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By signing electronically or checking the consent box, I confirm that:
I have read and understood this Telehealth Informed Consent.
I understand that a consultation is required and that I may not qualify for treatment.
I understand that treatment may be declined based on clinical review.
I voluntarily consent to receive telehealth services from an MDI physician.
This document is intended to inform me of what I can expect of my telehealth provider and in connection with my treatment via telehealth. After I have carefully read this document and had an opportunity to have my questions answered, certain state laws mandate that I must sign or virtually accept this consent, before commencing services.
I understand that Blueprint facilitates access to medical services provided by independent, board-certified physicians through MD Integrations (MDI). These physicians are licensed in all 50 U.S. states and provide medical consultations via telehealth.
I understand that my provider’s credentials will be made available as part of the telehealth visit. If I have any questions about these credentials, I will direct them to my telehealth provider. For those states that require it, an explanation of the levels of regulation applicable to telehealth clinicians under the STATE DISCLOSURES section of this document.
Telehealth services may include review of my medical history, assessment of symptoms, medical evaluation, diagnosis, treatment recommendations, and, if appropriate, prescription of medication.
Telehealth consultations are conducted through secure electronic communication methods and may be asynchronous or synchronous, depending on the treatment and physician’s determination.
I understand that:
A medical consultation is required before any prescription medication can be issued. No prescriptions are guaranteed.
The physician will independently review my intake form and medical information.
Treatment may be declined based on clinical review.
I may not qualify for treatment if, in the physician’s medical judgment, the requested therapy is not appropriate or safe for me.
I understand that telehealth services do not replace the relationship between me and my primary care doctor.
I understand there is a risk of technical failures during the telehealth encounter beyond the control of Blueprint or MDI. I agree to hold harmless Blueprint and MDI for delays in evaluation or for information lost due to such technical failures.
I understand that I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time, without affecting my right to future care or treatment. I understand that I may suspend or terminate use of the telehealth services at any time for any reason or for no reason.
I understand that alternatives to telehealth consultation, such as in-person services are available to me, and in choosing to participate in a telehealth consultation, I understand that some parts of the services involving tests may require that I follow testing instructions provided to me by Blueprint and MDI.
I understand that if I participate in a consultation, I have the right to request a copy of my medical records which will be provided to me at reasonable cost of preparation, shipping and delivery.
I have read and understand the disclosures set forth next to the state in which I am located at the time of the telehealth encounter, as set forth below.
I acknowledge that submission of payment or enrollment in a subscription does not guarantee eligibility to receive a prescription, or treatment and I may cancel my subscription in accordance with the Blueprint Terms of Service.
I certify that all information I provide is complete, truthful, and accurate to the best of my knowledge.
I understand that:
Withholding relevant medical information may result in denial of treatment or medical risk.
The prescribing physician relies on the information I provide to make medical decisions.
I understand that telehealth has many benefits such as:
Improved access to care by enabling me to remain in my home or other location while the provider consults with me.
More efficient care evaluation and management, and obtaining expertise of a specialist as appropriate.
I understand that telehealth has limitations compared to in-person care, including:
No in-person physical examination will be conducted by the MDI provider.
Potential technical issues or delays due to such technical issues.
Reliance on self-reported medical information.
If the physician determines that telehealth is not appropriate for my condition, I may be advised to seek in-person care.
If treatment is approved:
The physician may prescribe medication consistent with applicable laws and clinical guidelines.
Prescriptions may be transmitted to a licensed pharmacy partner for fulfillment.
The physician may request additional information before issuing a prescription.
If treatment is declined:
I understand I will not receive a prescription.
I may seek care elsewhere at my discretion.
| State | What You Should Know | Who To Contact with Questions or Concerns |
|---|---|---|
| Alaska | Your primary care provider may obtain a copy of the records associated with your telehealth encounter. Alaska Stat. § 08.63.210(c)(2). |
Alaska State Medical Board Division of Corporations, Business & Professional Licensing P.O. Box 110806 Juneau, AK 99811-0806 Tel: (907) 465-2550 Email: medicalboard@alaska.gov |
| 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). |
Arizona Medical Board 1740 West Adams Street, #3600 Phoenix, AZ 85007 Tel: (480) 551-2700 Fax: (480) 551-2702 Email: Submit form here. |
| California |
Physicians: All physicians licensed to practice in the State of California are licensed and regulated by the Medical Board of California. To check on a physician’s license or to file a complaint, go to www.mbc.ca.gov, email licensecheck@mbc.ca.gov, or call (800) 633-2322. |
Medical Board of California 2005 Evergreen Street, Suite 1200 Sacramento, CA 95815 Email: webmaster@mbc.ca.gov Phone: (800) 633-2322 / (916) 263-2382 |
