Table of Contents:

ALASKA

I understand my primary care provider may obtain a copy of my records of my telehealth encounter. (Alaska Stat. § 08.64.364).

ARIZONA

I understand that all medical records resulting from a telemedicine consultation are part of my medical record. (A.R.S. § 12-2291.)

CALIFORNIA

Medical doctors are licensed and regulated by the Medical Board of California. To check up on a license or to file a complaint go to www.mbc.ca.gov, email licensecheck@mbc.ca.gov, or call 800-633-2322.

Visit the Medical Board of California’s Notice to Consumer webpage at https://www.mbc.ca.gov/licensing/Notice-to-Consumers.aspx or scan the quick response (QR) code below:

COLORADO

I am informed that if I want to register a formal complaint about a provider, I should file at https://dpo.colorado.gov/FileComplaint.

CONNECTICUT

I understand that my primary care provider may obtain a copy of my records of my telehealth encounter, and that I can revoke my consent at any time.  (Conn. Gen. Stat. Ann. § 19a-906).

D.C.

I have been informed of alternate forms of communication between me and a physician for urgent matters.  (D.C. Mun. Regs. tit. 17, § 4618.10).

FLORIDA

FLORIDA WEIGHT LOSS CONSUMER BILL OF RIGHTS

Florida Statute 501.0575 outlines the rights of consumers seeking professional weight-loss services. Please read these rights below:

A. Warning: Rapid weight loss may cause serious health problems. Rapid weight loss is weight loss of more than 1 ½ to 2 pounds per week or weight loss of more than 1% of body weight per week after the second week of participation in a weight loss program.

B. Consult your personal physician before starting any weight-loss program. 

C. Only permanent lifestyle changes, such as making healthful food choices and increasing physical activity, promote long-term weight loss. 

D. Qualifications of this provider are available upon request.

You have the right to: 

1. Ask questions about the potential health risks of this program and its nutritional content, psychological support and educational components. 

2. Receive an itemized statement of the actual or estimated price of the weight loss program, including extra products, services, supplements, examinations, and laboratory tests. 

3. Know the actual or estimated duration of the program. 

4. Know the name, address, and qualifications of the physical, dietician or nutritionist who has reviewed and approved the weight-loss program according to Section 468.505(1)(i)of the Florida Statute.

Patient Informed Consent to Use Appetite Suppressants:  Please carefully read the following statements. On the next page, please sign indicating your understanding and agreement.  

I. Procedures and Alternatives:

A. I understand there is a lack of scientific data regarding the potential danger of long term use of combination weight management programs that include GLP-1 medications and I have read and understand each of the following statements. 

B. I understand that I am responsible to follow my physician’s instructions carefully and to report any medical problems immediately, regardless of whether I think that they may be related to my weight management program. I further affirm that I am not now pregnant and will report any pregnancy to my physician immediately.  

C. I understand that there are other ways and programs that can assist me in decreasing my body weight and maintaining any weight loss. A balanced diet combined with physical exercise could prove successful without use of a GLP-1 medication if I followed it.

II. Risks of Proposed Treatment: I understand that the use of any medication poses various risks and that the use of GLP-1 medications have been associated with gastrointestinal symptoms, mainly nausea, vomiting and diarrhea. Other common side effects include injection site reactions, headache, and nasopharyngitis. Low blood sugar levels (hypoglycemia) may be a risk if I’m taking another drug known to lower blood sugar at the same time, such as sulfonylureas or insulin. I understand that GLP-1 medications are not recommended if I have a personal or family history of medullary thyroid cancer or multiple endocrine neoplasia or if I’ve had pancreatitis.

III. Risks Associated With Having Overweight or Obesity: I understand that having overweight or obesity poses certain risks, among them being tendencies to high blood pressure, diabetes, heart attack and heart disease, arthritis at the joints, hips, knees and feet, and certain cancers. I understand that these risks may be modest if I am not very overweight, but that these risks increase significantly with any weight gain.

IV. No Guarantees: I understand that much of the success of this program will depend on my efforts and compliance with the program. Notwithstanding my efforts, I understand that there are no guarantees or assurances that this program will be successful. I also understand that I will have to continue managing my weight all my life if I am to be successful.

