Informed Consent

Informed Consent

Last modified: April 8, 2024

Last modified: April 8, 2024

General Information

Counsel Medical Group, P.A. and its associated medical groups (collectively “Counsel Medical”,

“we”, “our” or “us”) provides medical and health services through its engaged physicians and

health professionals (the “Providers”) with support from its technology partner, Counsel, Inc.

(“Counsel”). This Agreement describes Counsel Medical’s services and clinical programs. It is

important for you to read this document and discuss any questions you might have with us.


By using the Services and where applicable, you further certify that you have legal authority to

act as guardian or personal representative of all children registered under your account and you

consent to the treatment of all minors registered under your account.


Our Services and Technology

When you become a patient of Counsel Medical (a “Member”), you will be given access to

Counsel’s website and applications (the “Counsel App”) and Counsel Medical’s team of

Providers. The Counsel App provides you personalized content and interactive resources,

services as your hub for information, and connects you to Counsel Medical’s Providers.

Counsel Medical provides you with an opportunity to ask personalized questions to our

Providers and interact with our artificial intelligence program. The artificial intelligence program

is a large language model that allows you to ask questions and receive real-time answers and

feedback. You understand that while the artificial intelligence program may provide informational

content, it does not intend to provide medical or clinical advice and is not a licensed clinical

provider. If you are seeking medical or clinical advice, please reach out to our Providers or your

primary care provider. For more information about the use of artificial intelligence, please refer to

the Counsel Terms of Use.


Telehealth Informed Consent - Risks and Benefits

Our Providers will interact with you via telehealth primarily using asynchronous messaging

services. They may prescribe you medication or recommend other treatment, as needed.

Telehealth is a flexible and convenient way to get health care, but it may not be right for

treating certain symptoms or illnesses that need an in-person doctor or urgent care visit.

Responsibility for your overall medical care should remain with your primary care provider. If

you are having a medical emergency, call 9-1-1 or go to the nearest emergency room.


Telehealth services are convenient and offer better access to health care. However, as with any

health service, there are potential risks associated with using technology. These risks include

service problems due to technology or internet failures, not having enough information to make

health care decisions, rare security errors, and other risks. These risks are inherent to telehealth

and you accept the risk of information loss due to technology problems.


Payment and Billing

Each bill for all charges must be paid by the date shown on the bill. If you choose to pay your bill

using a credit card, you are authorizing us to charge the provided credit card number for the

agreed upon services and use your credit card details for future transactions on your account.

Your charges will not be refunded in the event that you cannot complete a session due to an

interruption in your internet service or other malfunction of your technology.


Privacy Practices

We follow certain healthcare privacy and security protocols to protect your health information.

We work hard to make sure that your personal information is secure. We use physical,

electronic, and business security methods (such as encryption) customary among telehealth

providers to help prevent access to your health information by people who should not see it.

Despite our best efforts, we cannot promise that data sent over the Internet or through a data

storage facility will be perfectly secure. So, although we try to protect your personal information,

we cannot guarantee the security of any information you send to us. You can read more

information about our use of health information and other personal information in our Notice of

Health Information Privacy Policy.


Sharing of Health Records with Your Providers and Health Plans

By signing this agreement, you authorize Counsel Medical to share your health records

including information relating to genetic tests, mental health, and other health conditions:

● With your PCP and other health care providers, either directly or through our

participation in health information exchanges, for healthcare coordination, payment,

operations and treatment purposes.

● With other individuals involved in your care such as caregivers or family members.

● With your health plan for payment purposes, if applicable.

● With Counsel, its and our subcontractors as necessary for Counsel Medical to conduct

its health care operations including collection and payment.

● As otherwise permitted in our Notice of Health Information Privacy Policy and by

applicable law.


By signing this agreement, you acknowledge receipt of the Notice of Health Information Privacy

Policy.


