Telehealth Informed Consent

This document explains what telehealth is, the benefits and risks of receiving care via telehealth, and your rights as a telehealth patient. Please read carefully before consenting to telehealth services with Align Integrative Wellness, LLC (“Align”).

What is telehealth?

Telehealth is the delivery of healthcare services using interactive audio, video, or data communications when the patient and provider are in different physical locations. With Align, your visits are conducted by secure HIPAA-compliant video platform, with messaging and document exchange via our secure patient portal.

Services delivered via telehealth

• Initial and follow-up consultations
• Lab order review and interpretation
• Prescription evaluation, ordering, and management
• Protocol design and adjustment
• Patient education and counseling

Benefits of telehealth

• Convenient access to specialty functional medicine care
• No travel required for routine visits
• Flexible scheduling, including evening and weekend availability
• Same provider continuity across visits
• Privacy of receiving care from your home

Risks and limitations of telehealth

While telehealth offers significant benefits, you should be aware of certain risks:

• Technical risks: Connection failures, audio/video quality issues, or platform outages may interrupt or delay your visit. We will reschedule promptly if a visit cannot be completed due to technical issues.
• Limited physical examination: We cannot perform hands-on physical examinations via telehealth. For services that require in-person examination or procedures (e.g., SOT injections, IV therapy), we will refer you to in-person providers or schedule when our physical clinic opens (Q3 2026).
• Privacy risks: Despite HIPAA-compliant platforms and security measures, no electronic communication is completely secure. We use industry-standard encryption and access controls to minimize risk.
• Continuity-of-care risks: If you experience an emergency between visits, you must seek in-person emergency care. Telehealth is not appropriate for emergency conditions.
• Diagnostic limitations: Some clinical issues are best evaluated in person. Your provider will tell you when in-person evaluation is necessary and refer accordingly.

Emergency situations

Telehealth is not appropriate for medical emergencies. If you are experiencing chest pain, difficulty breathing, signs of stroke, severe bleeding, suicidal thoughts, or any other medical emergency:

• Call 911 or your local emergency number
• Go to your nearest emergency department
• For mental health crises, you may also call the 988 Suicide & Crisis Lifeline

Do not use the patient portal or wait for a telehealth visit during an emergency.

Your rights as a telehealth patient

Right to refuse telehealth

You have the right to refuse telehealth services and request in-person care instead. If we cannot offer in-person care for your needs, we will refer you to a provider who can.

Right to withdraw consent

You may withdraw your consent to telehealth at any time, in writing, without affecting your right to future care.

Right to access your records

Records of your telehealth visits are part of your medical record and subject to the rights described in our HIPAA Notice of Privacy Practices.

Right to know who is providing care

Your provider will identify themselves at the start of each visit. You will know the name and credentials of every clinician involved in your care.

Provider licensure

Telehealth services are provided by providers licensed in the state where you are physically located at the time of service:

• Cory Fowler, FNP-C, licensed in Utah
• Rayna Fowler, FNP-C, licensed in Utah

You are responsible for being physically located in a state where your provider is licensed at the time of each visit. We may verify your location.

Privacy and security

Telehealth visits are conducted on a HIPAA-compliant platform with encryption in transit. Visit records are stored in our HIPAA-compliant electronic health record system. See our HIPAA Notice of Privacy Practices for full details on how we protect your information.

We will not record any telehealth visit without your specific written consent. You are also asked not to record visits without our consent.

Costs and billing

Costs for telehealth visits are described on our service pages and at the time of booking. Telehealth visits are typically not covered by insurance for our cash-pay services as of the effective date of this consent. Insurance billing for office visits is anticipated to begin in Q3 2026 once credentialing is complete.

Consent

By scheduling and attending a telehealth visit with Align Integrative Wellness, LLC, you acknowledge that you have read this Telehealth Informed Consent, understand the benefits and risks of telehealth, and consent to receive healthcare services via telehealth.

A signed copy of this consent will be obtained at intake and stored in your medical record.

Contact

Questions about telehealth services or this consent:
Align Integrative Wellness, LLC
Mailing address available on request
care@alignintegrative.com
(385) 316-1345