Informed Consent for Telehealth and Doula Services

DO NOT USE THIS SERVICE IF YOU MAY BE EXPERIENCING A MEDICAL EMERGENCY.

In an emergent situation, you can: (i) call 911; (ii) go to the nearest emergency room; (iii) contact your local crisis center; (iv) if applicable, call the National Suicide Prevention Lifeline (1-800-273-8255); or (v) if applicable, contact the Crisis Text Line (text “GO” to 741-741).

We are pleased you have chosen Pomelo P.C. and its associated physician practices, Pomelo CA, P.C., Pomelo KS, P.A., Pomelo NJ, P.C., and Women's and Children's Health, P.C. (“Pomelo”). This document is intended to inform you of what you can expect of your care team in terms of your care and treatment via telehealth, the credentials of your providers, and support by in-person doulas, as applicable. After you have carefully read this document and had an opportunity to have your questions answered, certain state laws mandate that you must sign and date it before commencing services.

YOUR TELEHEALTH PROVIDER’S CREDENTIALS

Your provider’s credentials will be made available to you. If you have any questions about these credentials, please direct them to your telehealth provider. For those states that require it, you can find an explanation of the levels of regulation applicable to telehealth providers under the STATE REGULATIONS section of this document.

IMPORTANT INFORMATION REGARDING YOUR TREATMENT BY TELEHEALTH PROVIDERS, INCLUDING POTENTIAL RISKS AND BENEFITS

Pomelo offers care, treatment and support for women and children by various types of healthcare providers and care coordinators via telecommunications technology (also referred to as “telehealth”). Our providers include physicians, nurse practitioners, nurses, registered dietitians, therapists, lactation consultants and other licensed or certified professionals. Additionally, we offer support services by doulas via telehealth and in-person (the “Doula” and “Doula Services”, respectively). Additional limitations of this service line are detailed in this consent. The services provided may also include certain remote monitoring, appointment scheduling, refill reminders, health information sharing, and non-clinical services, such as patient education, offered via care coordinators or care navigators. 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. There are various benefits associated with telehealth services, including improved access to care by enabling you to remain in your home while the provider consults with you, more efficient evaluation and management, and ability to obtain expertise of a specialist as appropriate. Possible risks include that delays in evaluation and treatment could occur due to deficiencies or failures of the equipment and technologies, and, 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 in-person provider.

DOULA SERVICES

If you are eligible for Doula Services and choose to receive them through Pomelo, you understand that the Doula will not make decisions for you but will help you understand your options. The Doula will not perform any medical procedures, including but not limited to: vaginal exams, listening to fetal heart tones, or taking blood pressure. Doulas provide emotional and physical support only and do not offer clinical care. They will not provide transportation for you.

Additionally, the Doula will not speak to the hospital, birth center, or clinical staff on your behalf. They may discuss your concerns with you and suggest possible options, but you will be responsible for speaking to the hospital / birth center / clinical staff directly. Doula Services are only available for births that occur with in-person providers located at a licensed hospital or birth center.

CONFIDENTIALITY

You agree and consent to our use and disclosure of your information as described in the Pomelo Notice of Privacy Practices. You specifically agree and consent to Pomelo using, disclosing, and/or releasing your information, including your “sensitive health information”, for purposes of treatment, payment, or health care operations, such as with your other health care providers in connection with your treatment, including through health information exchanges, with Pomelo Care, Inc. or other contractors and/or affiliates of Pomelo for scheduling, billing and other administrative purposes, with any person or entity liable for payment on your behalf in order to verify coverage or payment questions, or for any other purpose related to benefit coverage and payment. “Sensitive health information” includes information about psychiatric treatment, mental health or illness, developmental or intellectual disability, substance use disorder treatment, genetic information, reproductive health information, and any other type of information that is given special privacy protection under state or federal laws.

Exceptions to confidentiality do exist in certain situations, such as: threat of serious harm to self or others; reasonable suspicion of abuse or neglect of a child, or abuse, neglect, or exploitation of an incapacitated or dependent adult; court order and/or subpoena; permission from the client or guardian (e.g., voluntary release signed by the client or guardian); diagnosis and dates of service shared with an insurance company to collect payments; and as otherwise required by law.

TREATMENT AND CONFIDENTIALITY OF MINORS

In accordance with state laws, consent for treatment of a minor can only be authorized by a current legal guardian for the minor (unless an exception applies). If the parents of a minor are separated, treatment is provided to the minor only with the written consent of both parents. If the parents of the minor are divorced, consent for treatment of the minor may be given by the parent authorized to make medical decisions for the minor. If a court of law has ordered that medical decisions for the minor are to be made jointly by the minor’s parents, then consent of both parents is required for treatment of the minor. In the case of minors, as defined by state law, parents may request information about their child’s diagnosis or treatment. While release of this information will be provided, it is best that the process be a collaborative one involving the minor, parent, and provider in order to maintain the rapport established between the minor and provider since rapport is vital to treatment success.

