Telehealth Consent

Informed Consent for Telehealth Services

last modified August 10, 2022

Informed Consent for Telehealth Services

Telehealth involves the use of electronic communications to enable healthcare providers at different locations to share individual patient medical information for the purpose of improving patient care. Telehealth services offered by Wellround Provider Group, P.A., Wellround Medical Group, Wellround Provider Group of New Jersey, P.A., Wellround Provider Group of California, P.C. and Wellround of Kansas, P.A.(collectively, “Wellround”) include telemental health services to the public, specifically, for patients within a broad range of mental health diagnoses and disorders that are treatable through telemental health services and consistent with Wellround’s protocols for treatment. Not all mental health disorders are treatable by telemental health services. These telehealth services may also include, without limitation, chart review, remote prescribing, medication management, laboratory services, appointment scheduling, health information sharing (including care coordination with your other treating providers), and non-clinical services, such as patient education (“Services”).  The information you provide may be used for diagnosis, therapy, medication management, follow-up care and/or patient education, and may include any combination of the following: (1) health records and test results; (2) images and asynchronous communications; (3) live two-way audio and video; (4) interactive audio with store and forward; and (5) output data from medical devices and sound and video files. The platform, telehealth technologies through which the Services are provided and the portal which enables you to communicate with the Wellround Providers and other affiliated support personnel, are operated and maintained by Mantra Health, Inc. (“Mantra”).

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.

Wellround psychiatrists, nurse practitioners, therapists, social workers, and care managers (“Providers”)(care managers are employed by and under the management of another affiliated entity, Mantra) are an addition to, and not a replacement for, your primary care physician.  Responsibility for your overall medical care should remain with your local primary care doctor, if you have one, and we strongly encourage you to locate one if you do not have a primary care doctor.

Expected Benefits:

  • Improved access to care by enabling you to remain in your home while the Provider consults and obtains test results at distant/other sites.
  • More efficient care evaluation and management.
  • Obtaining expertise of a specialist as appropriate.

Possible Risks: 

  • Delays in evaluation and treatment could occur due to deficiencies or failures of the equipment and technologies.
  • In rare events, our Provider may determine that the transmitted information is of inadequate quality, thus necessitating a rescheduled telehealth consult or a meeting with your local primary care doctor.
  • In rare events, security protocols could fail, causing a breach of privacy of personal medical information.
  • In rare events, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors.

If you need to receive follow-up care, assistance in the event of an adverse reaction to the treatment, or in the event of an inability to communicate as a result of a technological or equipment failure, please contact Wellround through the patient portal or via email at hi@mantrahealth.com. If this is a true medical emergency, you should immediately contact the emergency services operating in your area by dialing 911 or visit your local hospital’s emergency department.

By checking the box associated with "Informed Consent", you acknowledge that you understand and agree with the following:

  1. I hereby consent to receiving Wellround’s services via telehealth technologies.  I understand that Wellround and its Providers offer telehealth-based medical and therapy services, but that these services do not replace the relationship between me and my primary care doctor.  I also understand it is up to the Wellround Provider to determine whether or not my specific clinical needs are appropriate for a telehealth encounter. If in the professional judgment of my Provider I am not appropriate for telehealth-based care, I understand that I will be notified and provided with some assistance to find an in-person service which may be more appropriate.
  2. Depending upon my state and the availability of Providers, I understand I may have a choice as to the Wellround provider who can provide the Services, but should I be dissatisfied with my Provider, I may submit a request to change Providers by sending an email to hi@mantrahealth.com.  I acknowledge that all reasonable effort will be made to honor my request.   If my request cannot be honored I understand I have the right to seek services from a provider other than Wellround.
  3. I understand that Wellround will rely on all information I provide as accurate and complete.  I understand that Wellround will use such information in its delivery of services to me.  I further understand that the inaccuracy of any such information I provide to Wellround may impact the efficacy of such services.
  4. I understand Wellround will provide me with information related to my diagnosis, treatment and ongoing care and that the success of my treatment and care is dependent upon my review of this information. Therefore, I agree to review all such information Wellround provides to me.
  5. I understand that federal and state law requires health care providers to protect the privacy and the security of health information.  I understand that Wellround will take steps to make sure that my health information is not seen by anyone who should not see it. If I am a higher education student and able to access the Services through a contract that my college or university (“University”) has with Wellround and Mantra, my health information may be shared with providers and others who are affiliated with my University and authorized to receive such information.I also understand that telehealth may involve electronic communication of my personal medical information to other health practitioners who may be located in other areas, including out of state.
  6. I understand there is a risk of technical failures during the telehealth encounter beyond the control of Wellround. I agree to hold harmless Wellround for delays in evaluation or for information lost due to such technical failures.
  7. I understand that I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time, for any reason or no reason, without affecting my right to future care or treatment. Should I decide to do so, I will no longer receive services, telehealth or otherwise, from Wellround.  
  8. I understand that alternatives to telehealth consultation, such as in-person services may be available to me, and in choosing to participate in a telehealth consultation, I understand that some parts of the services involving tests may be conducted by individuals at my location, or at a testing facility, at the direction of the Wellround Provider (e.g., labs or bloodwork).
  9. I understand that I may expect the anticipated benefits from the use of telehealth in my care, but that no results can be guaranteed or assured.
  10. I understand that my healthcare information may be shared with other individuals for scheduling, billing and other operational purposes. Persons may be present during the consultation other than the Wellround Provider in order to operate the telehealth technologies. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history/examination that are personally sensitive to me; (2) ask non-medical personnel to leave the telehealth examination; and/or (3) terminate the consultation at any time.
  11. I understand that my medical record kept by the Provider may contain information from a referring provider (or University provider, if you are a student user)  including any clinical, laboratory data, or referral information. This may be considered protected health information (“PHI”) or personally identifiable information (“PII”).  That information remains your property. If you are a student user, the Provider or Mantra may share with your University provider your PHI and PII. Your Provider (or Mantra) may de-identify and anonymize your PHI or PII  such that it is no longer considered either PHI or PII, and as such, will not contain any reference to you. In that instance, I understand that the Provider (or Mantra)  may modify or create derivative works which contain this de-identified information and perform all acts as may be necessary to provide or enhance the Services. In addition, the Provider (or Mantra) may use this information for purposes including but not limited to analytics, research, preparation of case studies and other educational and research related publication and usage. Any derivative works or other improvements made by the Provider (or Mantra) based upon or with respect to this de-identified and anonymized information shall be the property of the Provider and Mantra. Under no circumstances will the Provider (or Mantra) sell or commercially market your information.
  12. I understand that I will not be prescribed any narcotics for pain, nor is there any guarantee that I will be given a prescription at all.
  13. I understand there may be side effects from certain medications prescribed, and that my provider will specifically address these risks when prescribing such medication to me.
  14. I understand that if I participate in a consultation, that I have the right to request a copy of my medical records which will be provided to me at reasonable cost of preparation, shipping, and delivery.
  15. I understand that Welllround may review prescription monitoring program (PMP) information related to controlled substances prescribed to me in order to provide the best possible clinical care.
  16. I understand Wellround is a telehealth-based service that is not equipped to handle psychiatric or medical emergencies. If I have an emergency that needs immediate response, I will call 911 or go to my nearest emergency room, and I understand that the Wellround providers are not able to connect me directly to any local emergency services.

Patient Consent

I have read this document carefully, and understand the risks and benefits of the telehealth consultation, and I have had my questions regarding the procedure explained.  I hereby give my informed consent to participate in a telehealth consultation under the terms described herein.