Patient’s Signature: ______________________   Physician’s Signature: _________________

Date: ________________________    Date:  ________________________ 

Title XXXIII REGULATION OF TRADE, COMMERCE, INVESTMENTS, AND SOLICITATIONS 

Chapter 501  CONSUMER PROTECTION 

501.0575 Weight-Loss Consumer Bill of Rights.—

(1) The Weight-Loss Consumer Bill of Rights shall consist of the following provisions: 

(A) WARNING: RAPID WEIGHT LOSS MAY CAUSE SERIOUS HEALTH PROBLEMS. RAPID WEIGHT LOSS IS WEIGHT LOSS OF MORE THAN 11/2 POUNDS TO 2 POUNDS PER WEEK OR WEIGHT LOSS OF MORE THAN 1 PERCENT OF BODY WEIGHT PER WEEK AFTER THE SECOND WEEK OF PARTICIPATION IN A WEIGHT-LOSS PROGRAM. 

(B) CONSULT YOUR PERSONAL PHYSICIAN BEFORE STARTING ANY WEIGHT-LOSS PROGRAM. 

(C) ONLY PERMANENT LIFESTYLE CHANGES, SUCH AS MAKING HEALTHFUL FOOD CHOICES AND INCREASING PHYSICAL ACTIVITY, PROMOTE LONG-TERM WEIGHT LOSS.

(D) QUALIFICATIONS OF THIS PROVIDER ARE AVAILABLE UPON REQUEST. 

(E) YOU HAVE A RIGHT TO: 

1. ASK QUESTIONS ABOUT THE POTENTIAL HEALTH RISKS OF THIS PROGRAM AND ITS NUTRITIONAL CONTENT, PSYCHOLOGICAL SUPPORT, AND EDUCATIONAL COMPONENTS. 

2. RECEIVE AN ITEMIZED STATEMENT OF THE ACTUAL OR ESTIMATED PRICE OF THE WEIGHT-LOSS PROGRAM, INCLUDING EXTRA PRODUCTS, SERVICES, SUPPLEMENTS, EXAMINATIONS, AND LABORATORY TESTS. 

3. KNOW THE ACTUAL OR ESTIMATED DURATION OF THE PROGRAM. 

4. KNOW THE NAME, ADDRESS, AND QUALIFICATIONS OF THE DIETITIAN OR NUTRITIONIST WHO HAS REVIEWED AND APPROVED THE WEIGHT-LOSS PROGRAM ACCORDING TO s. 468.505(1)(j), FLORIDA STATUTES. 

(2) The copies of the Weight-Loss Consumer Bill of Rights to be posted according to s. 501.0573(6) shall be printed in at least 24-point boldfaced type on one side of a sign. The palm-sized copies to be distributed according to s. 501.0573(5) shall be in boldfaced type and legible. Each weight-loss provider shall be responsible for producing and printing appropriate copies of the Weight-Loss Consumer Bill of Rights.

History.—s. 4, ch. 93-274; s. 45, ch. 2000-154

GEORGIA

I have been given clear, appropriate, accurate instructions on follow-up in the event of needed emergent care related to the treatment. (Ga. Comp. R. & Regs. 360-3-.07(7)).

IDAHO

I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website.

ILLINOIS

I have been informed that if I want to register a formal complaint about a provider, I should visit the Illinois Division of Professional Regulation.

INDIANA

To file a consumer compliant you can request a complaint form by calling 1-800-382-5516 or 317-232-6330 and file the form with the Attorney General’s Office or use the online complaint form.

IOWA

I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website.

KANSAS

I understand that if I have a primary care provider or other treating physician, I may request that the person providing telemedicine services send a report to my primary care or other treating physician of the treatment and services rendered to me during the telemedicine encounter within three business days (see Kan. Stat. Ann. § 40-2,212(2)(d)(2)(A). I understand that the complaint process may be found here: http://www.ksbha.org/complaints.shtml.

KENTUCKY

I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website.

LOUISIANA

I understand the role of other health care providers that may be present during the consultation other than the telehealth provider.  (46 La. Admin. Code Pt XLV, § 7511).

MAINE

I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website.

MARYLAND

Regarding audiologists, speech language pathologists, and hearing aid dispensers, I recognize the inability to have direct, physical contact with the patient is a primary difference between telehealth and direct in-person service delivery. The knowledge, experiences, and qualifications of the consultant providing data and information to the provider of the telehealth services need not be completely known to and understood by the provider. The quality of transmitted data may affect the quality of services provided by the provider. Changes in the environment and test conditions could be impossible to make during delivery of telehealth services. Telehealth services may not be provided by correspondence only. (Md. Code Regs. 10.41.06.04).  I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website. 