Communications

As part of providing services, we may communicate with you, including for purposes such as

clinical care, using SMS, MMS, and RCS text messages and emails. Text messages and

emails are not always secure because they travel over networks that we do not control.

By signing this agreement and providing us your cell phone number and email address, you

permit us to contact you by text message and email. You may also ask us to stop sending SMS

text messages at any time, by contacting support@counselhealth.com. You understand that you

may have to pay standard data and messaging costs (from your wireless provider) to receive

SMS text messages that we send to your mobile phone. You can cancel the SMS service at any

time by contacting support@counsel.health. If you have any questions about your text plan or

data plan, it is best to contact your wireless provider. If you have any questions regarding

privacy, please read our Privacy Policy.


Complaint Policy

All Members have the right to communicate grievances regarding their care. Should you wish to

make a formal complaint about one of your care providers you may do so in writing and submit

the concern to Counsel Medical at support@counselhealth.com.


Additional State-Specific Consents: The following consents apply to Members accessing our

website for the purposes of participating in a telehealth consultation as required by the states

listed below:

General Information

Counsel Medical Group, P.A. and its associated medical groups (collectively “Counsel Medical”,

“we”, “our” or “us”) provides medical and health services through its engaged physicians and

health professionals (the “Providers”) with support from its technology partner, Counsel, Inc.

(“Counsel”). This Agreement describes Counsel Medical’s services and clinical programs. It is

important for you to read this document and discuss any questions you might have with us.


By using the Services and where applicable, you further certify that you have legal authority to

act as guardian or personal representative of all children registered under your account and you

consent to the treatment of all minors registered under your account.


Our Services and Technology

When you become a patient of Counsel Medical (a “Member”), you will be given access to

Counsel’s website and applications (the “Counsel App”) and Counsel Medical’s team of

Providers. The Counsel App provides you personalized content and interactive resources,

services as your hub for information, and connects you to Counsel Medical’s Providers.

Counsel Medical provides you with an opportunity to ask personalized questions to our

Providers and interact with our artificial intelligence program. The artificial intelligence program

is a large language model that allows you to ask questions and receive real-time answers and

feedback. You understand that while the artificial intelligence program may provide informational

content, it does not intend to provide medical or clinical advice and is not a licensed clinical

provider. If you are seeking medical or clinical advice, please reach out to our Providers or your

primary care provider. For more information about the use of artificial intelligence, please refer to

the Counsel Terms of Use.


Telehealth Informed Consent - Risks and Benefits

Our Providers will interact with you via telehealth primarily using asynchronous messaging

services. They may prescribe you medication or recommend other treatment, as needed.

Telehealth is a flexible and convenient way to get health care, but it may not be right for

treating certain symptoms or illnesses that need an in-person doctor or urgent care visit.

Responsibility for your overall medical care should remain with your primary care provider. If

you are having a medical emergency, call 9-1-1 or go to the nearest emergency room.


Telehealth services are convenient and offer better access to health care. However, as with any

health service, there are potential risks associated with using technology. These risks include

service problems due to technology or internet failures, not having enough information to make

health care decisions, rare security errors, and other risks. These risks are inherent to telehealth

and you accept the risk of information loss due to technology problems.


Payment and Billing

Each bill for all charges must be paid by the date shown on the bill. If you choose to pay your bill

using a credit card, you are authorizing us to charge the provided credit card number for the

agreed upon services and use your credit card details for future transactions on your account.

Your charges will not be refunded in the event that you cannot complete a session due to an

interruption in your internet service or other malfunction of your technology.


Privacy Practices

We follow certain healthcare privacy and security protocols to protect your health information.

We work hard to make sure that your personal information is secure. We use physical,

electronic, and business security methods (such as encryption) customary among telehealth

providers to help prevent access to your health information by people who should not see it.

Despite our best efforts, we cannot promise that data sent over the Internet or through a data

storage facility will be perfectly secure. So, although we try to protect your personal information,

we cannot guarantee the security of any information you send to us. You can read more

information about our use of health information and other personal information in our Notice of

Health Information Privacy Policy.


