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strict";a.d(t,{Gz:()=>r,e6:()=>l,F6:()=>s,l2:()=>d,YG:()=>c});var o=a(37876),n=a(15030),i=a.n(n);function r(e){let{title:t,htmlContent:a}=e;return(0,o.jsx)("div",{className:i().outer,children:(0,o.jsxs)("div",{className:i().container,children:[(0,o.jsx)("header",{className:i().titleBlock,children:(0,o.jsx)("h1",{className:i().titleLabel,children:t})}),(0,o.jsx)("div",{className:i().content,dangerouslySetInnerHTML:{__html:a}})]})})}let s="Health Information Exchange Patient Form",l='\n<p>A Health Information Exchange ("HIE") is a safe way for healthcare providers to get the most up-to-date health information. The HIE will allow FlyteHealth to access or share your health information with other healthcare providers (internally at FlyteHealth and externally with other clinical providers who are overseeing your health care conditions). This may improve your overall clinical care through the use of an electronic medical record that either FlyteHealth manages, or other third party systems that your additional clinical care providers submit information to or manage themselves. By signing this form, you are agreeing that your personal health information, including test results, lab reports, X-rays/imaging studies, medication lists, or any other relevant personal health information, may be shared across participating healthcare organizations and clinical providers, including FlyteHealth.</p>\n\n<p>You acknowledge that you have read this form, were given the opportunity to ask questions, and received answers that you understood.</p>\n\n<p>1. I understand that I may revoke this authorization at any time by <strong>submitting a written request</strong> to my clinical provider and FlyteHealth. I understand that if I withdraw authorization, no new health information may be shared with the other clinical providers and their supporting staffs, including FlyteHealth, and may not be used unless it has already been used in reliance on my previous authorization. This authorization will be shortened, extended, or will cease to be effective on the date the written instructions are received except to the extent action it has already been taken in reliance upon it.</p>\n\n<p>2. I understand that personal health information used or disclosed pursuant to this HIE authorization may be subject to re-disclosure by the recipient outside of FlyteHealth and no longer be protected by state or federal privacy regulations. However, other state or federal laws may prohibit the recipient from disclosing specially protected information, such as substance abuse treatment information, HIV/AIDS-related information, and psychiatric/mental health information.</p>\n\n<p>3. I understand that my refusal to sign this HIE authorization will not jeopardize my right to medical treatment from FlyteHealth or payment for my medical treatment except where disclosure of my health information is required for the provision of medical treatment or to obtain payment for medical treatment.</p>\n\n<h5>Use of Personal Health Information</h5>\n\n<p>These are the following details related to the electronic personal health information exchanged (accessed or shared) through <strong>AthenaOne</strong> (the electronic medical records platform used by FlyteHealth and integrated with the FlyteHealth patient application); <strong>CommonWell</strong>, a not-for-profit trade association devoted to the simple vision that health data should be available to individuals and caregivers regardless of where care occurs <a href="https://www.commonwellalliance.org/about" target="_blank" rel="noopener noreferrer">https://www.commonwellalliance.org/about</a> ; and <strong>Care Quality</strong>, the interoperability framework that is connecting health information networks throughout the United States of America ( <a href="https://carequality.org" target="_blank" rel="noopener noreferrer">https://carequality.org</a> ) and your HIE consent process:</p>\n\n<p><strong>1. How Your Information May be Used.</strong> Your electronic personal health information will be used by the organizations, clinical providers, or programs set forth above only to:</p>\n\n<ul>\n  <li>Provide you with medical treatment and related services.</li>\n  <li>Check whether you have health insurance and what it covers.</li>\n  <li>Conduct care management activities to assist you in obtaining appropriate medical care, improving the quality of medical treatment services provided to you, coordinating the provision of multiple healthcare services provided to you, or supporting you in following a plan of medical treatment and clinical care.</li>\n  <li>Evaluate and improve the quality of medical care provided to all patients.</li>\n  <li>Limited to AthenaOne: Support research directly related to the COVID-19 Public Health Emergency, as permitted by law through the duration of the public health emergency.</li>\n</ul>\n\n<p>Unless otherwise permitted by state and federal law, your electronic personal health information shall be disclosed, accessed, and used by healthcare insurance plans (commercial, Medicare, and self insured employers) who are affiliated with FlyteHealth only to:</p>\n\n<ul>\n  <li><strong>Provide Care Management Activities.</strong> These include assisting you in obtaining appropriate medical treatment and clinical care, improving the quality of healthcare services provided to you, coordinating the provision of multiple health care services provided to you, or supporting you in following a plan of medical treatment and clinical care.</li>\n  <li><strong>Provide Quality Improvement Activities.</strong> These include evaluating and improving the quality of medical treatment and clinical care provided to you and all FlyteHealth patients and members.</li>\n</ul>\n\n<p><strong>NOTE:</strong> The choice you make in this HIE Consent Form does NOT allow health insurance companies or your employer to have access to your individual information for the purpose of deciding whether or not to provide you with health insurance coverage or pay your medical bills.