FEES AND BILLING ARRANGEMENTS

You may be responsible for out-of-pocket fees depending on your insurance and the terms of your plan. Prices are subject to change. You are required to pay all applicable fees for your telehealth and/or Doula Services; however, you are not obligated to pay any fees which another party (e.g., your employer or health plan) pays on your behalf.

If you believe any of the fees you have been charged are incorrect, you must immediately contact us via email (patientbilling@pomelocare.com for telehealth services; client_billing@pomelocare.com for doula services) regarding the amount in question to be eligible to receive a refund. You irrevocably waive your right to challenge the accuracy of any charge, or otherwise receive a refund, if you fail to notify us in writing within fifteen (15) calendar days after the charge, that you believe the charge is inaccurate (setting forth an explanation of why). You also hereby authorize the direct payment of all insurance and plan benefits, including Medicaid and/or Tricare, otherwise payable for services rendered, to Pomelo, as applicable. If you receive payment directly from your insurance company or third-party payer, you agree to immediately forward all healthcare payments that you receive for services provided to you.

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

1. You hereby consent to receive Pomelo’s services via telehealth technologies. You understand that Pomelo and its providers offer telehealth-based medical services, but that these services do not replace the relationship between you and your in-person providers (e.g., obstetrician, primary care provider, pediatrician). You also understand it is up to the Pomelo provider to determine whether or not your specific clinical needs are appropriate for a telehealth encounter.
2. You also hereby consent to receive Doula Services via in-person and/or telehealth technologies. You understand that you will discuss your wishes for Doula support with your healthcare provider and/or Doula. You understand that in planning for your baby’s birth, the Doula cannot ensure that the birth will go as you plan but will be there to support you.
3. You understand that federal and state law requires health care providers to protect the privacy and the security of health information. You understand that Pomelo will take steps to make sure that your health information is not seen by anyone who should not see it. You understand that telehealth may involve electronic communication of your personal medical information to health practitioners who may be located in other areas, including out of state.
4. You agree that Pomelo providers and staff may communicate with you regarding your care through electronic means, including email and text messaging. Such communications may include appointment reminders, care instructions, prescription notifications, and other information related to your treatment. You understand and acknowledge that email and text messaging may not be secure and there is a risk that such communications may be intercepted, accessed, or viewed by unauthorized third parties. You agree to promptly notify Pomelo of any changes to your contact information. You may update your consent to receive electronic communications at any time by emailing your preferences to privacy-inquiries@pomelocare.com.
5. You understand there is a risk of technical failures during the telehealth encounter beyond the control of Pomelo. You agree to hold harmless Pomelo for delays in evaluation or for information lost due to such technical failures.
6. You agree to provide complete and accurate identifying information, including the State where you are currently located when receiving services from Pomelo.
7. You agree to pay for any applicable out-of-pocket fees not covered by your insurance.
8. You understand that if you are experiencing a medical emergency, that you should dial 9-1-1 immediately and that the Pomelo providers are not able to connect you directly to any local emergency services.
9. You understand that you have the right to withhold or withdraw your consent to the use of telehealth in the course of your care at any time, without affecting your right to future care or treatment. You understand that you may suspend or terminate use of the telehealth services at any time for any reason or for no reason.
10. You understand that alternatives to telehealth consultation, such as in-person services are available to you. In choosing to participate in a telehealth consultation, you understand that some parts of the services involving tests may be conducted by individuals at your location, or at a testing facility, at the direction of the Pomelo provider (e.g., labs or bloodwork).
11. You understand that you may expect the anticipated benefits from the use of telehealth in your care, but that no results can be guaranteed or assured.
12. You understand that your healthcare information may be shared with other individuals for treatment, scheduling and billing purposes. Persons may be present during the consultation other than the Pomelo provider in order to operate the telehealth technologies. You further understand that you will be informed of their presence in the consultation and will have the right to request that Pomelo: (a) omit specific details of your medical history/examination that are personally sensitive; (b) ask non-medical personnel to leave the telehealth examination; and/or (c) terminate the consultation at any time.
13. You understand that information derived from your care may be used for quality improvement and research purposes, which may include collaboration with academic or research partners, and that de-identified or aggregate findings may be published or shared.
14. You acknowledge and agree that your visit may be recorded and transcribed using automated transcription software, including through AI enabled services. This technology converts the visit into written text to support accurate clinical documentation and improve the quality of your care. Recordings and transcripts are treated as part of your medical record and are subject to the same privacy protections under applicable law. You may opt out of recording and transcription at any time by notifying your provider before or during the visit. Opting out will not affect your ability to receive care or the quality of services provided.
15. You will discuss the risks and benefits of recommended treatments, based on your specific needs and preferences, with your provider. You understand that there is no guarantee that you will be given a prescription. If a prescription is provided, reasonable efforts will be made to check your insurance for coverage, but medications may not be covered. Medication shortages can occur that Pomelo does not have any control over. Your provider may prescribe medications off-label. Your provider may prescribe medications that require compounding, which is a process that can introduce risks. By embarking on a Pomelo-recommended or prescribed treatment plan, you acknowledge that you understand and agree to the risks and benefits of the treatment plan.
16. You understand that if you participate in a consultation, that you have the right to request a copy of your medical records, which will be provided to you at reasonable cost of preparation, shipping and delivery.
17. You understand that, if you are a parent or guardian providing consent on behalf of a minor, then by registering you (a) affirm that you have the legal authority to seek medical care on behalf of the minor child in your care, and (b) provide Pomelo with consent to provide care for the minor child.
18. For Doula Services, you understand that unforeseen circumstances may prevent the Doula from attending part of or the entirety of your birth. If the Doula cannot attend, a backup Doula will attend, subject to Doula availability. The Doula will inform you of times when they are unavailable and discuss these options with you, as needed, to aid in your care.
19. For Doula Services, you understand that your Doula may offer additional services such as placenta encapsulation, essential oils, TENS or other named services. By accepting Doula Services, you are in no way obligated to purchase any additional services from your Doula. Your decision to accept or refuse additional services, or their associated costs, will in no way impact the Doula Services you are provided as a benefit of your insurance and as offered by Pomelo.
20. You have read and you understand the disclosures set forth next to the state in which you are located at the time of the telehealth encounter, as set forth below:

STATE REGULATIONS

Alaska

You understand your primary care provider may obtain a copy of the records of your telehealth encounter. (Alaska Stat. § 08.63.210(C)(2)).

Arizona

You understand that all medical records resulting from a telemedicine consultation are part of your medical record. (Ariz. Rev. Stat. Ann. § 36-3602(D)).

California

You understand that you have the right to withhold or withdraw your consent to the use of telehealth in the course of your care at any time, without affecting your right to future care or treatment, or, affecting your ability to access covered services from Medi-Cal in the future. You understand that you have the right to access Medi-Cal covered services through an in-person, face-to-face visit or through telehealth. You understand that Medi-Cal provides coverage for transportation services to in-person services when other resources have been reasonably exhausted. (Cal. Welf. & Inst. Code Ann. § 14132.725(d)).

Connecticut

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

D.C.

You have been informed of alternate forms of communication between you and a physician for urgent matters. (D.C. Mun. Regs. tit. 17, § 4618.10). Relevant communications with the physician, including those done via electronic methods shall be documented and filed in your medical record. (D.C. Mun. Regs. tit. 17, § 4618.9).

Georgia

You 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

You have been informed that if you want to register a formal complaint about a provider, you should visit the medical board’s website, here: https://dopl.idaho.gov/filing-a-complaint/ (Idaho Guidelines for Appropriate Regulation of Telemedicine). You further understand that your informed consent for the use of telehealth services shall be obtained by applicable law. (Idaho Statutes 54-5708).

Indiana

If a prescription is issued to you, and subject to your consent, the prescriber shall notify your primary care provider of any prescriptions the prescriber has issued for you if the primary care provider's contact information is provided by you. This requirement does not apply if: (A) The practitioner is using an electronic health record system that your primary care provider is authorized to access. (B) The practitioner has established an ongoing provider-patient relationship with the patient by providing care to the patient at least 2 consecutive times through the use of telehealth services.
If the conditions of this clause are met, the practitioner shall maintain a medical record for you and shall notify your primary care provider of any issued prescriptions. (Ind. Code Ann. 25-1-9.5-7).

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If you are a Medicaid patient, you have the right to choose between an in-person visit or telehealth visit. (Indiana Medicaid Manual: Telehealth and Virtual Services).

Iowa

To file a complaint, fill out the complaint form and email it to the medical board at ibmcomplaints@iowa.gov. (Iowa Admin. Code 653-13.11(147,148,272C)(13.11(18))).
As appropriate, your provider will identify the medical home or treating physician(s) for you, when available, where in-person services can be delivered in coordination with the telemedicine services. Your provider shall provide a copy of the medical record to your medical home or treating physician(s). (Iowa Admin. Code 653-13.11(147,148,272C)(13.11(11))).

