Telehealth Informed Consent

Privy Clinic – Telehealth Informed Consent

By using Privy Clinic’s telehealth services, you acknowledge and agree to the following:

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1. Nature of Telehealth Services

Telehealth involves the delivery of healthcare services through electronic communication, including secure messaging, online forms, and electronic medical records. Privy Clinic provides care through an asynchronous (message-based) telehealth model, which does not involve real-time video or in-person visits.

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2. Scope of Care

Privy Clinic provides limited telehealth services focused on sexual health, including evaluation, testing, and treatment of certain sexually transmitted infections (STIs) and related conditions.

Telehealth services:

• Do not include physical examinations

• Are not appropriate for emergencies

• Do not replace an in-person primary care provider

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3. Benefits and Limitations

Potential benefits of telehealth include convenience, privacy, and timely access to care.

Limitations may include:

• Incomplete clinical information due to the lack of a physical exam

• Technical issues or communication delays

• The possibility that telehealth may not be appropriate for your condition

If telehealth is not clinically appropriate, you may be referred for in-person evaluation.

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4. Prescribing and Clinical Judgment

Treatment decisions, including whether to prescribe medications or order laboratory tests, are made solely at the clinician’s professional discretion and based on clinical appropriateness.

Payment for a visit does not guarantee a prescription, diagnosis, or treatment.

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5. Laboratory Testing

If laboratory testing is recommended, tests may be performed through third-party laboratories. Laboratory services may involve separate charges, and patients are responsible for all associated costs. Pricing and coverage may vary.

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6. Privacy and Security

Privy Clinic takes reasonable steps to protect the privacy and security of your health information in accordance with applicable laws, including HIPAA. However, no electronic communication is entirely risk-free.

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7. Emergencies

Privy Clinic does not provide emergency care.

If you experience chest pain, difficulty breathing, severe pain, heavy bleeding, suicidal thoughts, or any other medical emergency, call 911 or go to the nearest emergency room immediately.

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8. Consent and Right to Withdraw

You may withdraw your consent for telehealth services at any time by discontinuing use of the platform. Withdrawal of consent will not affect your ability to seek future care elsewhere.

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9. State-Specific Telehealth Disclosures

Telehealth services are provided in compliance with applicable state laws. Privy Clinic currently provides care to patients physically located in:

• Colorado

• Arizona

• New Mexico

You must be located in one of these states at the time services are rendered.

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10. Acknowledgment and Acceptance

By accessing or using Privy Clinic’s telehealth services, you confirm that:

• You have read and understand this Telehealth Informed Consent

• You agree to receive care via telehealth

• You understand the benefits, risks, and limitations of telehealth services