</p>\n\n<p><strong>2. What Types of Information About You Are Included.</strong> When you give your HIE consent, the health information exchange services and electronic medical record platforms listed above may access ALL of your electronic personal health information available in your FlyteHealth electronic medical records. This includes all participating organizations and all employees, agents, and members of the medical staff of FlyteHealth and affiliated entities with FlyteHealth. This includes personal health information created before and after the date of this HIE Consent Form. Your personal health records may include a history of illnesses or injuries you have had (e.g., diabetes or a broken bone), test results (e.g., X-rays or blood tests), and lists of medicines you have taken.</p>\n\n<p>This information may relate to sensitive health conditions, including but not limited to:</p>\n\n<ul>\n  <li>Alcohol or drug use problems</li>\n  <li>Allergies</li>\n  <li>Birth control and abortion (family planning)</li>\n  <li>Claims Encounter Data</li>\n  <li>Clinical notes</li>\n  <li>Diagnostic Information</li>\n  <li>Discharge summary</li>\n  <li>Employment Information</li>\n  <li>Genetic (inherited) diseases or tests</li>\n  <li>HIV/AIDS</li>\n  <li>Lab Test</li>\n  <li>Living Situation</li>\n  <li>Medication and Dosages</li>\n  <li>Mental health conditions</li>\n  <li>Sexually transmitted diseases</li>\n  <li>Social Supports</li>\n  <li>Substance use history summaries</li>\n</ul>\n\n<p><strong>3. Effective Period.</strong> This HIE Consent Form will remain in effect until the day you change your consent choice, death, or until such time as the applicable HIE ceases operation. If consent is signed by a parent or legal guardian of a minor, the consent decision will expire on the 18th birthday when the minor becomes an adult, and the patient will have to file a new consent decision. If any FlyteHealth affiliated health information exchange merges with another health information exchange, your consent choices will remain effective with the newly merged entities.</p>\n\n<p><strong>4. Where Health Information About You Comes From.</strong> Information about you comes from places that have provided you with medical care or health insurance ("Information Sources"). These may include hospitals, physicians, nurse practitioners, nurses, medical assistants, registered dietitians, pharmacies, clinical laboratories, health insurers, Medicare (if applicable), Medicaid (if applicable), and other health organizations that exchange personal health information electronically.</p>\n\n<p><strong>5. Who May Access Information About You, If You Give Consent.</strong> Physicians, nurse practitioners, nurses, medical assistants, registered dietitians, pharmacies, clinical laboratories, health insurers, Medicare (if applicable), Medicaid (if applicable), employees, trainees, students, volunteers, and agents other health organizations that you have given consent to access your personal health information electronically in order to carry out activities permitted in this HIE Consent Form as described above.</p>\n\n<p><strong>6. Public Health and Organ Procurement Organization Access.</strong> Federal, state, or local public health agencies and certain organ procurement organizations are authorized by law to access personal health information without a patient’s consent for certain public health and organ transplant purposes. These entities may access your information for these purposes without regard to whether you give consent, deny consent, or do not fill out a consent form.</p>\n\n<p><strong>7. Penalties for Improper Access to or Use of Your Information.</strong> There are penalties for inappropriate access to or use of your electronic personal health information. If at any time you suspect that someone who should not have seen or gotten access to information about you has done so, you can contact the FlyteHealth Privacy Officer by calling <a href="tel:844-359-8363">844-359-8363</a>. If at any time you suspect that someone should not have seen or gotten access to information about you, you can contact us <a href="mailto:compliance@flytehealth.com">compliance@flytemedical.com</a>.</p>\n\n<p><strong>8. Re-disclosure of Information.</strong> Any organization(s) you have given consent to access personal health information about you in the HIE Consent Form may re-disclose your health information, but only to the extent permitted by state and federal laws and regulations. Alcohol/drug treatment-related information or confidential HIV-related information may only be accessed and may only be re-disclosed if accompanied by the required statements regarding prohibition of re-disclosure.</p>\n\n<p><strong>9. Changing Your Consent Choice.</strong> You can change your consent at any time by signing a new HIE Consent Form with your new choice. You can obtain the HIE Consent Form from by contacting FlyteHealth at <strong><a href="mailto:mymedicalrecords@flytehealth.com">mymedicalrecords@flytehealth.com</a></strong> for us to update your HIE Consent designations.</p>\n\n<p><strong>10. Copy of Your HIE Consent Form.</strong> You are entitled to get a copy of this HIE Consent Form at any time by sending an email <strong><a href="mailto:mymedicalrecords@flytehealth.com">mymedicalrecords@flytehealth.com</a>.</strong></p>\n\n<p><strong>Note:</strong> Organizations, including any clinical providers that participate in the health information exchanges noted above, that access your personal health information as noted in this HIE Consent Form, while your consent is in effect, may save, copy, or include your personal health information in their own medical records. Even if you later decide to withdraw your HIE consent with FlyteHealth, the affiliated health information exchange platforms and clinical providers who access them are not required to return your personal health information to you or remove it from their records.