quality sleep, and coping with stress. |
| Whole Health | You’ll work with a Vida Medical registered dietitian on condition management for cardiometabolic conditions such as diabetes, high blood pressure, and high cholesterol. You’ll learn about caring for health conditions. You’ll be encouraged to monitor health with devices such as a blood sugar meter and blood pressure monitor, eat healthy, improve exercise, take medicine as directed, stay on track with preventive exams and tests, problem solve, and cope with health issues and daily stress. |
| Whole Health Medicaid | You’ll work with a Vida Medical registered dietitian on condition management for diabetes. You’ll be encouraged to monitor your health with a blood sugar meter or CGM, eat healthy, improve exercise, take medicine as directed, stay on track with preventive exams and tests, problem solve, and cope with health issues and daily stress. |
By checking the box associated with “Informed Consent”, you are representing that you have read this document and understand the information found in it.
At times, your Clinician may seek supervision or consultation with other Vida Medical or non-Vida Medical Clinicians regarding your treatment, to enhance the care being provided to you given the multiple perspectives, experiences, and treatment philosophies. All team members are ethically and legally bound to maintain your privacy and confidentiality in this scenario and none of your personal information will be shared or disclosed with any other individual without your consent. Exceptions to confidentiality do exist in certain situations, such as: threat of serious harm to self or others; reasonable suspicion of abuse or neglect of a child, or abuse, neglect, or exploitation of an incapacitated or dependent adult; court order and/or subpoena; permission from the client or guardian (i.e. voluntary release signed by the client or guardian); during supervisory consultations; diagnosis and Encounter dates shared with an insurance company to collect payments; information released as outlined in Vida Health’s Notice of Privacy Practices and Privacy Policy; and as otherwise required by law.
SCHEDULING AND CANCELLATIONS. Please carefully review the Scheduling and Cancellations Policy. By checking the box associated with “Informed Consent”, you are attesting that you have read, understood and will comply with the Scheduling and Cancellations Policy.
FEES AND BILLING ARRANGEMENTS. Prices are subject to change. You are required to pay all fees for your Telehealth Services upfront at the time of the Encounter; however, you are not obligated to pay any fees for which another party (e.g., your employer or health plan) pays on your behalf. If you believe any of the fees you have been charged are incorrect, you must immediately contact us in writing by sending a message to support@vida.com regarding the amount in question to be eligible to receive a refund. You irrevocably waive your right to challenge the accuracy of any charge, or otherwise receive a refund, if you fail to notify us in writing within fifteen (15) calendar days after the charge that you believe the charge is inaccurate (setting forth an explanation of why).
You also hereby authorize the direct payment of all insurance and plan benefits, including Medicare, Medicaid and/or Tricare, otherwise payable to or on your behalf for Telehealth Services rendered, to Vida Medical. If you receive payment directly from your insurance company or third-party payer, you agree to immediately forward all healthcare payments that you receive for Telehealth Services provided to you by Vida Medical.
By checking the box associated with “Informed Consent”, you acknowledge that you understand and agree with the following:
- You hereby consent to receiving Telehealth Services via Telehealth technologies. You understand that Vida Medical and its Providers offer Telehealth-based health and wellness services, but that these Telehealth Services do not replace the relationship between you and your primary care physician. You also understand it is up to the Provider to determine whether or not your specific clinical needs are appropriate for an Encounter.
- For selected Programs, you have been given an opportunity to select a Provider from Vida Medical prior to the Encounter, including a review of the Provider’s credentials.
- You understand that federal and state law requires healthcare Providers to protect the privacy and the security of health information. You understand that Vida Medical will take steps to make sure that your health information is not seen by anyone who should not see it. You understand that Telehealth may involve electronic communication of your personal medical information to other health practitioners who may be located in other areas, including out of state.
- You understand there is a risk of technical failures during the Encounter beyond the control of Vida Medical. You agree to hold harmless Vida Medical for delays in evaluation or for information lost due to such technical failures.
