AC Wellness Consent to Care: State-Specific Disclosures
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What You Should Know
Your primary care provider may obtain a copy of the records associated with your telehealth encounter.
Who To Contact with Questions or Concerns
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
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What You Should Know
You understand that all medical records resulting from a telemedicine consultation are part of your medical record.
Who To Contact with Questions or Concerns
Arizona Medial Board
1740 West Adams Street, #3600
Phoenix, AZ 85007
Tel: (480) 551-2700
Fax: (480) 551-2702
Email: Submit form here.
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What You Should Know
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 go to:
email: licensecheck@mbc.ca.gov,
or call (800) 633-2322.
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The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and https://openpaymentsdata.cms.govteaching hospitals. It can be found at https://openpaymentsdata.cms.gov/
Who To Contact with Questions or Concerns
Medical Board of California
Consumer Information Unit
2005 Evergreen Street, Suite 1200
Sacramento, CA 95815
Tel: (800) 633-2322
Fax: (916) 263-2944
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What You Should Know
You are informed that if you want to register a formal complaint about a provider, you should file it at: https://dpo.colorado.gov/FileComplaint.
Who To Contact with Questions or Concerns
Colorado Medical Board
1560 Broadway, Suite 1350
Denver, Colorado 80202
Tel: (303) 894-7800
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What You Should Know
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 concerting 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.
Who To Contact with Questions or Concerns
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
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What You Should Know
You have been informed of alternate forms of communication between you and a physician for urgent matters. Relevant communications with the physician, including those done via electronic methods shall be documented and filed in your medical record.
Who To Contact with Questions or Concerns
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
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What You Should Know
You have been given clear, appropriate, accurate instructions on follow-up in the event of needed emergent care related to the treatment.
Who To Contact with Questions or Concerns
Georgia Composite Medical Board
2 Peachtree Street, NW, 6th Floor
Atlanta, GA 30303-3465
Email: medbd@dch.ga.gov
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What You Should Know
If you need to register a formal complaint about a physician, you may visit the medical board’s website here. You understand that your informed consent for the use of telehealth services shall be obtained by applicable law.
Who To Contact with Questions or Concerns
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
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What You Should Know
If you need to register a formal complaint about a professional regulated under the Illinois Division of Professional Regulation, you may file a formal complaint here: https://www.idfpr.com/admin/DPR/DPRcomplaint.asp.
Who To Contact with Questions or Concerns
Illinois Department of Financial & Professional Regulation (Chicago Office)
555 West Monroe St., 5th Floor
Chicago, IL 60661
Illinois Department of Financial & Professional Regulation (Springfield Office)
320 W. Washington Street, 3rd Floor
Springfield, IL 62786
Tel: (888) 473-4858
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What You Should Know
If you want to register a formal complaint about a physician, you should visit the medical board’s website, here: https://www.in.gov/attorneygeneral/2434.htm
Who To Contact with Questions or Concerns
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
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What You Should Know
To file a complaint, fill in the form below or fill out the complaint form and email it to the medical board at ibmcomplaints@iowa.gov.
Who To Contact with Questions or Concerns
Iowa Board of Medicine
400 SW 8th St., Suite C
Des Moines, IA 50309
Tel: (515) 281-5171
Email: ibmcomplaints@iowa.gov
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What You Should Know
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 AC Wellness On Demand provider during the telemedicine encounter.
The process for filing a complaint may be found here: http://www.ksbha.org/complaints.shtml
Who To Contact with Questions or Concerns
Kansas Board of the Healing Arts
800 SW Jackson, Lower Level - Suite A
Topeka, KS 66612
Tel: (785) 296-7413
Fax (785) 368-7102
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What You Should Know
You understand that if you have a 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.
Information related to filing grievances may be found here: https://kbml.ky.gov/grievances/Documents/Information%20on%20Filing%20A%20Grievance.pdf
Who To Contact with Questions or Concerns
Kentucky Board of Medical Licensure
310 Whittington Parkway, Suite 1B
Louisville, KY 40222
Tel: (502) 429-7150
Fax: (502) 429-7158
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What You Should Know
You understand the role of other health care providers that may be present during the consultation, other than the AC Wellness On Demand provider with whom you are connected.
