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

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.

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:

www.mbc.ca.gov,

email: licensecheck@mbc.ca.gov,

or call (800) 633-2322.

***

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

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

Email: dora_medicalboard@state.co.us

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

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

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

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

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

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

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

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

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

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

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

www.maine.gov/professionallicensing

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

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

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

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)

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

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

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

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

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

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

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

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