- You understand that you have the right to withhold or withdraw your consent to the use of Telehealth in the course of your care at any time, without affecting your right to future care or treatment. You understand that you may suspend or terminate use of the Telehealth Services at any time for any reason or for no reason. You understand that if you are experiencing a medical emergency, that you will be directed to dial 911 immediately and that the Providers are not able to connect you directly to any local emergency responders. Vida Medical may contact outside emergency responders, provide referrals to outside services, and/or contact a designated emergency contact person on your behalf if there is a concern related to your safety or the safety of others. Vida Medical may contact an emergency contact person you have designated to support you in getting connected to the proper medical care or support.
- You understand the importance of answering all questions fully and truthfully. You understand that Vida Medical has no way of verifying the information that you provide and that Vida Medical will consider all the information you provide to be accurate, true and complete, including all your answers to health questions. You understand that if you provide information that isn’t true and complete, then you will be at greater risk of adverse events or misdiagnosis. You understand that if you fail to comply, that may result in the termination of the patient-provider relationship.
- With your consent and only as permitted by applicable law, in certain cases we may make video or audio recordings of your Encounter. Those recordings may be used internally for treatment, quality improvement, and care coordination purposes in accordance with our privacy policies.
- You understand that alternatives to Telehealth care, such as in-person medical care are available to you, and in choosing to participate in an Encounter, you understand that some parts of the Telehealth Services involving tests may be conducted by a third-party at another location, such as a testing facility, at the direction of the Provider (e.g., labs or bloodwork) and that Vida Medical cannot guarantee the accuracy or reliability of these tests.
- You understand that you may expect the anticipated benefits from the use of Telehealth in your care, but that no results can be guaranteed or assured.
- You understand that your healthcare information may be shared with other individuals for scheduling and billing purposes. Persons may be present during the Encounter other than the Provider in order to operate the Telehealth technologies. You further understand that you will be informed of their presence in the Encounter and thus will have the right to request the following: (a) omit specific details of your medical history that are personally sensitive to you; (b) ask non-medical personnel to leave the Encounter; and/or (c) terminate the Encounter at any time.
- You understand that you will not be prescribed any narcotics, nor is there any guarantee that you will be given a prescription at all.
- You understand that if you participate in a consultation, that you have the right to request a copy of your medical records which will be provided to you at reasonable cost of preparation, shipping, and delivery.
- You have read and you understand the disclosures set forth next to the state in which you are located at the time of the telehealth encounter, as set forth below:
STATE REGULATIONS:
| State | What You Should Know | Who To Contact with Questions or Concerns |
|---|---|---|
| Alaska | Your primary care provider may obtain a copy of the records associated with your telehealth encounter with Vida Medical, PC. Alaska Stat. § 08.63.210(c)(2). | Alaska State Medical Board Division of Corporations, Business & Professional Licensing P.O. Box 110806 Juneau, AK 99811-0806 Tel: (907) 465-2550 Email: medicalboard@alaska.gov |
