Matrix Reformed, LLC
Telehealth Medical Consent
Last updated: 02/01/2025
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I. Introduction
You are reviewing and acknowledging this Telehealth Informed Consent because you are seeking healthcare services through Matrix Reformed utilizing telehealth technologies. This consent applies to services accessed via the Matrix Reformed website, or other telehealth technologies collectively known as the “Matrix Platform.” This consent does not modify or supersede the Terms of Use, Privacy Policy, or Notice of Privacy Practices of Matrix Reformed or its Providers, but rather supplements these terms and documents.
By creating an account, starting a consultation, clicking “I consent to telehealth,” checking a related box to signify acceptance, or using any other acceptance protocol presented on the Matrix Platform, you indicate that you have reviewed the risks associated with receiving services via telehealth and consent to receiving these services. This consent is maintained in your records, and your ongoing participation indicates your acceptance of this Telehealth Informed Consent and any updates herein.
II. What is Telehealth?
Telehealth involves the delivery of health and wellness services via electronic communications, information technology, or other means between a licensed, certified, or registered healthcare professional and a patient in separate locations. Telehealth may be used for diagnosis, treatment, follow-up, and patient education. Telehealth services may include various modalities such as asynchronous interactions, real-time video and audio encounters, and interactive audio with store-and-forward. This Telehealth Informed Consent informs you, the patient, about the treatment methods, risks, and limitations of telehealth.
III. What are the Possible Benefits of Telehealth?
Telehealth may make healthcare services more accessible and efficient. You can obtain healthcare services at times convenient for you without requiring an in-office appointment. If follow-up care is needed, contact us through the Matrix Platform or by phone at:
Phone: 727-748-1880
Hours: Mon – Fri, 8:00 am PST – 5:00 pm EST
IV. What are the Possible Risks of Telehealth?
Information transmitted may not be sufficient to meet all clinical needs.
Certain medical conditions may not be suitable for telehealth, and your Provider will determine suitability.
Technology failures could delay or impact your care.
Lack of access to complete medical records or quality of transmitted data may result in adverse interactions or clinical judgment errors.
In case of technical failure, contact Matrix Reformed at the number provided above.
V. Patient Acknowledgments
By accepting this Telehealth Informed Consent, you acknowledge understanding and consent to the following:
Review of Consent: You have carefully reviewed and understand the risks, limitations, and benefits of telehealth.
Privacy Risks: You understand that telehealth may pose a greater privacy risk to your health information.
Provider Qualifications: Your Provider may be a nurse practitioner or physician assistant, not always a physician.
Presence of Others: Other personnel may be present during your telehealth visit to operate the technologies or provide language translation if requested. You will be informed if anyone else is present.
Accurate Information: The information you provide as part of telehealth offerings must be accurate, true, and complete.
Store-and-Forward Communication: In compliance with applicable law, your Provider may determine that asynchronous communication (e.g., store-and-forward technology) is appropriate.
No Guarantee of Prescription: There is no guarantee you will be given a prescription. Prescriptions are issued at the Provider’s professional discretion.
Technical Risks: You agree to hold Matrix Reformed, its affiliates, and all associated personnel harmless for technical failures beyond their control.
Testing Limitations: Some diagnostic testing services, including lab products offered via the Matrix Platform, may contain defects that could impact the quality, accuracy, or effectiveness of your care.
Limitations of the Platform: The Matrix Platform may not meet all your healthcare needs. Providers on the Platform do not offer in-person treatment.
Delay in Communication: Telehealth services may not involve real-time communication. Regularly check the Matrix Platform for updates from your Provider.
Discussion Rights: You have the right to discuss telehealth use, including its benefits, risks, and alternatives, with your Provider.
Medical Record Access: You have access to your medical records in accordance with applicable laws, and you may allow other treating providers to access this information with your consent.
Pharmacy and Lab Options: While the Matrix Platform may coordinate pharmacy or diagnostic lab services, you may use any pharmacy or lab you prefer.
Third-Party Beneficiary: You agree that Matrix Reformed is a third-party beneficiary of this consent and may enforce it.
VI. Additional State-Specific Disclosures
The following disclosures apply to users participating in telehealth visits from specific states:
Iowa
If you wish to file a complaint about a provider, visit the Iowa medical board’s website at: medicalboard.iowa.gov/consumers/filing-complaint.
Kentucky
To file a complaint about a provider, visit the Kentucky medical board’s website at: kbml.ky.gov/grievances.
Maine
To file a complaint about a provider, visit the Maine medical board’s website at: maine.gov/md/complaint/file-complaint.
New York
For information on your rights and to report professional misconduct, visit: health.ny.gov/professionals/doctors/conduct.
Oregon
To file a complaint about a provider, visit the Oregon medical board’s website at: oregon.gov/omb/investigations/pages/how-to-file-a-complaint.aspx.
Rhode Island
To file a complaint about a provider, visit the Rhode Island medical board’s website at: health.ri.gov/complaints.
Texas
To file a complaint about a physician or other licensees, visit the Texas Medical Board’s website at: tmb.state.tx.us.
Vermont
To file a complaint about a provider, visit the Vermont medical board’s website at: healthvermont.gov or the Board of Osteopathic Examiners at sos.vermont.gov.
Wyoming
To file a complaint about a provider, visit the Wyoming medical board’s website at: wyomedboard.wyo.gov.