</p>\n\n<p>I understand that I can request a copy of this HIE Consent Form after I sign it. A photocopy of this form will be considered as valid as the original. I hereby acknowledge that I have received my clinical provider’s Healthcare Information Exchange Patient Authorization. I agree to the terms of this authorization. This HIE Consent Form applies and extends to subsequent telehealth visits and appointments with all FlyteHealth affiliated clinical providers.</p>\n\n<h5>You have the following choices:</h5>\n\n<p>By clicking <strong>ACCEPT</strong> you agree that <strong>I GIVE CONSENT</strong> to ALL of the organizations, clinical providers, and programs explained in this HIE Consent Form to access ALL of my electronic personal health information. And, I GIVE CONSENT to ALL employees, agents and members of the medical staffs of FlyteHealth and affiliated entities to access ALL of my electronic personal health information through all of the organizations, clinical providers, and programs explained in this HIE Consent Form, including AthenaOne, CommonWell, and Care Quality, in connection with any of the permitted purposes described in the fact sheet, including providing me any healthcare services and medical treatment.</p>\n\n<p>By clicking <strong>DECLINE</strong> you agree that <strong>I DENY CONSENT</strong> to the organizations, providers, and programs explained in this Authorization Form that would otherwise require my consent to access my electronic personal health information in my FlyteHealth medical record, and I DENY CONSENT to employees, agents and members of the medical staff of FlyteHealth and affiliated entities to access my electronic personal health information for any purpose, even in a medical emergency.</p>\n',c="Patient Consent Form Policy",d='\n<p>Thank you for choosing FlyteHealth as your healthcare provider. We realize you have a choice in selecting healthcare providers and we are honored you have chosen us. Our staff is committed to providing our patients with high-quality and compassionate care. As part of our relationship with you, it is important that you understand your consent to be treated and any financial responsibilities with respect to your health care. Please contact us if you have any questions, concerns, or suggestions.</p>\n\n<p>Before you can schedule your initial visit with a FlyteHealth clinical provider and receive treatment, please download and use the FlyteHealth patient application and submit the one or more of the following pieces of information:</p>\n\n<ul>\n  <li>Your first name, last name, street address, city, state, postal code, email address, mobile phone number;</li>\n  <li>Your health insurance card - may not be required if you are part of an employer-sponsored program;</li>\n  <li>Your driver’s license or passport - may not be required if you are part of an employer-sponsored program;</li>\n  <li>Your most recent labs (blood panel within the last 12 months). If you do not have recent labs or need additional labs for this type of care, please contact our FlyteHealth office;</li>\n  <li>A health information exchange (“HIE”) consent form to release your medical records for our FlyteHealth clinical team to collaborate and share protected health information with your existing doctors and health systems;</li>\n  <li>Answer FlyteHealth’s health assessment questionnaires (“HRA”) to establish a baseline for our FlyteHealth clinical team to assess your current overall health and weight health.</li>\n</ul>\n\n<p>All of this information will be saved within FlyteHealth’s patient application and electronic health records platform as part of your patient record which you can access at any time through a secure internet connection.</p>\n\n<p>During the course of your clinical care, several of these pieces of information will need to be updated annually. FlyteHealth will send you electronic messages via email or through secure mobile text messages to update this information in the FlyteHealth patient application.</p>\n\n<p><strong>IF YOU ARE EXPERIENCING A MEDICAL EMERGENCY, DIAL 911 OR PROCEED TO THE NEAREST EMERGENCY DEPARTMENT IMMEDIATELY. FlyteHealth does not provide emergency medical treatment. If you are experiencing a behavioral health crisis, there are additional options to get help, including contacting your local crisis center, calling or texting the 988 Lifeline at 988, or contacting the Crisis Text Line (text “HOME” to 741741).</strong></p>\n\n<h3>Consent to be Treated</h3>\n<p>Your signature below indicates your voluntary and informed consent to the rendering of medical treatment by FlyteHealth’s clinical providers and affiliated staff based upon their professional judgment, and also indicates your agreement with the terms contained herein.</p>\n\n<p>When you initiate a telehealth visit (a “virtual visit”) with a FlyteHealth clinical provider, you hereby consent to participate in such telehealth visit, its recording by FlyteHealth, and you understand you may terminate such virtual visit at any time by leaving the visit. There are various benefits associated with telehealth services, including improved access to medical treatment and clinical care by enabling our patients to remain in their home or office while consulting with a FlyteHealth clinical provider. There are risks, as well though, such as certain privacy risks and some limitations on a provider’s ability to perform a physical examination. A provider may refer you to in-person or a higher level of care, if indicated. FlyteHealth’s goal is to provide you with efficient clinical care evaluation and medical management.</p>\n\n<p>During any visit with FlyteHealth, you attest that the physical location information you provide is accurate and current for the duration of the session. You agree that you will not record, photograph, screen-capture, or otherwise attempt to store any part of any visit with FlyteHealth.</p>\n\n<p>FlyteHealth’s staff is composed of licensed physicians, nurse practitioners, and registered dieticians who are supported by medical assistants, nurses, wellness coaches, and patient care coordination personnel. Where required, FlyteHealth’s clinical providers may be practicing under collaboration, supervision, or delegation agreements, in accordance with applicable state law.