| Arizona | You understand that all medical records resulting from a telemedicine consultation with Vida Medical, PC are part of your medical record. Ariz. Rev. Stat. Ann. § 36-3602(D). Pursuant to Ariz. Admin. Code § 4-6-1102 your provider will: 1. Work jointly with you or your legal representative (as applicable) to prepare an integrated, individualized, written treatment plan, based on the provider’s provisional or principal diagnosis and assessment of behavior and the treatment needs, abilities, resources, and circumstances of you that includes: a. One or more treatment goals; b. One or more treatment methods; c. The date when your treatment plan will be reviewed; d. If a discharge date has been determined, the aftercare needed; e. The dated signature of your or your legal representative; and f. The dated signature of the provider; 2. Review and reassess the treatment plan: a. According to the review date specified in the treatment plan as required under subsection (1)(c); and b. At least annually with the you or your legal representative to ensure the continued viability and effectiveness of the treatment plan and, where appropriate, add a description of the services you may need after terminating treatment with the provider. 3. Ensure that all treatment plan revisions include the dated signature of you or your legal representative and the provider; 4. Upon written request, provide you or your legal representative an explanation of all aspects of your condition and treatment; and 5. Ensure that your treatment is in accordance with your treatment plan. | Arizona Medial Board 1740 West Adams Street, #3600 Phoenix, AZ 85007 Tel: (480) 551-2700 Fax: (480) 551-2702 Email: Submit form here. |
| California | You understand that you have the right to withhold or withdraw your consent to the use of telehealth in the course of your care at any time, without affecting your right to future care or treatment, or, affecting your ability to access covered services from Medi-Cal in the future. You understand that you have the right to access Medi-Cal covered services through an in-person, face-to-face visit or through telehealth. You understand that Medi-Cal provides coverage for transportation services to in-person services when other resources have been reasonably exhausted. Cal. Welf. & Inst. Code Ann. § 14132.725(d)). You have been informed of the notice below: Medical doctors are licensed and regulated by the Medical Board of California. To check up on a license or to file a complaint go to www.mbc.ca.gov, email: licensecheck@mbc.ca.gov, or call (800) 633-2322. Visit the Medical Board of California’s Notice to Consumer webpage at https://www.mbc.ca.gov/licensing/Notice-to-Consumers.aspx or scan the quick response (QR) code below:  For informational purposes only, a link to the federal Centers for Medicare and Medicaid Services (CMS) Open Payments web page is provided here. The federal Physician Payments Sunshine Act requires that detailed information about payment and other payments of value worth over ten dollars ($10) from manufacturers of drugs, medical devices, and biologics to physicians and teaching hospitals be made available to the public. You may search this federal database for payments made to physicians and teaching hospitals by visiting this website: https://openpaymentsdata.cms.gov/ The California Board of Behavioral Sciences receives and responds to complaints regarding services provided within the scope of practice of (marriage and family therapists, licensed educational psychologists, clinical social workers, or professional clinical counselors). You may contact the board online at www.bbs.ca.gov, or by calling (916) 574-7830. | Medical Board of California 2005 Evergreen Street, Suite 1200 Sacramento, CA 95815 Email: webmaster@mbc.ca.gov Phone: (800) 633-2322 (916) 263-2382 |
| Colorado | You are entitled to the consent requirements outlined under 2 CO ADC 502-1:21.170.4. The confidentiality of your individual records, including all medical, mental health, substance use, psychological, and demographic information shall be protected with the applicable state and federal laws and regulations, as provided under 2 CO ADC 502-1:21.170.2. 