NEBRASKA

If I am a Medicaid recipient, I retain the option to refuse the telehealth consultation at any time without affecting my 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 shall apply to the telehealth consultation. I shall have access to all medical information resulting from the telehealth consultation as provided by law for access to my medical records. Dissemination of any patient identifiable images or information from the telehealth consultation to researchers or other entities shall not occur without my written consent. I understand that I have the right to request an in-person consult immediately after the telehealth consult and I will be informed if such consult is not available. (Neb. Rev. Stat. Ann. § 71-8505; 471 Neb. Admin. Code § 1-006.05).  I have been informed that if I want to register a formal complaint about a provider, I should visit this webpage. 

NEW HAMPSHIRE

I understand that the telehealth provider may forward my medical records to my primary care or treating provider.  (N.H. Rev. Stat. § 329:1-d).

NEW JERSEY

I understand I have the right to request a copy of my medical information and I understand my medical information may be forwarded directly to my primary care provider or health care provider of record, or upon my request, to other health care providers.  (N.J. Rev. Stat. Ann. § 45:1-62).

OKLAHOMA

I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here: http://www.okmedicalboard.org/complaint. Board of Osteopathic Examiners can be found at: https://www.ok.gov/osboe/faqs.html.

RHODE ISLAND

If I use e-mail or text-based technology to communicate with my provider, then I understand the types of transmissions that will be permitted and the circumstances when alternate forms of communication or office visits should be utilized.  I have also discussed security measures, such as encryption of data, password protected screen savers and data files, or utilization of other reliable authentication techniques, as well as potential risks to privacy.  I acknowledge that my failure to comply with this agreement may result in the telehealth provider terminating the e-mail relationship.  (Rhode Island Medical Board Guidelines).

SOUTH CAROLINA

I understand my medical records may be distributed in accordance with applicable law and regulation to other treating health care practitioners.  (S.C. Code Ann. § 40-47-37).

SOUTH DAKOTA

I have received disclosures regarding the delivery models and treatment methods or limitations. I have discussed with the telehealth provider the diagnosis and its evidentiary basis, and the risks and benefits of various treatment options. (S.D. Codified Laws § 34-52-3).

TENNESSEE

I understand that I may request an in-person assessment before receiving a telehealth assessment if I am a Medicaid recipient. 

TEXAS

I understand that my medical records may be sent to my primary care physician.  (Tex. Occ. Code Ann. § 111.005). I have been informed of the following notice:

NOTICE CONCERNING COMPLAINTS -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 www.tmb.state.tx.us.  

AVISO SOBRE LAS QUEJAS- Las quejas sobre médicos, asi como sobre otros profesionales acreditados e inscritos del Consejo Médico de Tejas, incluyendo asistentes de médicos, practicantes de acupuntura y asistentes de cirugia, se pueden presentar en la siguiente dirección para ser investigadas: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018, Si necesita ayuda para presentar una queja, llame al: 1-800-201-9353, Para obtener más información, visite nuestro sitio web en www.tmb.state.tx.us.

UTAH

I understand (i) any additional fees charged for telehealth services, if any, and how payment is to be made for those additional fees, if the fees are charged separately from any fees for face-to-face services provided in combination with the telehealth services; (ii) to whom my health information may be disclosed and for what purpose, and have received information on any consent governing release of my patient-identifiable information to a third-party; (iii) my rights with respect to patient health information; (iv) appropriate uses and limitations of the site, including emergency health situations. I understand that the telehealth services meets industry security and privacy standards, and comply with all laws referenced in Subsection 26-60-102(8)(b)(ii). I was warned of: potential risks to privacy notwithstanding the security measures and that information may be lost due to technical failures, and agree to hold the provider harmless for such loss. I have been provided with the location of telehealth company’s website and contact information. I was able to select my provider of choice, to the extent possible. I was able to select my pharmacy of choice. I am able to a (i) access, supplement, and amend my patient-provided personal health information; (ii) contact my provider for subsequent care; (iii) obtain upon request an electronic or hard copy of my medical record documenting the telemedicine services, including the informed consent provided; and (iv) request a transfer to another provider of my medical record documenting the telemedicine services. (Utah Admin. Code r. 156-1-603).

VERMONT

I understand that I have the right to receive a consult with a distant-site provider and will receive one upon request immediately or within a reasonable time after the results of the initial consult.  

I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website or submit a report to the Board of Osteopathic Examiners.

VIRGINIA

I acknowledge that I 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; I agree to hold harmless MeMD for information lost due to technical failures; and I provide my express consent to forward patient-identifiable information to a third party.  (Virginia Board of Medicine Guidance Document 85-12).