</p>\n\n<p>The medical treatment services provided by FlyteHealth may also include medical chart review, medication prescribing, medication refill reminders, health information sharing with other clinical professionals not directly affiliated with FlyteHealth, and non-clinical services, such as appointment scheduling and patient education.</p>\n\n<p>The electronic communication systems FlyteHealth uses will incorporate secure, encrypted network and software security protocols to protect the confidentiality of patient identification and imaging data. FlyteHealth implements measures to safeguard your protected health information to ensure its integrity against intentional or unintentional corruption consistent with our obligations under applicable federal and state laws.</p>\n\n<p>Group Nutrition Visits (if applicable): If you qualify for and choose to participate in a Group Nutrition Visit (“GNV”), you understand that GNVs are led by a facilitator who does not provide medical diagnosis or treatment. You agree to continue to rely on your treating provider for medical advice. You understand GNVs will be conducted via a video call system and is a group meeting, and that therefore, there are inherent privacy and other risks, including that other participants will see you and hear information about you, and that there is a chance other people may overhear the conversation. You acknowledge that other participants will be asked to keep participant identities confidential, but they are under no legal obligation to do so. By participating in a GNV, you agree to hold FlyteHealth, its staff, and the facilitator harmless from liability arising from another participant’s disclosure of your information. You agree to join GNVs from a private, secure space and use headphones or earbuds if others may overhear; and I will not disclose the names, personal details, health information, or any other information about any other participant.</p>\n\n<h3>Risks of Treatment</h3>\n<p>You acknowledge that neither a FlyteHealth clinical provider, nor any of his or her staff have made any guarantee or promise as to the results that you will obtain from our medical treatment.</p>\n\n<p>Possible risks associated with your medical treatment and ongoing care include those risks associated with any medications prescribed, underlying health conditions, or medical or diagnostic procedures. Additional risks include delays in clinical evaluation and immediate treatment due to deficiencies or failures of the medical equipment and technologies FlyteHealth clinical providers use to care for you. In rare events, our clinical providers may determine that your transmitted information is of inadequate quality or reflects an elevated health concern, or that your condition requires in-person examination, thus necessitating a rescheduled telehealth visit with your FlyteHealth clinical provider or a recommended clinical visit with your primary care physician or specialist.</p>\n\n<h3>Your Telehealth Provider’s Credentials</h3>\n<p>Your FlyteHealth clinical provider’s credentials are made available to you before scheduling a telehealth appointment. If you have any questions about your FlyteHealth provider’s credentials, please direct them to <a href="mailto:support@flytehealth.com">support@flytehealth.com</a>. For those states that require it, you can find an explanation of the levels of regulation applicable to mental health clinicians under the STATE REGULATIONS section of this document.</p>\n\n<h3>Consent to Contact</h3>\n<p>You understand that your FlyteHealth clinical provider and FlyteHealth staff may contact you based upon the contact information you have provided to FlyteHealth, and you consent to such contact which may be delivered through phone calls/voicemails (mobile and landline phone numbers on file), emails (email address on file), and/or secure mobile text messaging (mobile phone number on file). This consent and permission includes (1) to leave answering machine and voicemail messages for me, and include in such messages any information required by law (including debt collection laws) and/or information regarding amounts owed by me; (2) to send me text messages or emails using any email addresses or cellular device numbers I have provided; (3) to send me paperless billing statements or other information by email or text notification; (4) to use pre-recorded/artificial voice messages, and (5) to use an automatic dialing device in connection with these communications. I represent that I am the owner of the phone number(s) provided and have the authority to grant the permission and consent to contact as provided herein.</p>\n\n<p>These communications may notify you of the availability of your care summaries (after visit summary), or of treatment instructions or recommendations, test results, outstanding balances, or any other communications from your provider. By seeking treatment with FlyteHealth, you are consenting to these means of communication, but you may opt out of receiving any or all of these types of communications by notifying a member of our team in writing.</p>\n\n<h3>Recommended Devices to Support Your Care</h3>\n<p>While receiving care from a FlyteHealth clinical provider, it may be recommended for you to utilize a FlyteHealth issued cellular weight scale and/or blood pressure cuff with a heart rate monitor for our clinical staff to monitor your health progress. These devices automatically sync your health information results data with our FlyteHealth patient application and electronic health record platform, each time you use them. The synced health information results data will be used by our FlyteHealth clinical provider and supporting clinical care team to measure and manage your medical treatment, and these measurement results will be discussed with you during the course of your clinical care.