2 CO ADC 502-1:21.170.2. You understand that your mental health records may not be maintained after the seven-year period for filing a complaint pursuant to Colorado Rev. Stat. 12-245-226 (1)(a)(II)(A). You further understand, in accordance with Colorado Rev. Stat. 12-245-216: I. You are entitled to receive information about the methods of therapy, the techniques used, the duration of therapy, if known, and the fee structure; II. You may seek a second opinion from another therapist or may terminate therapy at any time; III. In a professional relationship, sexual intimacy is never appropriate and should be reported to the board that licenses, registers, or certifies the licensee, registrant, or certificate holder (located at the right). IV. The information provided by you during therapy sessions is legally confidential in the case of individuals licensed, certified, or registered pursuant to this article 245, except as provided in section 12-245-220 and except for certain legal exceptions that will be identified by the licensee, registrant, or certificate holder should any such situation arise during therapy. If an unlicensed psychotherapist is involved in your care, you understand that such provider is a psychotherapist listed in the state’s database and is authorized by law to practice psychotherapy in Colorado but is not licensed by the state and is not required to satisfy any standardized educational or testing requirements to obtain a registration from the state. You have been provided in writing the following information regarding your provider: The name, business address, and business phone number of the licensee, registrant, or certificate holder [1] | The practice of licensed or registered persons in the field is regulated by the below Divisions: State Board of Licensed Professional Counselor Examiners, State Board of Social Work Examiners, State Board of Marriage and Family Therapist Examiners, State Board of Addiction Counselor Examiners, and State Board of Psychologist Examiners 1560 Broadway, Suite 1350, Denver, Colorado 80202, (303) 894-7800 Email: DORA_Customercare@state.co.us |
| Connecticut | You understand that each telehealth provider shall, at the time of the initial telehealth interaction, ask you whether you consent to that provider’s disclosure of records concerning the telehealth interaction to your primary care provider. You further understand that your primary care provider may obtain a copy of your records of your telehealth encounter, upon your consent. Conn. Gen. Stat. Ann. § 19a-906(d). | Connecticut Department of Public Health Medical Examining Board 410 Capitol Ave., MS #13 PHO P.O. Box 340308 Hartford, CT 06134 Tel: (860) 509-7603 Fax: (860) 509-8457 |
| District of Columbia | You have been informed of alternate forms of communication between you and a physician from Vida Medical, PC for urgent matters. D.C. Mun. Regs. tit. 17, § 4618.10. Relevant communications with the physician, including those done via electronic methods shall be documented and filed in your medical record. D.C. Mun. Regs. tit. 17, § 4618.9. | District of Columbia Board of Medicine 899 North Capitol Street, NE Washington, DC 20002 Tel: (202) 724-4900 Fax: (202) 442-8117 Email: doh@dc.gov |
| Florida | Statute 501.0575 outlines the rights of consumers seeking professional weight-loss services. You have been informed of the rights below: (1) The Weight-Loss Consumer Bill of Rights shall consist of the following provisions: (A) WARNING: RAPID WEIGHT LOSS MAY CAUSE SERIOUS HEALTH PROBLEMS. RAPID WEIGHT LOSS IS WEIGHT LOSS OF MORE THAN 1-1/2 POUNDS TO 2 POUNDS PER WEEK OR WEIGHT LOSS OF MORE THAN 1 PERCENT OF BODY WEIGHT PER WEEK AFTER THE SECOND WEEK OF PARTICIPATION IN A WEIGHT-LOSS PROGRAM. (B) CONSULT YOUR PERSONAL PHYSICIAN BEFORE STARTING ANY WEIGHT-LOSS PROGRAM. (C) ONLY PERMANENT LIFESTYLE CHANGES, SUCH AS MAKING HEALTHFUL FOOD CHOICES AND INCREASING PHYSICAL ACTIVITY, PROMOTE LONG-TERM WEIGHT LOSS. (D) QUALIFICATIONS OF THIS PROVIDER ARE AVAILABLE UPON REQUEST. (E) YOU HAVE A RIGHT TO: 1. ASK QUESTIONS ABOUT THE POTENTIAL HEALTH RISKS OF THIS PROGRAM AND ITS NUTRITIONAL CONTENT, PSYCHOLOGICAL SUPPORT, AND EDUCATIONAL COMPONENTS. 2. RECEIVE AN ITEMIZED STATEMENT OF THE ACTUAL OR ESTIMATED PRICE OF THE WEIGHT-LOSS PROGRAM, INCLUDING EXTRA PRODUCTS, SERVICES, SUPPLEMENTS, EXAMINATIONS, AND LABORATORY TESTS. 3. KNOW THE ACTUAL OR ESTIMATED DURATION OF THE PROGRAM. 4. KNOW THE NAME, ADDRESS, AND QUALIFICATIONS OF THE DIETITIAN OR NUTRITIONIST WHO HAS REVIEWED AND APPROVED THE WEIGHT-LOSS PROGRAM ACCORDING TO s. 468.505(1)(j), FLORIDA STATUTES. (2) The copies of the Weight-Loss Consumer Bill of Rights to be posted according to s. 501.0573(6) shall be printed in at least 24-point boldfaced type on one side of a sign. The palm-sized copies to be distributed according to s. 501.0573(5) shall be in boldfaced type and legible. Each weight-loss provider shall be responsible for producing and printing appropriate copies of the Weight-Loss Consumer Bill of Rights. Fla. Stat.501.0575 | Florida Department of Health 4052 Bald Cypress Way, Bin C75 Tallahassee, FL 32399-3275 Tel: (850) 488-0595 Fax: (850)488-0796 Email: MQA.ConsumerServices@FLhealth.gov |
