Telemedicine Consent

TELEMEDICINE CONSENT

Last updated: June 22, 2026

This telemedicine consent is provided to you by your healthcare provider, which currently is either Delaware Telehealth Medical Group, P.A., Kansas Telehealth Medical Group, P.A., Florida Telehealth Medical Group, P.A., New Jersey Telehealth Medical Group, P.A., or California Telehealth Medical Group, P.C. (each, the “Practice”).

For more information about the MOD platform, please see our Privacy Policy, Terms and Conditions, or email us at support@mod.com.

Telemedicine involves using technology to enable healthcare providers at the Practice (each, a “Provider”) to evaluate and treat patients from different locations. Telemedicine communications may include transmission of your medical records, photos and other personal health information, and may include interactions via dynamic intake forms, live 2-way video and audio, and other methods. Your Provider leverages one or more technology platform’s network and software security protocols to help protect the privacy and security of your health information, including the MOD platform.

POSSIBLE BENEFITS OF TELEMEDICINE

Easier access to medical care and treatment, at times and from locations that may be more convenient to you.
You do not need to be physically present for an in-office appointment.
Reduced healthcare costs, including lowered costs for online visits and prescriptions.

POSSIBLE RISKS OF TELEMEDICINE

Telemedicine is not intended to replace a relationship with your local and in-person physicians.
Because your Provider does not have access to your complete medical records, if you do not disclose a full list of your medical history, including diagnoses, treatments, and medications/supplements, your Provider may not receive enough information to enable diagnosis or prescription treatments, which may result in negative outcomes.
Your Provider will not be able to conduct certain tests, blood work, or assess vital signs in-person, which could prevent your Provider from identifying a need for emergency medical care or treatment or underlying causes of any condition for which you are seeking treatment.
Your Provider may advise you to seek alternative care or meet with your local physician and may not provide you with a prescription or other treatment.
Delays in evaluation, consultation, diagnosis, or treatment may occur due to technical or Internet deficiencies or failures, which may include poor video and audio quality or other service interruption issues. If the telemedicine services provided to you are interrupted due to a technical or Internet deficiency or failure or another service issue, please contact your Provider.
Telemedicine is not appropriate for certain medical scenarios, including immediate medical situations or allergic or adverse reactions. In these scenarios, please contact your primary care provider or go to your local hospital. If the situation is a medical emergency, dial 911 immediately.
Security protocols or safeguards could fail causing a breach of privacy and unintentional disclosure of your health information.
State laws may prohibit telemedicine or treatment options, including that you may not be able to receive prescription medications via telemedicine if you reside in certain states.

CONTROLLED SUBSTANCE PRESCRIPTIONS

While controlled substance prescriptions can be used to treat some conditions, success is not guaranteed. Controlled substance prescriptions also have a high potential for misuse and are closely regulated by local, state, and federal governments. Our Providers must observe strict rules to help minimize the risks of abuse and misuse. All patients seen by our Providers must acknowledge and follow the policies outlined below as a condition to be eligible for your Provider to prescribe a controlled substance.

By clicking “I agree” below, you acknowledge:

Prescriptions for controlled substances and other prescription drugs will only be prescribed if your Provider determines that it is medically necessary.
Your Provider may require identity verification before prescribing controlled substances, including government-issued identification, video verification, or other reasonable methods designed to verify identity and prevent fraud, misuse, or diversion.
Consumption of controlled substances is associated with risks, including psychological addiction, physical dependence, withdrawal, and overdose.
You must wait until the next eligible fill date to receive another prescription. There are no temporary refills. Your Provider may terminate your provider-patient relationship and discharge you from the Practice if you request an early refill.
You will only use the prescribed medication as your Provider instructs. You will not change the manner in which you take your prescribed medication without first consulting your Provider. You understand that changing the manner in which you take your prescribed medications without consulting your Provider can result in adverse health outcomes. For example:
- You will not alter the date, quantity, or strength of your medications.
- You will not break, chew, crush, inject, or snort your medications.
- You will not in any way alter a prescription or your medications.
- You understand that forging prescriptions or your Provider’s signature violates state and federal law.
- You will keep your prescriptions and medications in a secure and safe location and will safeguard your prescriptions and medications against loss or theft.
- You will not sell, share, or otherwise allow others to possess or use your medications.
You will not obtain controlled substance prescriptions from multiple providers, practices, or clinics. If you receive other controlled substance prescriptions from any source other than your Provider, without notifying your Provider, your Provider may terminate your provider-patient relationship and discharge you from the Practice.
Your Provider may use resources to obtain a history of your prescribed medications, such as:
- Requesting information from past/current treating health care providers.
- Requesting information from your current or previous pharmacies.
- Prescription Drug Monitoring Database (PDMP) reports.
Such information and reports will become part of your patient medical record.
You will notify your Provider of any adverse effects you experience from your medications.
You will provide complete and accurate information regarding your current and past use of alcohol, prescription medications, controlled substances, recreational drugs, and any history of substance use disorder, misuse, dependence, or addiction.
You will follow your Provider's recommendations regarding safe medication use.
You are aware that attempting to obtain a controlled substance under false pretenses is illegal.
You understand that driving while under the influence of any substance, including a prescribed controlled substance, or any combination of substances that impairs your driving ability, may result in DUI charges or other legal charges.