</p>\n\n<p>For patients who have bluetooth devices (e.g., weight scales, heart rate monitors, Apple Health Kit watches/mobile phones/tablets, or Google Fit watches/mobile phones/tablets) that are approved by FlyteHealth to sync health information data with the FlyteHealth patient application, these synced health information results data will be used by our FlyteHealth clinical provider and supporting clinical care team to measure and manage your medical treatment, and these measurement results will be discussed with you during the course of your clinical care.</p>\n\n<p>It is important that only your data is provided to FlyteHealth, and that you do not allow others to use or sync their data with your patient profile at FlyteHealth.</p>\n\n<p>If you need any assistance with connecting cellular or bluetooth devices with the FlyteHealth patient application, please contact <a href="mailto:support@flytehealth.com">support@flytehealth.com</a>.</p>\n\n<p>As a patient of FlyteHealth, you may request a copy of your medical records, or to have FlyteHealth send your personal medical records to another healthcare provider. Any request for your medical records can be submitted to our staff by filling out a Medical Record Release form which can be obtained at <a href="https://www.joinflyte.com/health-information-exchange-consent" target="_blank" rel="noopener noreferrer">mymedicalrecords@flytehealth.com</a>.</p>\n\n<h3>Financial Responsibility - Commercial Health Insurance Carrier or Self-Payment</h3>\n<p>Patients are ultimately responsible for all charges for medical treatment services and devices provided by FlyteHealth. You acknowledge you have requested medical treatment services from FlyteHealth, for yourself and/or your dependents, and understand that by making this request for medical treatment you become financially responsible for any and all charges incurred.</p>\n\n<p>Payment is expected at the time of the telehealth visit for all charges owed as well as any prior balance owed by you or your dependent as a patient of FlyteHealth. When FlyteHealth is provided information from your commercial insurance carrier on patient responsibility, we may request payment for that amount before the start of the telehealth visit. For any payment collected prior to medical treatment services being rendered, including telehealth visits, it will be applied toward total charges for your telehealth visits. If there is a difference in the amount provided up-front as part of the patient responsibility, an invoice statement will be sent to you for any balance due to FlyteHealth.</p>\n\n<h3>Financial Responsibility - Employer Sponsored Plans</h3>\n<p>For patients enrolled in a self-funded, Employer Sponsored Plan, your employer (the “Employer Payer”) is ultimately responsible for all charges for services provided by FlyteHealth for medical treatment services provided to you or your dependents.</p>\n\n<p>You and your dependents acknowledge you are eligible and have requested medical treatment services from FlyteHealth on behalf of yourself and/or your dependents, and you understand that by making this request, the Employer Payer has become financially responsible for any and all charges incurred in the course of the medical treatment authorized.</p>\n\n<p>Payment by an Employer Payer will occur based upon your Employer Payer’s agreement terms with FlyteHealth and your Employer Payer shall be responsible for payments to FlyteHealth for all charges owed as well as any prior balance. When and if we are provided information from your Employer Payer who requires direct patient responsibility for payment in addition to what your Employer Payer is contracted to pay FlyteHealth for medical treatment services rendered to you and/or your dependents, we may request payment from you for that amount before the start of the telehealth visit or medical treatment services. For any payment collected prior to a telehealth visit or medical treatment services being rendered, it will be applied toward total charges for your telehealth visits or medical treatment services. If there is a difference in the amount provided up-front as patient responsibility, an invoice statement will be sent to you for any balance due to FlyteHealth in addition to the payments made to FlyteHealth by your Employer Payer.</p>\n\n<h3>Guarantee of Payment</h3>\n<p>In consideration of the medical treatment services provided by your FlyteHealth clinical provider, except for Employer Sponsored Plan participants, you agree that you are responsible for all charges for medical treatment services, including devices you receive that are not covered by your commercial health insurance carrier plan. You are responsible for understanding the benefits and limitations of your commercial health insurance carrier plan and are expected to pay the entire amount determined by your commercial health insurance carrier plan to be the patient’s responsibility. FlyteHealth will provide medically necessary clinical care based on a patient\'s needs, not a patient’s insurance coverage. FlyteHealth is not responsible for knowing your plan’s specific benefit and coverage limitations.</p>\n\n<h3>Scheduling and Cancellation Notification (No Show Fee)</h3>\n<p>Please be advised, as a courtesy, you will receive an automated email and/or call to the primary phone number listed on file with FlyteHealth to remind you of your telehealth visit appointment date and time.</p>\n\n<p>If you need to reschedule your telehealth visit appointment, please call the FlyteHealth office at 844-359-8363 forty-eight (48) hours in advance to change your telehealth visit appointment in order for you to reschedule your telehealth visit appointment and not be charged a fee.</p>\n\n<p>For commercial health insurance carrier patients, self-pay patients, and in some Employer Payer program patients, failure to notify the office within forty-eight (48) hours may result in a minimum cancellation fee amount of $75 for a physician or nurse practitioner telehealth visit appointment, and $50 for a registered dietitian telehealth visit appointment. Repeated failure to call and cancel your scheduled telehealth visit appointment without the proper forty-eight (48) hour notice may result in your dismissal as a patient.