| Georgia | You have been given clear, appropriate, accurate instructions on follow-up in the event of needed emergent care related to the treatment. Ga. Comp. R. & Regs. 360-3-.07(a)(7). | Georgia Composite Medical Board 2 Peachtree Street, NW, 6th Floor Atlanta, GA 30303-3465 Email: medbd@dch.ga.gov |
| Idaho | If you need to register a formal complaint about a physician from Vida Medical, PC, you may visit the medical board’s website, here. Idaho Guidelines for Appropriate Regulation of Telemedicine. You further understand that your informed consent for the use of telehealth services shall be obtained by applicable law. Idaho Statutes 54-5708. | Idaho Board of Medicine Logger Creek Plaza 345 Bobwhite Ct., Suite 150 Boise, ID 83706 Email: info@bom.idaho.gov Division of Professional Licenses 11351 W. Chinden Blvd., Bldg. #6 Boise, ID 83714 |
| Indiana | If a prescription is issued to you, and subject to your consent the prescriber shall notify your primary care provider of any prescriptions the prescriber has issued for you if the primary care provider’s contact information is provided by you. This requirement does not apply if: (A) The practitioner is using an electronic health record system that your primary care provider is authorized to access. (B) The practitioner has established an ongoing provider-patient relationship with the patient by providing care to the patient at least 2 consecutive times through the use of telehealth services. If the conditions of this clause are met, the practitioner shall maintain a medical record for you and shall notify your primary care provider of any issued prescriptions. Ind. Code Ann. 25-1-9.5-7. If you are a Medicaid patient, you have the right to choose between an in-person visit or telehealth visit. Indiana Medicaid Manual: Telehealth and Virtual Services. | Indiana Professional Licensing Agency 402 W. Washington St., Room W072 Indianapolis, IN 46204 Tel: (317) 234-2054 Fax: (317) 233-4236 Email: pla8@pla.IN.gov |
| Iowa | To file a complaint about Vida Medical, PC, fill out the complaint form and email it to the medical board at ibmcomplaints@iowa.gov. Iowa Admin. Code 653-13.11(147,148,272C)(13.11(18)). As appropriate your provider will identify the medical home or treating physician(s) for you, when available, where in-person services can be delivered in coordination with the telemedicine services. Your provider shall provide a copy of the medical record to your medical home or treating physician(s). Iowa Admin. Code 653-13.11(147,148,272C)(13.11(11)). | Iowa Board of Medicine 400 SW 8th St., Suite C Des Moines, IA 50309 Tel: (515) 281-5171 Email: ibmcomplaints@iowa.gov |
| Kansas | You understand that if you have a primary care or other treating provider and if you consent to us sharing your information with such provider, then we are obligated to send within three business days a report to such primary care or other treating physician of the treatment and services rendered by a Vida Medical, P.A. KS provider during the telemedicine encounter. Kan. Stat. Ann. § 40-2,212(2)(d)(2)(A). | Kansas Board of the Healing Arts 800 SW Jackson, Lower Level – Suite A Topeka, KS 66612 Tel: (785) 296-7413 Fax (785) 368-7102 |
| Kentucky | You have been informed that if you want to register a formal complaint about a provider, you should visit the medical board’s website, here: https://kbml.ky.gov/board/Pages/default.aspx. If requested by you, your Vida Medical, PC. physician must share the medical record with your primary care physician and other relevant members of your existing care team. Kentucky Board Opinion on the Use of Telemedicine Technologies (2014), as amended September 15, 2022. | Kentucky Board of Medical Licensure 310 Whittington Parkway, Suite 1B Louisville, KY 40222 Tel: (502) 429-7150 Fax: (502) 429-7158 |