Kansas

You understand that if you have a primary care provider or other treating physician, the person providing telemedicine services must send within three business days a report to such primary care or other treating physician of the treatment and services rendered to you during the telemedicine encounter. (Kan. Stat. Ann. § 40-2,212(2)(d)(2)(A)).

Kentucky

You have been informed that if you want to register a formal complaint about a provider, you should visit the medical board’s website, here: https://kbml.ky.gov/board/Pages/default.aspx.

If requested by you, your physician must share the medical record with your primary care physician and other relevant members of your existing care team. (Kentucky Board Opinion on the Use of Telemedicine Technologies (2014), as amended September 15, 2022).

Louisiana

You 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

You have been informed that if you want to register a formal complaint about a provider, you should visit the medical board’s website, here: https://www.maine.gov/md/complaint/file-complaint. (Code Me. R. tit. 02-373 Ch. 11, § 3).

Nebraska

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

New Hampshire

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

New Jersey

You understand that you have the right to request a copy of your medical information and you understand your medical information may be forwarded directly to your primary care provider or health care provider of record, or upon your request, to other health care providers. If you do not have a primary care provider or other health care provider of record, the health care provider engaging in telemedicine or telehealth may advise you to contact a primary care provider, and, upon request by you, may assist you with locating a primary care provider or other in-person medical assistance that, to the extent possible, located within reasonable proximity to you. (N.J. Rev. Stat. Ann. § 45:1-62).

Ohio

You understand that the telehealth provider may forward your medical records to your primary care or treating provider. (Ohio Admin. Code 4731-37-01(C)(4)).

Oregon

If you have a concern or complaint about the providers providing care to you, you may contact a board agency to assist you. You understand that the provider may ask if you need more detail. (ORS 17-52-677.07). (See also Or. Medical Board, Statement of Philosophy: Telemedicine (Oct 2, 2020)).

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Complaints may be filed with:
Oregon Medical Board
1500 SW 1st Ave., Suite 620
Portland, OR 97201-5847
Complaint Resource Staff: 971-673-2702 | complaintresource@omb.oregon.gov

Rhode Island

If you use e-mail or text-based technology to communicate with your provider, then you understand the types of transmissions that will be permitted and the circumstances when alternate forms of communication or office visits should be utilized. You 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. You acknowledge that your failure to comply with this agreement may result in the telehealth provider terminating the relationship. (Rhode Island Medical Board Guidelines).

South Carolina

You understand your medical records may be distributed in accordance with applicable law and regulation to other treating health care practitioners. You understand the value of having a primary care medical home and, if requested, we can provide assistance in identifying available options for a primary care medical home. (S.C. Code Ann. § 40-47-37).
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You also understand that if you are a Medicaid beneficiary, you can withdraw your consent at any time.(South Carolina Health and Human Svcs. Dept. Physicians Provider Manual, p. 35 (Feb. 2024)).

South Dakota

You have received disclosures regarding the delivery models and treatment methods or limitations. You 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

You understand that you may request an in-person assessment before receiving a telehealth assessment if you are a Medicaid recipient. (TN Dept. of Mental Health and Substance Abuse Services. Office of Crisis Services Telecommunications Guidelines, p. 8, (2012) (Accessed Jan. 2024)).

Texas

You understand that your medical records may be sent to your primary care physician within 72 hours. (Tex. Occ. Code Ann. § 111.005). You 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: 1-800-201-9353
For more information, please visit: 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 dirección anterior. Si necesita ayuda para presentar una queja, llame al 1-800-201-9353. Para obtener más información, visite www.tmb.state.tx.us.

Utah

You are able to (i) access, supplement, and amend your patient-provided personal health information; (ii) contact your provider for subsequent care; (iii) obtain upon request an electronic or hard copy of your medical record documenting the telemedicine services, including the informed consent provided; and (iv) request a transfer to another provider of your medical record documenting the telemedicine services. (Utah Admin. Code r. 156-1-602).

Virginia

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

Vermont

You understand that you 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. You understand that receiving telehealth services via store-and-forward technologies by Pomelo does not preclude you from receiving real-time telemedicine or face-to-face services with the distant provider at a future date. (Vt. Stat. Ann. § 9361).

You have been informed that if you want to register a formal complaint about a provider, you should visit the medical board’s website, here: http://www.healthvermont.gov/health-professionals-systems/board-medical-practice/file-complaint; Board of Osteopathic Examiners can be found at: https://sos.vermont.gov/opr/complaints-conduct-discipline/#emr (Vt. Board of Medical Practice, Policy on the Appropriate Use of Telemedicine Technologies in the Practice of Medicine (March 1, 2023)).

You have read this document carefully, and understand the risks and benefits of the telehealth services and Doula Services and have had your questions regarding the services explained and you hereby give your informed consent to participate in these services under the terms described herein.