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TELEHEALTH CONSENT & OPEN PAYMENTS

TELEHEALTH CONSENT & OPEN PAYMENTS

Authorization to Use and Disclose My Medical Information and Consent to Telehealth

Open Payments Notice

Last Updated: December 16, 2025

IMPORTANT NOTICE
BY CLICKING “I AGREE,” CHECKING A BOX, OR OTHERWISE ACCEPTING THIS CONSENT, YOU ACKNOWLEDGE THAT YOU HAVE READ AND UNDERSTAND THIS CONSENT AND AGREE TO BE BOUND BY IT. IF YOU DO NOT AGREE, DO NOT CREATE AN ACCOUNT OR USE THE SERVICE.

IF SOMEONE ACCEPTS THIS CONSENT ON YOUR BEHALF, YOU AUTHORIZE THAT PERSON TO ACT AS YOUR AGENT FOR THE PURPOSE OF ACCEPTING THIS CONSENT.

🚨 EMERGENCIES
The Service is not for emergencies. If you are experiencing a medical emergency, call 911 immediately.
If you are contemplating self-harm, call or text 988 (Suicide & Crisis Lifeline).

1. Purpose

This consent (“Consent”) provides information about telehealth and obtains your informed consent to receive healthcare services through telehealth provided by licensed clinicians (“Providers”) using the online platforms operated by VitalPeak, Inc. (“VitalPeak,” “we,” “us,” or the “Service”).

In this Consent, “you” and “your” refer to the person using the Service. The Service is intended for adults age 18+ in the United States.

2. Who Provides Medical Care

VitalPeak does not practice medicine or provide medical care. Clinical services are provided by independent Providers affiliated with or contracted through an independent medical group (“Medical Group”), such as [Medical Group Name].

Your patient-provider relationship is only with your Provider and/or Medical Group, not VitalPeak.

3. What Telehealth Means

Telehealth is the delivery of healthcare services using electronic communications and information technology when you and your Provider are not in the same physical location.

Telehealth may be used for evaluation, diagnosis, treatment, follow-up, and education. It may include:

  • secure messaging and asynchronous “store-and-forward” communication

  • phone or video visits (where available)

  • electronic transmission of records, forms, photos, or other health information

  • review of device outputs or lab results (if applicable)

Alternative methods of care may be available, including in-person care. You may discuss alternatives with your Provider at any time.

4. Anticipated Benefits

Telehealth may:

  • improve convenience and access to care

  • reduce travel and time barriers

  • support efficient follow-up and continuity

  • allow care to occur at times that may be easier to fit into your routine

5. Potential Risks and Limitations

Telehealth has limitations and risks, including:

  • technology failures, bugs, or service interruptions

  • incomplete or inaccurate information (e.g., poor photo quality) affecting clinical decisions

  • the inability to perform certain physical exams or in-office testing

  • delays due to provider availability or technical issues

  • rare privacy/security incidents despite safeguards

  • lack of access to complete medical records possibly contributing to adverse reactions, interactions, or clinical judgment errors

  • regulatory restrictions that may limit diagnosis or prescribing in certain jurisdictions

Your Provider may determine that your condition is not appropriate for telehealth and may recommend in-person evaluation or other care.

6. Emergencies and Follow-Up Care

Telehealth is not appropriate for urgent or emergency situations. Providers may not respond immediately to messages.

If you need urgent or emergent care, seek care at an emergency room or urgent care facility.

If a technical issue prevents you from accessing the Service, contact VitalPeak Support:
Phone: [Support Phone]
Email: [Support Email]
Hours: [Support Hours]

7. Data Privacy and Security

The Service uses security protocols designed to protect your information and comply with applicable privacy laws, including HIPAA where applicable.

However, no system can guarantee absolute security. You understand that communications may include email and/or text reminders and that these channels may be more susceptible to unintended disclosure depending on your email or mobile provider and your device settings.

Your Provider/Medical Group’s handling of PHI is described in the applicable Notice of Privacy Practices.

8. Authorization to Use and Disclose Medical Information

By accepting this Consent, you authorize your Provider and/or Medical Group to use and disclose your medical information as permitted by law for:

  • treatment and care coordination

  • prescribing and pharmacy services

  • payment and billing

  • healthcare operations (including quality improvement and compliance)

You also authorize disclosure of necessary health information to vendors involved in care delivery (e.g., e-prescribing, pharmacy, lab partners) as needed to provide services to you.

You may revoke this authorization as permitted by law by contacting the Medical Group at [Medical Group Privacy Email]. Revocation will not affect disclosures already made in reliance on this authorization.

9. Laboratory Products and Services

Some Providers may recommend or require diagnostic testing (including at-home testing kits) through third-party laboratories.

These laboratory services are provided by third parties. Results may be false positive, false negative, inconclusive, or delayed. Neither VitalPeak nor your Provider can guarantee test accuracy or reliability, and test results may impact diagnosis or treatment decisions.

10. Open Payments Notice

For informational purposes only: The federal Physician Payments Sunshine Act requires that certain payments or transfers of value from drug and device manufacturers to physicians and teaching hospitals be reported and made public.

The federal Open Payments database can be accessed at:
https://openpaymentsdata.cms.gov

11. Your Acknowledgements

By clicking “I Agree” or otherwise accepting this Consent, you acknowledge and agree that:

  1. Telehealth Delivery: Your healthcare services through the Service will be delivered by telehealth.

  2. Provider Type: Your treating Provider may be a physician, nurse practitioner, or physician assistant, depending on availability and clinical appropriateness.

  3. No Guarantee of Outcomes: No specific results are guaranteed. Your condition may improve, remain the same, or worsen.

  4. Technology Risks: Technology may contain errors or become unavailable, which could impact care.

  5. Appropriateness Determination: Your Provider will determine whether telehealth is appropriate for your condition and may recommend alternative care.

  6. No Recording: You agree that telehealth sessions will not be recorded by you or your Provider, unless explicitly stated and consented to where permitted by law.

  7. Right to Withdraw: You may withdraw your consent to telehealth at any time by providing written notice to your Provider/Medical Group. You understand that the Medical Group may not offer in-person visits and that withdrawal may limit your ability to receive services through the platform.

  8. Accurate Information: You will provide truthful, accurate, and complete information, including medical history, current medications, allergies, and emergency contact information.

  9. Prescriptions: Prescriptions are not guaranteed. If prescribed, you may choose your pharmacy.

  10. Financial Responsibility: You are responsible for the costs of the Service and any prescriptions or lab services not covered by insurance.

  11. Complaints: If you have concerns about a Provider, you may contact your state medical or licensing board. (State-specific information may be provided in the Service.)

12. Consent

By selecting “I Agree,” you confirm that you have read and understood this Consent and voluntarily consent to receive telehealth services through the Service and authorize the use and disclosure of your medical information as described above.

DBA: VitalPeak Meds
119 Clifford St. Detroit, MI 48226
United States
support@vitalpeakmeds.com