| Louisiana | You understand the role of other healthcare providers that may be present during the consultation, other than the Vida Medical, PC provider. 46 La. Admin. Code Pt XLV, § 7511. | Louisiana State Board of Medical Examiners 630 Camp Street New Orleans, LA 70130 Tel: (504) 568-6820 Fax: (504) 568-5754 Email: investigations@lsbme.la.gov |
| Maine | If you want to register a formal complaint about a Vida Medical of Delaware, PA physician, you should visit the medical board’s website, here: https://www.maine.gov/md/complaint/file-complaint Code Me. R. tit. 02-373 Ch. 11, § 3. | Complaint Coordinator Office of Licensing and Registration 35 State House Station Augusta, ME 04333 Tel: (207) 624-8660 www.maine.gov/professionallicensing |
| Mississippi | ||
| Nebraska | If you are a Medicaid recipient, you retain the option to refuse the telehealth consultation at any time without affecting your right to future care or treatment and without risking the loss or withdrawal of any program benefits to which the patient would otherwise be entitled. All existing confidentiality protections shall apply to the telehealth consultation. You shall have access to all medical information resulting from the telehealth consultation with Vida Medical of Delaware, PA as provided by law for access to your medical records. Dissemination of any patient identifiable images or information from the telehealth consultation to researchers or other entities shall not occur without your written consent. You understand that you have the right to request an in-person consult immediately after the telehealth consult and you will be informed if such consult is not available. Neb. Rev. Stat. Ann. § 71-8505; 471 Neb. Admin. Code § 1-006.05. You can report a concern or complaint here: https://dhhs.ne.gov/Pages/Complaints.aspx | Nebraska DHHS Licensure Unit Attn: [insert relevant profession] PO Box 94986 Lincoln, NE 68509-4986 Tel: (402) 471-3121 |
| New Hampshire | You understand that the provider may forward your medical records from Vida Medical, PC to your primary care or treating provider. N.H. Rev. Stat. § 329:1-d. | Office of Professional Licensure & Certification 7 Eagle Square Concord, NH 03301 Tel: (603) 271-2152 |
| New Jersey | You understand that you have the right to request a copy of your medical information from Vida Medical, New Jersey, P.C. and you understand your medical information may be forwarded directly to your primary care provider or healthcare provider of record, or upon your request, to other healthcare providers. If you do not have a primary care provider or other healthcare provider of record, the healthcare provider engaging in telemedicine or telehealth may advise you to contact a primary care provider, and, upon request by you, may assist you with locating a primary care provider or other in-person medical assistance that, to the extent possible, located within reasonable proximity to you. N.J. Rev. Stat. Ann. § 45:1-62. | New Jersey Board of Medical Examiners 140 East Front Street PO Box 183 Trenton, New Jersey 08608 Tel: (609) 826-7100 Email: bme@dca.lps.state.nj.us |
| New York | You have been informed of the notice below: A) NOTICE TO PATIENTS The Office of Professional Medical Conduct reviews all complaints of professional medical misconduct against licensed physicians, physician assistants and specialist assistants, including complaints of sexual harassment and assault. As a patient, you have a right to file a complaint if you believe your physician may have committed professional misconduct. To file a complaint, go to www.health.ny.gov/professionals/doctors/conduct/, or call 1-800-663-6114. B) WEIGHT LOSS AND DIETING INFORMATION a. WARNING! Rapid weight loss may cause serious health problems. Rapid weight loss is weight loss of more than 1 1/2 to 2 pounds per week or weight loss of more than 1 percent of body weight per week after the second week of participation in a weight loss program. b. Consult your physician before starting any weight loss program or using any diet medications or formulas. c. Long term weight control is the safest and most important goal of any diet program. Permanent lifestyle changes such as eating nutritious foods, calorie control and increasing physical activity help promote long term weight loss according to medical experts. d. Ask the person providing or selling you weight loss advice or diet products, medications or formulas