| Connecticut | You understand that each telehealth provider shall, at the time of the initial telehealth interaction, ask you whether you consent to that provider’s disclosure of records concerning the telehealth interaction to your primary care provider. You further understand that your primary care provider may obtain a copy of your records of your telehealth encounter, upon your consent. Conn. Gen. Stat. Ann. § 19a-906(d). |
Connecticut Department of Public Health Medical Examining Board 410 Capitol Ave., MS #13 PHO P.O. Box 340308 Hartford, CT 06134 Tel: (860) 509-7603 Fax: (860) 509-8457 |
|
District of Columbia |
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. |
District of Columbia Board of Medicine 899 North Capitol Street, NE Washington, DC 20002 Tel: (202) 724-4900 Fax: (202) 442-8117 Email: doh@dc.gov |
| 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(a)(7). |
Georgia Composite Medical Board 2 Peachtree Street, NW, 6th Floor Atlanta, GA 30303-3465 Email: medbd@dch.ga.gov |
| Idaho | If you need to register a formal complaint about a physician, you may visit the medical board’s website here. 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. |
Idaho Board of Medicine Logger Creek Plaza 345 Bobwhite Ct., Suite 150 Boise, ID 83706 Email: info@bom.idaho.gov Division of Professional Licenses 11351 W. Chinden Blvd., Bldg. #6 Boise, ID 83714 |
| 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. |
Indiana Professional Licensing Agency 402 W. Washington St., Room W072 Indianapolis, IN 46204 Tel: (317) 234-2054 Fax: (317) 233-4236 Email: pla8@pla.IN.gov |
| 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)). |
Iowa Board of Medicine 400 SW 8th St., Suite C Des Moines, IA 50309 Tel: (515) 281-5171 Email: ibmcomplaints@iowa.gov |
| Kansas | You understand that if you have a primary care or other treating provider and if you consent to us sharing your information with such provider, then we are obligated to send within three business days a report to such primary care or other treating physician of the treatment and services rendered by the MDI provider during the telemedicine encounter. Kan. Stat. Ann. § 40-2,212(2)(d)(2)(A). |
Kansas Board of the Healing Arts 800 SW Jackson, Lower Level – Suite A Topeka, KS 66612 Tel: (785) 296-7413 Fax: (785) 368-7102 |
| 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. |
Kentucky Board of Medical Licensure 310 Whittington Parkway, Suite 1B Louisville, KY 40222 Tel: (502) 429-7150 Fax: (502) 429-7158 |
| Louisiana | You understand the role of other health care providers that may be present during the consultation, other than the MDI provider. 46 La. Admin. Code Pt XLV, § 7511. |
Louisiana State Board of Medical Examiners 630 Camp Street New Orleans, LA 70130 Tel: (504) 568-6820 Fax: (504) 568-5754 Email: investigations@lsbme.la.gov |
| Maine |
If you want to register a formal complaint about a physician, you should visit the medical board’s website here: https://www.maine.gov/md/complaint/file-complaint |
Complaint Coordinator Office of Licensing and Registration 35 State House Station Augusta, ME 04333 Tel: (207) 624-8660 |
| Nebraska | You can report a concern or complaint here: https://dhhs.ne.gov/Pages/Complaints.aspx |
Nebraska DHHS Licensure Unit Attn: [insert relevant profession] PO Box 94986 Lincoln, NE 68509-4986 Tel: (402) 471-3121 |
|
New Hampshire |
You understand that the provider may forward your medical records to your primary care or treating provider. N.H. Rev. Stat. § 329:1-d. |
Office of Professional Licensure & Certification 7 Eagle Square Concord, NH 03301 Tel: (603) 271-2152 |
|
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. |
New Jersey Board of Medical Examiners 140 East Front Street PO Box 183 Trenton, New Jersey 08608 Tel: (609) 826-7100 Email: bme@dca.lps.state.nj.us |
| Ohio | You understand that the provider may forward your medical records to your primary care or treating provider. Ohio Admin. Code 4731-37-01(C)(4). |
Ohio Medical Board Tel: (614) 466-3934, option 1 Email: complaints@med.ohio.gov State Medical Board of Ohio’s Confidential Complaint Hotline Tel: (833) 333-SMBO (7626) |
| 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). Complaints may be filed with: Oregon Medical Board Complaint Resource Staff: 971-673-2702 | complaintresource@omb.oregon.gov |
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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. |
Rhode Island Board of Medical Licensure and Discipline Department of Health 3 Capitol Hill, Room 401 Providence, RI 02908 Phone: (401) 222-3855 Fax: (401) 222-2158 |
|
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. |
South Carolina Board of Medical Examiners 110 Centerview Drive, Suite 202 Columbia, SC 29210 Tel: (803) 896-4500 Fax: (803) 896-4515 Email: Medboard@llr.sc.gov |
|
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. |
South Dakota Board of Medical and Osteopathic Examiners 101 N. Main Avenue, Suite 301 Sioux Falls, SD 57104 Tel: (605) 367-7781 Email: Sdbmoe@state.sd.us |
| 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 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 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 cirugía, 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. |
Texas Medical Board Attn: Investigations 333 Guadalupe, Tower 3, Suite 610 P.O. Box 2018, MC-263 Austin, TX 78768-2018 Tel: (800) 201-9353 Website: 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. |
Utah Medical Board Tel: (801) 530-6628 Fax: (866) 275-3675 Email: b1@utah.gov |
| 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 [PC] 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. |
Virginia Department of Health Professions Enforcement Division Perimeter Center 9960 Mayland Drive, Suite 300 Henrico, VA 23233-1463 Tel: 1-800-533-1560 or (804) 367-4691 Fax: (804) 212-2174 |
| Vermont |
If you want to file a formal complaint about a physician (MD), you should visit the medical board’s website here: http://www.healthvermont.gov/health-professionals-systems/board-medical-practice/file-complaint You can file a complaint about an osteopathic physician here: https://sos.vermont.gov/opr/complaints-conduct-discipline/#emr 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 MDI 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. |
Office of Professional Regulation Attn: Director of the Office 89 Main Street, 3rd Floor Montpelier, VT 05620-3402 Tel: (802) 828-1505 |
