.avif)
Telehealth Consent From
THIS NOTICE IS EFFECTIVE ON JUNE 1, 2026
By reading and signing this document, I, the undersigned patient (or authorized representative) consent to and authorize a second opinion consultation via telehealth rendered to the patient receiving treatment (the “Patient”) by a Motion Medical Group, LLC (the “Practice”) physician or other health care provider. The Patient understands that all services provided by Practice are governed by the Practice’s Terms and Conditions, available at www.motiomsk.com/terms-and-conditions-06-01-2026 (the “Terms and Conditions”).
All disputes, if any, arising from the telehealth visit(s) will be resolved in the manner set forth in the Terms and Conditions.
1. DESCRIPTION OF TELEHEALTH VISIT. The Patient has elected to receive a telehealth visit by the Practice (the “Visit”). Telehealth is the delivery of healthcare services when the healthcare provider and the undersigned patient or such patient’s authorized representative (in either case, the “Patient”) are not in the same physical location and communicate through the use of technology. Electronically-transmitted information may be used for diagnosis, therapy, follow-up, certain prescription refills and/or patient education and may include medical records, medical images, interactive audio, video and/or data communications, and output data from medical devices and sound and video files. The Patient agrees that a Practice provider will determine whether the consultation is appropriate for telehealth. The Patient has elected for the Practice’s consulting physician solely to provide a second opinion. Neither the Practice nor the Practice’s consulting physician or other provider is assuming primary responsibility for the Patient’s ongoing care, and the Practice’s consulting physician or other provider will not prescribe medications during the encounter. Any clinical decisions regarding Patient’s treatment remain the Patient’s to make in consultation with the Patient’s treating physician(s).
2. POTENTIAL RISKS AND LIMITATIONS. There are potential risks and limitations associated with the use of telehealth, including, but not limited to: the Practice provider will not perform a physical examination and technical difficulties (loss of audio, video, or connectivity) may interrupt or delay the consultation. Telehealth is not appropriate for medical emergencies—if Patient experiences a medical emergency or a situation that could reasonably develop into an emergency, call 911 immediately or go to the nearest emergency room.
3. LOCATION OF SERVICES. The Patient understands that a patient must be physically located in the state where the Practice’s consulting provider is licensed during his or her telehealth consultation(s). The Patient understands that if he or she is not physically located in a state where the Practice’s provider is licensed, the Practice provider will decline to treat him or her via telehealth. You will be asked the Patient’s physical location prior to the telehealth visit, and you represent and warrant that you will accurately provide the Patient’s physical location for the duration of the telehealth visit.
4. COMMUNICATION/CONFIDENTIALITY. I authorize the Practice to communicate Patient’s clinical information, diagnoses and other sensitive information via a secure platform designated by the Practice and as further provided for in the Terms and Conditions. The Patient understands that telehealth visits may be recorded and that telehealth may involve electronic communication of the Patient’s health information, including, but is not limited to, the Patient’s personal, identifying information; medical history; diagnoses; communications to and from the Patient’s health care provider(s); etc. The Patient will be afforded the right to inspect all information obtained and recorded in the course of a telehealth visit. The Patient acknowledges receipt of a copy of the Practice’s Notice of Privacy Practices, available at https://www.motionmsk.com/privacy-policy-06-01-2026, which governs the Practice’s responsibilities and my rights and choices related to the Patient’s health information. The Practice reserves the right to disclose my health information as described in the Notice of Privacy Practices. In choosing to participate in a telehealth visit, the Patient understands that some parts of the exam may require physical testing to be performed at another location at the direction of the Practice provider. The Patient understands that, if others are present at Patient’s location during the Patient’s telehealth visit, the confidentiality of the Patient’s telehealth visit may be compromised. The Patient understands that health information may be lost due to technical failures and agrees to hold Practice harmless for any such loss.
5. ARTIFICIAL INTELLIGENCE. The Practice may use artificial intelligence (AI) technologies for administrative and operational purposes, including intake processing, text messaging, scheduling, and documentation support. AI tools do not independently make clinical decisions about your diagnosis or treatment. All clinical opinions and recommendations are made by licensed healthcare professionals who exercise independent medical judgment.
6. MOTION MEDICARE OPT OUT ACKNOWLEDGEMENT. I understand Motion MSK providers are opted out of Medicare. Motion MSK providers will notify me in advance of any appointment for which they will bill me for services, and I will have the opportunity to execute a private pay contract prior to receiving any billed service. I understand that I am not obligated to receive any such services.
The Patient has been advised of all the potential limitations, risks, alternatives and benefits of telehealth. The Patient’s Practice provider has discussed with him or her the information provided above and the Patient has had the opportunity to ask questions about the information presented on this form and the telehealth visit(s). All the Patient’s questions have been answered, and he or she understands the written information provided above and the explained to him or her. By signing this form, I certify that I have read, understand, and agree to its contents, including consenting to the rendition of medical services to the Patient by the Practice and agreeing to the Terms and Conditions. I represent, warrant, and agree that I am authorized to consent to the rendition of such services. I understand that I may revoke my consent in writing.