about their qualifications and training in nutrition and health. e. You have the right to: (i) Ask questions about the potential health risks of this program or product, its nutritional content, and its psychological-support and educational components; (ii) Know the price of treatment, including the price of any extra products, services, supplements, and laboratory tests; and (iii) Know the program duration of the program recommended to you. N.Y. Gen. Bus. Law § 642 | New York Office of Professions, Office of Professional Discipline 1411 Broadway, Tenth Floor, New York, NY 10018 Phone: 800-442-8106 Fax: 212-951-6420 Email: conduct@nysed.gov |
| Ohio | You understand that Vida Medical, PC may forward your medical records to your primary care or treating provider. Ohio Admin. Code 4731-37-01(C)(4). | Ohio Medical Board Tel: (614) 466-3934, option 1 Email: complaints@med.ohio.gov State Medical Board of Ohio’s Confidential Complaint Hotline Tel: (833) 333-SMBO (7626) |
| Oregon | If you have a concern or complaint about the Vida Medical, PC providers providing care to you, you may contact a board agency to assist you. You understand that the provider may ask if you need more detail. ORS 17-52-677.07. See also Or. Medical Board, Statement of Philosophy: Telemedicine (Oct 2, 2020). | Oregon Medical Board 1500 SW 1st Ave., Suite 620 Portland, OR 97201-5847 Complaint Resource Staff: 971-673-2702 complaintresource@omb.oregon.gov |
| Pennsylvania | You understand that you may be asked to confirm your consent to behavioral health or telepsychiatry services. 40 PS §1303.504(b). The information in this consent is required by the Board of Social Workers, Marriage and Family Therapists and Professional Counselors, which regulates marriage and family therapists and professional counselors. 63 PS § 1920.1. | State Board of Social Workers, Marriage and Family Therapists and Professional Counselors P.O. Box 2649, Harrisburg, PA 17105-2649 717-783-1389 |
| Rhode Island | If you use e-mail or text-based technology to communicate with your provider, then you understand the types of transmissions that will be permitted and the circumstances when alternate forms of communication or office visits should be utilized. You have also discussed security measures, such as encryption of data, password protected screen savers, and data files, or utilization of other reliable authentication techniques, as well as potential risks to privacy. You acknowledge that your failure to comply with this agreement may result in the telehealth provider terminating the relationship. Rhode Island Medical Board Guidelines. | Rhode Island Board of Medical Licensure and Discipline Department of Health 3 Capitol Hill, Room 401 Providence, RI 02908 Phone: (401) 222-3855 Fax: (401) 222-2158 |
| South Carolina | You understand your medical records may be distributed in accordance with applicable law and regulation from Vida Medical, PC to other treating healthcare practitioners. You understand the value having of having a primary care medical home and, if requested, we can provide assistance in identifying available options for a primary care medical home. S.C. Code Ann. § 40-47-37. You also understand that if you are a Medicaid beneficiary, you can withdraw your consent at any time. South Carolina Health and Human Svcs. Dept. Physicians Provider Manual, p. 35 (Feb. 2024). | South Carolina Board of Medical Examiners 110 Centerview Drive, Suite 202 Columbia, SC 29210 Tel: (803) 896-4500 Fax: (803) -896-4515 Email: Medboard@llr.sc.gov |
| South Dakota | You have received disclosures regarding the delivery models and treatment methods or limitations. You have discussed with the telehealth provider the diagnosis and its evidentiary basis, and the risks and benefits of various treatment options. S.D. Codified Laws § 34-52-3. | South Dakota Board of Medical and Osteopathic Examiners 101 N. Main Avenue, Suite 301 Sioux Falls, SD 57104 Tel: (605) 367-7781 Email: Sdbmoe@state.sd.us |
| Tennessee | You understand that you may request an in-person assessment before receiving a telehealth assessment if you are a telehealth recipient. TN Dept. of Mental Health and Substance Abuse Services. Office of Crisis Services Telecommunications Guidelines, p. 8, (2012) (Accessed Jan. 2024). | Tennessee Department of Health 710 James Robertson Parkway Nashville, TN 37243 Tel: (615) 532-3202 Email: tn.health@tn.gov |
