HIPAA Informed Consent to Treat

Your health information is protected under HIPAA. NPConnect may use and disclose your protected health information (PHI) for the following purposes:

• Treatment: To provide, coordinate, or manage your healthcare and related services.
• Payment: To obtain payment for your healthcare services from insurers or other payers.
• Healthcare Operations: For quality assessment, training, accreditation, and business management activities.

We will not use or disclose your PHI for any other purpose without your written authorization, except as required or permitted by law.

Your Rights Include:

• Right to access and receive a copy of your health records
• Right to request corrections to your records
• Right to request restrictions on certain uses and disclosures
• Right to receive an accounting of certain disclosures
• Right to receive confidential communications
• Right to receive a paper copy of this notice upon request
• Right to file a complaint with us or with HHS if you believe your privacy rights have been violated

I voluntarily consent to the examination, diagnosis, and treatment by the licensed nurse practitioner(s) and healthcare providers at NPConnect. I understand and agree to the following:

• Treatment will only be initiated after I have been informed of the nature of my condition, the proposed treatment plan, and any reasonable alternatives.
• I have the right to ask questions about my diagnosis, treatment plan, medications, potential side effects, and alternatives at any time during or after the visit.
• I have the right to refuse any specific treatment, medication, or procedure. I understand that refusal may carry medical risks, and those risks have been or will be explained to me.
• My provider may refer me to another healthcare provider, specialist, or emergency facility if my condition exceeds the scope of telehealth services or requires a higher level of care.
• Prescriptions issued are for my personal use only, are subject to provider clinical judgment, and must be filled through a licensed pharmacy. Controlled substances cannot be prescribed via telehealth under federal law.
• My provider will document our visit in a medical record, which may be shared with other treating providers as permitted by HIPAA.
• The provider-patient relationship formed through NPConnect is subject to the same standards of care as an in-person clinical encounter.

I understand and consent to the delivery of healthcare services via telehealth technology, including audio-video conferencing. I specifically acknowledge the following limitations of telehealth:

• No Physical Examination: A hands-on physical exam cannot be performed through telehealth. My provider cannot auscultate heart or lung sounds, palpate the abdomen, assess lymph nodes, perform a musculoskeletal exam, or conduct other assessments that require physical contact. This may affect the completeness of my evaluation.
• Diagnostic Limitations: Certain conditions require in-person assessment, laboratory testing, imaging, or diagnostic procedures that cannot be ordered or interpreted accurately through telehealth alone. My provider will advise me if such testing is needed.
• Scope of Practice: Not all medical conditions are appropriate for telehealth management. Conditions that are emergent, complex, or require physical examination may require referral to an in-person provider, urgent care center, or emergency department.
• Technology Dependence: The quality of care may be affected by the quality of my internet connection, device, camera, or microphone. Technical issues may limit the provider's ability to fully assess my condition.
• Privacy Responsibility: All sessions are conducted through HIPAA-compliant, encrypted platforms. I am responsible for ensuring my own privacy and confidentiality on my end (e.g., choosing a private location, using headphones).
• No Recording: Sessions will NOT be recorded by NPConnect without my explicit written consent. I agree not to record sessions without provider consent.
• Right to Withdraw: I may withdraw my consent for telehealth services at any time without affecting my right to future care.

Risks I acknowledge include:

• Diagnosis via telehealth may be based solely on reported symptoms, patient-provided history, and visual observation, which may be less comprehensive than an in-person evaluation.
• Delays in evaluation or treatment may occur due to technical failures, connectivity issues, or inability to transmit information securely.
• A misdiagnosis or delayed diagnosis could occur due to the inherent limitations of remote assessment.
• My provider may be unable to provide a definitive diagnosis or treatment plan and may recommend follow-up in person.

Alternatives to telehealth that have been made known to me:

• In-person visit with a primary care provider or specialist
• Urgent care clinic for acute or time-sensitive conditions
• Emergency department for serious or life-threatening conditions

By acknowledging this section, I confirm that I have read, understood, and had the opportunity to ask questions about all risks and alternatives described above.