</p>\n\n<h3>Outstanding Balances</h3>\n<p>Except for Employer Sponsored Plan participants, an invoice statement will be sent after your telehealth visit for any outstanding balances that have become your patient financial responsibility. All outstanding balances are due on receipt. If you have an outstanding balance for more than ninety (90) days, you may be referred to an outside collection agency and charged a collection fee in addition to the balance owed to FlyteHealth.</p>\n\n<h3>Card on File</h3>\n<p>When making a payment for your telehealth visit appointment with one of our FlyteHealth clinical providers, there is an option to store your credit card on file. This information will be held securely and is offered to simplify the payment process. Once FlyteHealth is notified of any additional amount that has been determined to be patient responsibility, we will notify you that your outstanding balance will be charged to your credit card on file. Please call the FlyteHealth office at 844-359-8363 if you have any questions about your outstanding balance.</p>\n\n<h3>No Suprises Act</h3>\n<p>Under the No Surprise Act, healthcare providers must give patients who do not have insurance or who are not using insurance an estimate of the bill for medical items and services. You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost. For questions or more information about your right to a Good Faith Estimate, visit <a href="https://www.cms.gov/nosurprises" target="_blank" rel="noopener noreferrer">https://www.cms.gov/nosurprises</a> or call the FlyteHealth office at 844-359-8363.</p>\n\n<h3>Assignment of Benefits and Authorization to Release Information</h3>\n<p>You certify the commercial health insurance plan or Employer Payer plan information provided is accurate, complete, and current and that you have no other insurance coverage. You understand and agree that payment of authorized benefits under Medicare, commercial health insurance plan, and/or any of your insurance carriers will be made to you or on your behalf to FlyteHealth for medical treatment services rendered to yourself and/or your dependents by FlyteHealth. You understand that you are responsible for any monetary amount not covered by your insurance.</p>\n\n<p>You hereby authorize your FlyteHealth clinical provider or any holder of your medical information, or the patient listed below, a release to your health insurance plan information needed to determine benefits or the benefits payable for related medical treatment services provided by FlyteHealth. You permit payment from your insurance or other third-party payor to go to FlyteHealth directly, and you permit FlyteHealth in its sole discretion, to determine, apply for and obtain benefits, and get paid from, any and/or all available payor sources until your account is paid in full.</p>\n\n<h3>Policies in Partnering with FlyteHealth</h3>\n<ol>\n  <li>You agree to create and maintain active FlyteHealth patient application and electronic health record accounts managed by FlyteHealth. You are required to provide accurate account information and update your information as it changes.</li>\n  <li>You agree to respond in a timely manner to communications from FlyteHealth staff members by phone, email, or secure text messaging from FlyteHealth patient application and/or electronic health record platform. FlyteHealth reserves the right to dismiss patients who are continuously unresponsive or fail to respond within a timely manner to phone, email, or secure text messaging from FlyteHealth staff.</li>\n  <li>You agree to submit to FlyteHealth only your personal information, health information, data, symptoms or other information, particularly when you are using a FlyteHealth-issued medical device, such as a blood pressure cuff or weight scale. You understand that allowing another person to use such devices or to submit their health information or other data to FlyteHealth under your account or patient profile, especially absent the establishment of a patient-provider relationship, is prohibited.</li>\n  <li>You agree to treat all FlyteHealth staff with dignity and respect regardless of situation or circumstances. FlyteHealth has a Zero-Tolerance Policy with regards to sexual harassment, racism, xenophobia, gender shaming, verbal or physical threats, or other hate messaging when communicating with the FlyteHealth staff by a patient. Should this be violated, FlyteHealth reserves the right to dismiss a patient from the practice.</li>\n  <li>FlyteHealth may refer patients to medical practices that offer in-person services if our clinical provider staff determines, in their sole discretion, that in-person care would be more appropriate for you as a patient.</li>\n  <li>You hereby consent to receiving FlyteHealth’s medical treatment services via telehealth technologies. You understand that FlyteHealth and its clinical providers offer telehealth-based medical treatment services, but that these services do not replace the relationship between you and your primary care doctor or other medical specialists who may be treating your health. You also understand it is up to the FlyteHealth clinical provider to determine, in their sole discretion, whether or not your specific clinical needs are appropriate for a telehealth visit.</li>\n  <li>You have been given an opportunity to select a clinical provider from FlyteHealth prior to your telehealth visit, including a review of the FlyteHealth clinical provider’s credentials.</li>\n  <li>You understand that federal and state law requires health care providers to protect the privacy and the security of protected health information. You understand that FlyteHealth will take steps to make sure that your protected health information is not seen by anyone who should not see it. You understand that telehealth may involve electronic communication of your personal medical information to other health practitioners who may be located in other areas, including out of state. You understand that our Notice of Privacy Practices provides detailed information about FlyteHealth’s obligations with regard to privacy.