Who To Contact with Questions or Concerns
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
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What You Should Know
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/discipline/file-complaint.html
Who To Contact with Questions or Concerns
Complaint Coordinator Office of Licensing and Registration
35 State House Station
Augusta, ME 04333
Tel: (207) 624-8660
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What You Should Know
The knowledge, experiences, and qualifications of the consultant providing data and information to the provider of the telehealth services need not be completely known to and understood by the provider. The quality of transmitted data may affect the quality of services provided by the provider. Changes in the environment and test conditions could be impossible to make during delivery of telehealth services. Telehealth services may not be provided by correspondence only.
If you want to register a formal complaint about a physician, you should visit the medical board’s website, here: https://www.mbp.state.md.us/resource_information/faqs/resource_faqs_complaints.aspx
Who To Contact with Questions or Concerns
Maryland Board of Physicians
4201 Patterson Avenue
Baltimore, MD 21215
Tel: (410) 764-4777
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What You Should Know
You understand that the provider may forward your medical records to your primary care or treating provider.
Who To Contact with Questions or Concerns
Office of Professional Licensure & Certification
7 Eagle Square
Concord, NH 03301
Tel: (603) 271-2152
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What You Should Know
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.
Who To Contact with Questions or Concerns
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
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What You Should Know
You understand that the provider may forward your medical records to your primary care or treating provider.
Who To Contact with Questions or Concerns
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)
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What You Should Know
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: http://www.okmedicalboard.org/complaint.
Board of Osteopathic Examiners can be found at: https://www.ok.gov/osboe/faqs.html
Who To Contact with Questions or Concerns
Oklahoma State Board of Licensure and Supervision
101 NE 51st Street
Oklahoma City, OK 73105
Tel: (405) 962-1400
Oklahoma State Board of Osteopathic Examiners
4848 North Lincoln Blvd., Suite 100
Oklahoma City, OK 73105
Tel: (405) 528-3340
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What You Should Know
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.
Who To Contact with Questions or Concerns
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
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What You Should Know
You understand your medical records may be distributed in accordance with applicable law and regulation to other treating health care practitioners.
Who To Contact with Questions or Concerns
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
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What You Should Know
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.
Who To Contact with Questions or Concerns
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
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What You Should Know
You understand that you may request an in-person assessment before receiving a telehealth assessment if you are a telehealth recipient.
Who To Contact with Questions or Concerns
Tennessee Department of Health
710 James Robertson Parkway
Nashville, TN 37243
Tel: (615) 532-3202
Email: tn.health@tn.gov
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What You Should Know
You understand that your medical records may be sent to your primary care physician.
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 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
Who To Contact with Questions or Concerns
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
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What You Should Know
You understand (i) the fees that may be charged to you for the telehealth service; (ii) to whom your health information may be disclosed and for what purpose, and have received information on any consent governing release of your patient-identifiable information to a third-party; (iii) your rights with respect to patient health information; (iv) appropriate uses and limitations of the site, including emergency health situations. You were warned of potential risks to privacy notwithstanding the security measures and that information may be lost due to technical failures, and agree to hold the provider harmless for such loss. You have been provided with the location of AC Wellness’s website and contact information. You understand that you are able to select a provider of your choice, to the extent possible. You are able to select a pharmacy of choice. You are able to a (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.
Who To Contact with Questions or Concerns
Utah Medical Board
Tel: (801) 530-6628
Fax: (866) 275-3675
Email: b1@utah.gov
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What You Should Know
Upon the Office of Professional Regulation’s receipt of a complaint, an administrative review determines if the issues raised are covered by the applicable professional conduct statute. If so, a committee is assigned to investigate, collect information, and recommend action or closure to the appropriate governing body. All complaint investigations are confidential. Should the investigation conclude with a decision for disciplinary action against a professional’s license and ability to practice, the name of the license holder will then be made public.
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 a osteopathic physician here: https://www.sec.state.vt.us/professional-regulation/file-a-complaint-employer-mandatory-reporting.aspx
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.
Who To Contact with Questions or Concerns
Office of Professional Regulation
Attn: Director of the Office
89 Main Street, 3rd Floor
Montpelier, VT 05620-3402
Tel: (802) 828-1505