| Texas | You understand that your medical records may be sent to your primary care physician within 72 hours from Vida Medical, PC. Tex. Occ. Code Ann. § 111.005. You have been informed of the following notice: NOTICE CONCERNING COMPLAINTS – Complaints about physicians, as well as other licensees and registrants of the Texas Medical Board may be reported for investigation at the following address: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018, Assistance in filing a complaint is available by calling the following telephone number: 1-800-201-9353, For more information, please visit our website at www.tmb.state.tx.us. AVISO SOBRE LAS QUEJAS- Las quejas sobre médicos, asi como sobre otros profesionales acreditados e inscritos del Consejo Médico de Tejas, incluyendo asistentes de médicos, practicantes de acupuntura y asistentes de cirugia, se pueden presentar en la siguiente dirección para ser investigadas: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018, Si necesita ayuda para presentar una queja, llame al: 1-800-201-9353, Para obtener más información, visite nuestro sitio web en www.tmb.state.tx.us | Texas Medical Board Attn: Investigations 333 Guadalupe, Tower 3, Suite 610 P.O. Box 2018, MC-263 Austin, TX 78768-2018 Tel: (800) 201-9353 Website: www.tmb.state.tx.us |
| Utah | You are able to a (i) access, supplement, and amend your patient-provided personal health information; (ii) contact your provider for subsequent care; (iii) obtain upon request an electronic or hard copy of your medical record documenting the telemedicine services, including the informed consent provided; and (iv) request a transfer to another provider of your medical record documenting the telemedicine services from Vida Medical, PC. Utah Admin. Code r. 156-1-602. | Utah Medical Board Tel: (801) 530-6628 Fax: (866) 275-3675 Email: b1@utah.gov |
| Virginia | You acknowledge that you have received details on security measures taken with the use of telemedicine services, such as encrypting date of service, password protected screen savers, encrypting data files, or utilizing other reliable authentication techniques, as well as potential risks to privacy notwithstanding such measures; You agree to hold harmless Vida Medical, PC for information lost due to technical failures; and you provide your express consent to forward patient-identifiable information to a third party. Virginia Board of Medicine Guidance Document 85-12. | Virginia Department of Health Professions Enforcement Division Perimeter Center 9960 Mayland Drive, Suite 300 Henrico, VA 23233-1463 Telephone: 1-800-533-1560 or (804) 367-4691 Fax: (804) 212-2174 Email: enfcomplaints@dhp.virginia.gov |
| Vermont | If you want to file a formal complaint about a physician (MD), you should visit the medical board’s website here: http://www.healthvermont.gov/health-professionals-systems/board-medical-practice/file-complaint You can file a complaint about an osteopathic physician here: https://sos.vermont.gov/opr/complaints-conduct-discipline/#emr Vt. Board of Medical Practice, Policy on the Appropriate Use of Telemedicine Technologies in the Practice of Medicine (March 1, 2023). You understand that you have the right to receive a consult with a distant-site provider and will receive one upon request immediately or within a reasonable time after the results of the initial consult. You understand that receiving telehealth services via store-and-forward technologies by Vida Medical, PC does not preclude you from receiving real-time telemedicine or face-to-face services with the distant provider at a future date. Vt. Stat. Ann. § 9361. | Office of Professional Regulation Attn: Director of the Office 89 Main Street, 3rd Floor Montpelier, VT 05620-3402 Tel: (802) 828-1505 |
You have read this document carefully, and understand the risks and benefits of the Telehealth Services and have had your questions regarding the Telehealth Services explained and you hereby give your informed consent to participate in an Encounter under the terms described herein.
By checking the box on the previous screen (the “Let’s set up your account” screen), you indicate that you have read and understood this document, and that you agree to abide by its terms.