Telehealth Informed Consent

This form explains how Preamble Health (“Preamble,” “we,” “us”) provides care using telehealth and asks for your consent to receive care this way. Please read it carefully and ask your provider about anything you do not understand before signing.

Table of Contents

1. What Telehealth Is
2. Services Offered by Telehealth
3. Your Location and Provider Licensure
4. Potential Benefits
5. Potential Risks and Limitations
6. Alternatives
7. Prescriptions Through Telehealth
8. Who Is Providing Your Care
9. Privacy and Protection of Your Health Information
10. Recording
11. Emergencies
12. Payment
13. Your Responsibilities
14. Voluntary Consent and Right to Withdraw
15. Acknowledgment and Consent

1. What Telehealth Is

Telehealth is the use of secure electronic communications — such as live (real-time) video and audio, secure messaging, and the transmission of images, labs, and health information (“store-and-forward”) — to deliver health care when you and your provider are in different locations. It allows your Preamble provider to evaluate, diagnose, consult, treat, and where clinically appropriate prescribe, without an in-person visit.

2. Services Offered by Telehealth

Depending on your needs, telehealth may be used for consultations, review of your labs and biomarkers, follow-up visits, care planning, and certain prescriptions. Some services cannot be provided remotely and require an in-person visit — for example, physical examinations, certain diagnostic testing and lab draws, and certain prescriptions. Your provider will tell you when an in-person visit is needed.

3. Your Location and Provider Licensure

Your Preamble providers are licensed to practice in the State of Arizona. Because telehealth care is generally governed by the laws of the state where you are physically located during the visit, you must be physically present in Arizona at the time of your telehealth appointment. Please tell us if you will be located outside Arizona; we may need to reschedule your visit or make other arrangements consistent with that state’s law.

4. Potential Benefits

• More convenient access to your care team without travel.
• Timely evaluation, follow-up, and review of results.
• Coordination of your care between visits.

5. Potential Risks and Limitations

• Technology may fail or be interrupted before or during your visit.
• Information transmitted may, in some cases, be insufficient for the provider to make a clinical decision, so an in-person visit may still be required.
• Despite our safeguards, no electronic transmission of information can be guaranteed to be completely secure or private.
• Rarely, a delay in evaluation or treatment could occur due to technical problems.

6. Alternatives

You may choose to receive care through an in-person visit instead of telehealth. Choosing telehealth is voluntary, and you may ask for an in-person visit at any time.

7. Prescriptions Through Telehealth

Prescriptions are issued only after your provider establishes a valid provider-patient relationship through a clinical evaluation, consistent with Arizona law. We do not prescribe based solely on an online questionnaire. Whether any medication is prescribed is based solely on your provider’s clinical judgment; no medication is guaranteed. Certain medications — including federally scheduled controlled substances such as testosterone — may require an in-person medical evaluation and are prescribed only in accordance with applicable federal and Arizona law. Preamble does not prescribe medications for emergency situations through telehealth.

8. Who Is Providing Your Care

At the start of your visit, your provider will identify themselves by name and role (for example, physician (MD) or physician assistant (PA-C)). You may ask your provider about their credentials and Arizona licensure at any time.

9. Privacy and Protection of Your Health Information

Preamble maintains your medical records and personal health information (PHI) using administrative, physical, and technical safeguards consistent with HIPAA. Access to PHI is role-based and limited to the minimum necessary; authorized users have unique accounts with multi-factor authentication. PHI is encrypted in transit and at rest, our infrastructure operates in Microsoft Azure under a Business Associate Agreement, and system activity is logged and monitored. You are entitled to the confidentiality protections provided under Arizona law (A.R.S. § 12-2292). In limited circumstances required or permitted by law (for example, mandatory reporting or a medical emergency), we may use or disclose information without your authorization.

10. Recording

Your telehealth visits will not be recorded by Preamble without your consent. Please do not record any visit without the consent of your provider.

11. Emergencies

Telehealth is not for emergencies. If you are experiencing a medical emergency, call 911 or go to the nearest emergency department. At the start of a visit you may be asked to confirm your current location and a local emergency contact so we can direct help if needed.

12. Payment

Preamble is a direct-pay practice. We do not bill or accept insurance; you are responsible for the fees for telehealth services, which are payable directly to Preamble. Your provider or care team can explain applicable fees before your visit.

13. Your Responsibilities

• Provide complete and accurate health information.
• Be in a private, well-lit location with a reliable internet connection and a working device.
• Confirm your identity and current location when asked.

14. Voluntary Consent and Right to Withdraw

Your consent to telehealth is voluntary. You may withdraw it at any time, in writing, without affecting your right to future care; however, withdrawing consent may affect our ability to provide certain services remotely. Withdrawal does not apply to care already provided.

15. Acknowledgment and Consent

By signing below, I acknowledge that:

• I have read (or had read to me) and understand this Telehealth Informed Consent, and I have had the opportunity to ask questions.
• I understand the benefits, risks, and limitations of telehealth and my alternatives, including in-person care.
• I understand I must be physically located in Arizona at the time of my telehealth visit.
• I voluntarily consent to receive health care services from Preamble Health through telehealth.