</li>\n  <li>You agree not to record, whether by audio or visual means, any FlyteHealth representative whether during a clinical encounter or other interaction.</li>\n  <li>You understand there is a risk of technical failures during the telehealth visit beyond the control of FlyteHealth. You agree to hold harmless FlyteHealth for delays in evaluation or for information lost due to such technical failures.</li>\n  <li>You understand that you have the right to withhold or withdraw your consent to the use of telehealth in the course of your clinical care at any time, without affecting your right to future care or medical treatment.</li>\n  <li>You understand that you may suspend or terminate use of the telehealth services at any time for any reason or for no reason. You understand that if you are experiencing a medical emergency, that you will be directed to dial 9-1-1 or proceed to your nearest emergency department immediately.</li>\n  <li>You understand there are alternatives to a telehealth visit, such as in-person services, which are available to you, and in choosing to participate in a telehealth visit, you understand that some parts of the services involving tests may be conducted by individuals at your location, or at a testing facility, at the direction of the FlyteHealth clinical provider (e.g., labs or bloodwork).</li>\n  <li>You understand that you may expect the anticipated benefits from the use of telehealth in your care, but that no results can be guaranteed or assured.</li>\n  <li>You agree to accurately represent your current location when you are receiving a telehealth visit, your demographic location, your address, your medical history, and all information about your medical condition(s) to the FlyteHealth staff and clinical providers during your medical treatment.</li>\n  <li>You understand that your healthcare information may be shared with other individuals for scheduling and billing purposes. Persons may be present during the telehealth visit other than the FlyteHealth provider in order to operate the telehealth technologies. You further understand that you will be informed of their presence in the telehealth visit and thus will have the right to request the following: (a) omit specific details of your medical history/examination that are personally sensitive to you; (b) ask non-medical personnel to leave the telehealth examination; and/or (c) terminate the telehealth visit at any time.</li>\n  <li>You understand that you will not be prescribed any narcotics, nor is there any guarantee that you will be given a prescription at all.</li>\n  <li>You understand that if you participate in a telehealth visit, that you have the right to request a copy of your medical records which will be provided to you at reasonable cost of preparation, shipping and delivery consistent with applicable law and regulations.</li>\n  <li>You have read and you understand the disclosures set forth next to the state in which you are located at the time of the telehealth visit, as set forth below:</li>\n</ol>\n\n<h3>STATE REGULATIONS[1]:</h3>\n<p><strong>Alaska:</strong> You understand your primary care provider may obtain a copy of your records of your telehealth visit. (Alaska Stat. \xa7 08.64.364).</p>\n\n<p><strong>Arizona:</strong> You understand that all medical records resulting from a telehealth visit are part of your medical record. (A.R.S. \xa7 12-2291.)</p>\n\n<p><strong>Colorado:</strong> You are informed that if you want to register a formal complaint about a provider, you should file at <a href="https://dpo.colorado.gov/FileComplaint" target="_blank" rel="noopener noreferrer">https://dpo.colorado.gov/FileComplaint</a>.</p>\n\n<p><strong>Connecticut:</strong> You understand that your primary care provider may obtain a copy of your records of your telehealth visit, and that you can revoke your consent at any time. (Conn. Gen. Stat. Ann. \xa7 19a-906).</p>\n\n<p><strong>D.C.:</strong> You have been informed of alternate forms of communication between your and a physician for urgent matters. (D.C. Mun. Regs. tit. 17, \xa7 4618.10).</p>\n\n<p><strong>Florida:</strong> Consumer Bill of Rights - <a href="https://www.flsenate.gov/Laws/Statutes/2011/501.0575" target="_blank" rel="noopener noreferrer">https://www.flsenate.gov/Laws/Statutes/2011/501.0575</a>.</p>\n\n<p><strong>Georgia:</strong> 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(7)).</p>\n\n<p><strong>Iowa:</strong> 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: <a href="https://medicalboard.iowa.gov/consumers/filing-complaint" target="_blank" rel="noopener noreferrer">https://medicalboard.iowa.gov/consumers/filing-complaint</a>.</p>\n\n<p><strong>Idaho:</strong> 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: <a href="https://dopl.idaho.gov/bom" target="_blank" rel="noopener noreferrer">https://dopl.idaho.gov/bom</a>.</p>\n\n<p><strong>Illinois:</strong> You have been informed that if you want to register a formal complaint about a provider, you should visit the Illinois Division of Professional Regulation at <a href="https://dph.illinois.gov/topics-services/health-care-regulation/complaints.html" target="_blank" rel="noopener noreferrer">https://dph.illinois.gov/topics-services/health-care-regulation/complaints.html</a>.</p>\n\n<p><strong>Kansas:</strong> You understand that if you have a primary care provider or other treating physician, the person providing telemedicine services must send within three business days a report to such primary care or other treating physician of the treatment and services rendered to you during the telemedicine encounter. (Kan. Stat. Ann. \xa7 40-2,212(2)(d)(2)(A)). You understand that the complaint process may be found here: <a href="http://www.ksbha.org/complaints.shtml" target="_blank" rel="noopener noreferrer">http://www.ksbha.org/complaints.shtml</a>.</p>\n\n<p><strong>Kentucky:</strong> 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: <a href="https://kbml.ky.gov/grievances/Pages/default.aspx" target="_blank" rel="noopener noreferrer">https://kbml.ky.gov/grievances/Pages/default.aspx</a>.