Sharing of Health Records with Your Providers and Health Plans

By signing this agreement, you authorize Counsel Medical to share your health records

including information relating to genetic tests, mental health, and other health conditions:

● With your PCP and other health care providers, either directly or through our

participation in health information exchanges, for healthcare coordination, payment,

operations and treatment purposes.

● With other individuals involved in your care such as caregivers or family members.

● With your health plan for payment purposes, if applicable.

● With Counsel, its and our subcontractors as necessary for Counsel Medical to conduct

its health care operations including collection and payment.

● As otherwise permitted in our Notice of Health Information Privacy Policy and by

applicable law.


By signing this agreement, you acknowledge receipt of the Notice of Health Information Privacy

Policy.


Communications

As part of providing services, we may communicate with you, including for purposes such as

clinical care, using SMS, MMS, and RCS text messages and emails. Text messages and

emails are not always secure because they travel over networks that we do not control.

By signing this agreement and providing us your cell phone number and email address, you

permit us to contact you by text message and email. You may also ask us to stop sending SMS

text messages at any time, by contacting support@counselhealth.com. You understand that you

may have to pay standard data and messaging costs (from your wireless provider) to receive

SMS text messages that we send to your mobile phone. You can cancel the SMS service at any

time by contacting support@counsel.health. If you have any questions about your text plan or

data plan, it is best to contact your wireless provider. If you have any questions regarding

privacy, please read our Privacy Policy.


Complaint Policy

All Members have the right to communicate grievances regarding their care. Should you wish to

make a formal complaint about one of your care providers you may do so in writing and submit

the concern to Counsel Medical at support@counselhealth.com.


Additional State-Specific Consents: The following consents apply to Members accessing our

website for the purposes of participating in a telehealth consultation as required by the states

listed below:

Alaska: 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.


California: I have been informed of the following notices: The Open Payments database

is a federal tool used to search payments made by drug and device companies to

physicians and teaching hospitals. It can be found at https://openpaymentsdata.cms.gov.


NOTICE TO PATIENTS Medical doctors are licensed and regulated by the Medical

Board of California. To check up on a license or to file a complaint here, email:

licensecheck@mbc.ca.gov, or call (800) 633-2322.


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, here.


Indiana: 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.


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, here (or, alternatively, by accessing

this URL in my browser: kbml.ky.gov/grievances/Pages/default.aspx).


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, here; Or, the Maine Board of

Osteopathic Licensure’s website, here.


New York: I have been informed that to get information regarding your rights and how to

report professional misconduct, I should visit medical board’s website, here.


Oregon: 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.


Rhode Island: 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.


Texas: 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.


Vermont: 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; Or, the Vermont Board of

Osteopathic Examiners’ website, here. I understand that I may be presented with the

option to receive services in person, through telehealth, or by audio-only telephone, to

the extent clinically appropriate. In the event I receive services by using audio-only

telephone, it will be my choice to do so, but I am not prevented from receiving services in

person or through telehealth at a later date. Opportunities and limitations of delivering

and receiving health care services using audio-only telephone include: convenience and

access to care from any location with phone service, but can also reduce the amount of

information that is available to my Provider (e.g., such as the availability of medical

images, clinical records, etc). If Counsel Medical is enrolled with my health insurance

plan, the services delivered by audio-only telephone will be billed to my health insurance

plan, if appropriate. In the event the audio-only services are billed to my health insurance

plan, I acknowledge I am financially responsible for any applicable co-payments,

coinsurance, and deductibles, and I understand that not all audio-only health care

services are covered by all health plans.


Wyoming: 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.

About Counsel Health

Counsel is a virtual medical practice specializing in messaging-based care. We provide patients unlimited access to medical advice from expert physicians.

About Counsel Health

Counsel is a virtual medical practice specializing in messaging-based care. We provide patients unlimited access to medical advice from expert physicians.