Telehealth Consent

MaVie Clinic – Telehealth Informed Consent: I voluntarily consent to receive telemedicine services from MaVie Clinic using HIPAA-compliant platforms, including OptiMantra and/or Spruce, as well as other secure telehealth technologies as appropriate, and I understand that telemedicine services are not the same as an in-person visit and have specific limitations regarding physical examinations. Benefits and Risks: I understand that telehealth may offer benefits such as improved access to care, reduced travel, and the convenience of receiving care from my home, and I also understand that telehealth carries potential risks, including technical interruptions, delays, unauthorized access, and limitations that may prevent a full clinical assessment. Clinical Limitations & Provider Discretion: I understand that the physical examination may be limited to visual inspection via video or review of photographs or videos I submit, and certain exam components, such as physical tests, examination of specific body parts, or vital signs, may require assistance from individuals at my location under the provider’s direction or may not be performed at all; I further understand that the provider or I may discontinue a telehealth visit at any time if the information available is insufficient to safely or appropriately address my medical needs, and that in-person evaluation or referral may be recommended. Clinical Oversight & Provider Credentials. Provider Disclosure: I understand that MaVie Clinic is a Professional Nursing Corporation and that my healthcare services are provided by Mukhtar Kohistani, NP, a Family Nurse Practitioner licensed by the California Board of Registered Nursing. I have been informed that I am being treated by a Nurse Practitioner and not a physician. Physician Collaboration & Oversight: I understand that this practice operates in accordance with California Standardized Procedures. Clinical oversight and medical direction for MaVie Clinic are provided by Alberto Gomez, M.D. California Medical License #C193938, who serves as the Medical Director. I acknowledge that Dr. Gomez is a licensed California physician and that his role is to collaborate on clinical protocols and provide oversight for the medical services rendered. Right to Consultation: I acknowledge my right to be seen by a physician or to request a referral or consultation with a physician at any time. By proceeding with this telehealth visit, I voluntarily agree to receive care under this collaborative model. Privacy and Confidentiality: I understand that if another individual is present during my telehealth visit, I will be informed and agree to disclose their presence, that all individuals present must maintain confidentiality, and that I may request non-medical individuals leave, omit personally sensitive information, or terminate the visit at any time; to protect my privacy, I agree not to share login credentials, video links, or other access information with anyone not authorized to attend the appointment. Emergency Care: I understand that telehealth services provided by MaVie Clinic are not emergency services, and in the event of an emergency or urgent medical condition I agree to call 911, go to the nearest emergency department, or seek appropriate in-person care immediately. Geographic Requirement: I understand that I must be physically located in the State of California at the time of my telehealth visit, that I agree to accurately disclose my physical location at the time of service, and that care may be declined, modified, or discontinued if I am not located in California or if legal requirements for telehealth are not met. Acknowledgment: By accessing this website and proceeding with telehealth services, I acknowledge that I have read, understood, and had the opportunity to ask questions regarding the above information and that I voluntarily agree to receive telehealth services under these terms.