The Practice and your Provider may disclose information as required or permitted by applicable law, including disclosures required for regulatory, public health, patient safety, or law enforcement purposes.

YOUR CONSENT TO TELEMEDICINE SERVICES

By Clicking “I Agree”, you confirm that you have read the prior sections, and you understand the risks and benefits of telemedicine and controlled substance prescriptions and you acknowledge and agree:

To receive telemedicine services from one or more Providers with whom you are connected via the MOD platform and with which MOD has relationships, although they are separate from MOD.
That your Provider retains sole discretion in determining whether your condition is suitable for treatment via the telemedicine services.
That a variety of alternative methods for health care services may be available to you and that you may choose one or more of those at any time.
That your information, including identifiable health information, will be collected, used, disclosed, and safeguarded in accordance with the MOD Privacy Policy and the Notice of Privacy Practices provided by your Provider and their practice.
The identity and credentials of your Provider are provided through email correspondence when a written request is submitted via the MOD platform.
That you authorize MOD, and your Provider with whom you are connected via the MOD platform to share information regarding telemedicine services for treatment, payment, and health care operations purposes, including consent to share medical records with your primary care or other physicians.
That if you receive a prescription from a Provider, you authorize MOD to send your healthcare and personal information to a licensed compounding pharmacy so that you may receive your prescription and other pharmacy services. You acknowledge that you will not receive a paper prescription and cannot forward or transfer the prescription yourself.
That you authorize pharmacies involved in your care to communicate with your Provider regarding prescription verification, medication history, medication safety, and other matters related to your treatment, as permitted by applicable law.
That although telemedicine and prescriptions may provide benefits for you, no benefits or specific results can be guaranteed, and that your condition may not improve, and in some cases, may get worse.
That the telemedicine services are not intended to replace your relationship with your primary care physician or any other existing provider.
You may have your medical records of the telemedicine encounter sent to your primary care provider. To do so, you must provide sufficient and accurate contact information of your primary care provider.
That failure to provide accurate health and medical information to your Provider may impact the benefits you receive from the telemedicine services.
That emergency medical services are not provided through the telemedicine services, and you should call 911 or seek immediate medical attention in your area if you believe you are experiencing a medical emergency.
You have access to all of your health and wellness information relating to telemedicine services in accordance with applicable laws and regulations.
Telemedicine is constantly evolving and may include different technology in the future that is not specifically described in this consent.
You will hold MOD, your Provider, and any applicable practice harmless for loss of your personal information resulting from a technical or Internet failure.
You are located in the city and state you provided above, and you will be present in that city and state during all telemedicine services the Practice provides.
You represent and warrant that you are at least 21 years old and no older than 79 years old. Telemedicine services made available through the MOD platform are intended solely for individuals between the ages of 21 and 79. If you are under 21 or over 79, you are not eligible to use the MOD platform or receive telemedicine services through the MOD platform. MOD, the Practice, and your Provider reserve the right to deny, suspend, terminate, or limit access to the platform or telemedicine services if it is determined that you do not meet eligibility requirements.
You can withhold or withdraw this consent at any time by emailing us at support@mod.com.
Unless you revoke your consent, this informed consent will be renewed upon each telemedicine encounter and your Provider may continue to provide services to you via telemedicine without the need for you to complete another consent.

ADDITIONAL STATE SPECIFIC DISCLOSURES AND CONSENTS

ARIZONA

You understand you are entitled to all existing confidentiality protections pursuant to A.R.S. § 12-2292. You also understand all medical reports resulting from the telemedicine consultation are part of your medical record as defined in A.R.S. § 12-2291. You also understand dissemination of any images or information identifiable to you for research or educational purposes shall not occur without your consent, unless authorized by state or federal law. (Ariz. Rev. Stat. Ann. § 36-3602).

CALIFORNIA - NOTICE TO PATIENTS

IOWA

If you wish to file a formal complaint against a physician, you may do so here.
If you wish to file a formal complaint against a nurse practitioner, you may do so here.
If you wish to file a formal complaint against a physician assistant, you may do so here.

MAINE

If you wish to file a formal complaint against a physician or physician assistant, you may do so here.
If you wish to file a formal complaint against a nurse practitioner, you may do so here.

NEBRASKA

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 will apply to the telehealth consultation. You will have access to all medical information resulting from the telehealth consultation 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 will not occur without your written consent. (Neb. Rev. Stat. Ann. § 71-8505(1)).

SOUTH DAKOTA

You have received disclosures regarding the delivery models and treatment methods or limitations. If you have concerns regarding the delivery models and treatment methods or limitations you will discuss them with your Provider.

TEXAS

Complaints about physicians, as well as other licensees and registrants of the Texas Medical Board, including physician assistants, acupuncturists, and surgical assistants 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 tmb.texas.gov.

VERMONT

The Vermont Board of Medical Practice investigates complaints of unprofessional conduct. If you have a concern about a medical professional, you may contact the Board as indicated below. For more information see the Board's website here.

VERMONT DEPARTMENT OF HEALTH
BOARD OF MEDICAL PRACTICE
108 Cherry Street, PO Box 70
Burlington, VT 05402-0070
802-657-4220

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 give your express consent to forward patient-identifiable information to third parties as described in the Consumer Health Data Privacy Policy.