</p>\n\n<p><strong>Louisiana:</strong> You understand the role of other health care providers that may be present during the telehealth visit other than the telehealth provider. (46 La. Admin. Code Pt XLV, \xa7 7511).</p>\n\n<p><strong>Maine:</strong> 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: <a href="https://www.maine.gov/md/complaint/file-complaint" target="_blank" rel="noopener noreferrer">https://www.maine.gov/md/complaint/file-complaint</a>.</p>\n\n<p><strong>Nebraska:</strong> All existing confidentiality protections shall apply to the telehealth visit. You shall have access to all medical information resulting from the telehealth visit as provided by law for access to your medical records. Dissemination of any patient identifiable images or information from the telehealth visit to researchers or other entities shall not occur without your written consent. You understand that you have the right to request an in-person consult immediately after the telehealth consult and you will be informed if such consult is not available. (Neb. Rev. Stat. Ann. \xa7 71-8505; 471 Neb. Admin. Code \xa7 1-006.05). You have been informed that if you want to register a formal complaint about a provider, you should visit: <a href="https://dhhs.ne.gov/Pages/Complaints.aspx" target="_blank" rel="noopener noreferrer">https://dhhs.ne.gov/Pages/Complaints.aspx</a>.</p>\n\n<p><strong>New Hampshire:</strong> You understand that the telehealth provider may forward your medical records to your primary care or treating provider. (N.H. Rev. Stat. \xa7 329:1-d).</p>\n\n<p><strong>New Jersey:</strong> You understand 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. (N.J. Rev. Stat. Ann. \xa7 45:1-62).</p>\n\n<p><strong>Ohio:</strong> You understand that the telehealth provider may forward your medical records to your primary care or treating provider. Ohio Admin. Code 4731-11-09(C).</p>\n\n<p><strong>Oklahoma:</strong> 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: <a href="http://www.okmedicalboard.org/complaint" target="_blank" rel="noopener noreferrer">http://www.okmedicalboard.org/complaint</a>. Board of Osteopathic Examiners can be found at: <a href="https://www.ok.gov/osboe/faqs.html" target="_blank" rel="noopener noreferrer">https://www.ok.gov/osboe/faqs.html</a>.</p>\n\n<p><strong>Rhode Island:</strong> 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).</p>\n\n<p><strong>South Carolina:</strong> You understand your medical records may be distributed in accordance with applicable law and regulation to other treating health care practitioners. (S.C. Code Ann. \xa7 40-47-37).</p>\n\n<p><strong>South Dakota:</strong> 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 \xa7 34-52-3).</p>\n\n<p><strong>Texas:</strong> You understand that your medical records may be sent to your primary care physician. (Tex. Occ. Code Ann. \xa7 111.005). You have been informed of the following notice:</p>\n\n<p><strong>NOTICE CONCERNING COMPLAINTS</strong> - Complaints about physicians, as well as other licensees and registrants of the Texas Medical Board, including physician assistants, acupuncturists, and surgical assistants 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 <a href="https://www.tmb.state.tx.us" target="_blank" rel="noopener noreferrer">https://www.tmb.state.tx.us</a>.</p>\n\n<p><strong>AVISO SOBRE LAS QUEJAS-</strong> Las quejas sobre m\xe9dicos, asi como sobre otros profesionales acreditados e inscritos del Consejo M\xe9dico de Tejas, incluyendo asistentes de m\xe9dicos, practicantes de acupuntura y asistentes de cirugia, se pueden presentar en la siguiente direcci\xf3n 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 m\xe1s informaci\xf3n, visite nuestro sitio web en <a href="https://www.tmb.state.tx.us" target="_blank" rel="noopener noreferrer">https://www.tmb.state.tx.us</a>.</p>\n\n<p><strong>Utah:</strong> You understand (i) any additional fees charged for telehealth services, if any, and how payment is to be made for those additional fees, if the fees are charged separately from any fees for face-to-face services provided in combination with the telehealth services; (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 understand that the telehealth services meets industry security and privacy standards, and comply with all laws referenced in Subsection 26-60-102(8)(b)(ii). 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 telehealth company’s website and contact information. You were able to select your provider of choice, to the extent possible. You were able to select your 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. (Utah Admin. Code r. 156-1-603).</p>\n\n<p><strong>Virginia:</strong> 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 FlyteHealth harmless 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).</p>\n\n<p><strong>Vermont:</strong> 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.</p>\n\n<p>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: <a href="http://www.healthvermont.gov/health-professionals-systems/board-medical-practice/file-complaint" target="_blank" rel="noopener noreferrer">http://www.healthvermont.gov/health-professionals-systems/board-medical-practice/file-complaint</a>. Board of Osteopathic Examiners can be found at: <a href="https://sos.vermont.gov/opr/complaints-conduct-discipline" target="_blank" rel="noopener noreferrer">https://sos.vermont.gov/opr/complaints-conduct-discipline</a>.</p>\n\n<p>You hereby acknowledge that you have received and reviewed your FlyteHealth clinical provider’s Patient Consent Form as well as the Notice of Privacy Practices. You agree to the terms of these policies and consent to medical treatment by your FlyteHealth clinical provider and clinical care coordination by the FlyteHealth staff. This form extends to subsequent telehealth visits with all FlyteHealth clinical providers.</p>\n\n<p class="consent-document-footer">Flyte Medical, PC dba FlyteHealth \xa9 2025<br/>Patient Consent Form. 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