Tembo Health Patient Consent Form
Tembo Health, Inc. and its affiliated medical practices SAH Telemedicine PC and SAH Telemedicine California PC (collectively referred to as “Tembo” or “Tembo Health”) provide virtual healthcare, clinical support services, and care coordination to older adults and their families. This form explains what services we provide, how we use your health information, and what choices you have.
Please read this form carefully. If you are signing on behalf of a loved one, please review the Legally Authorized Representative section. You can review Tembo’s HIPAA Notice of Privacy Practices at any time.
Section 1 — Consent for Care and Services
I authorize Tembo Health to provide the following services, as applicable to my enrollment:
- GUIDE Dementia Care Services (Medicare-covered)
- Virtual Urgent Care Services (24/7 clinical access, if selected by my community or family)
- Move-In or Transition Visits
- Ongoing care coordination, assessments, and support for caregivers
I understand:
- Tembo clinicians may be physicians or other non-physician providers practicing under supervision, like nurse practitioners or physician assistants.
- Tembo clinicians may review my medical history, medications, safety concerns, and care needs.
- Tembo may communicate with me, my family, and my care team to coordinate services. I may discuss any treatment plan issued by a Tembo clinician with any other health care provider if I choose to do so.
- I may choose to participate in any or all services available to me.
- I may stop services at any time without affecting my Medicare benefits or other healthcare.
The practice of medicine is not an exact science and that no guarantees have been made about any treatments, examinations or other services that I have or may receive from Tembo.
Section 2 – Consent to Treatment by Telemedicine
Some of the services delivered by Tembo Health or its clinicians may be delivered via telemedicine. Telemedicine involves the use of audio, visual, or other electronic communications to enable medical practitioners at different locations to share individual patient medical information for the purpose of providing patient care.
As part of receiving services from Tembo Health, I consent to Tembo Health delivering some of those services through telemedicine. By consenting to receive treatment via telemedicine, I understand the following:
Expected Benefits of Telemedicine –
- Improved access to care by enabling you to remain in your home while Tembo Health’s providers provide care remotely from other sites.
Possible Risks of Telemedicine –
- Delays in evaluation or treatment could occur due to errors of equipment and technology used to provide telemedicine services.
- The inability to conduct an in-person physical examination could result in misdiagnosis or delays in care.
- Tembo could determine that the transmitted health information is incomplete or of inadequate quality, requiring a rescheduled telemedicine encounter or an in-person visit.
- A lack of access to complete medical records could result in adverse drug interactions or other errors.
- Security controls could fail, causing a breach of privacy.
Tembo’s Duties and Obligations when Delivering Telemedicine – Telemedicine providers have the same duties and obligations that apply to in-person healthcare providers. This includes;
- A duty to warn if you may present a risk of serious harm to yourself or others.
- An obligation to report current elder abuse or neglect or disabled individual abuse or neglect to the appropriate state agency.
- An obligation to respond to a valid subpoena or court order seeking disclosure of medical records.
Medical Information and Records – The same laws that apply to medical records and privacy also apply to telemedicine. Tembo’s Notice of Privacy Practices, which is available online, describes how Tembo protects, uses and discloses medical information about you and how you may access your medical information.
Your Rights - You may withhold or withdraw your consent to a telemedicine consultation at any time before and/or during the consult without affecting your right to future care or treatment or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled.
Section 3 — Coordination With My Healthcare Providers
To provide care, Tembo may communicate and share information with:
- My primary care provider
- Specialists involved in my care
- Caregiving staff
- Hospitals or urgent care teams
- Other providers or agencies supporting my health
Information shared may include diagnoses, medications, assessments, treatment plans, and safety concerns, as needed for coordination and continuity of care.
Section 4 — Use of My Health Information
Tembo may use and disclose my health information to:
- Provide clinical care
- Coordinate with my care team
- Submit to health insurance carriers, government-sponsored health care programs, and/or other third-party payors as necessary to collect payments, process related health insurance claims, and/or to verify my health plan benefits.
- Improve the quality and safety of services
- Meet federal and state program requirements (including GUIDE)
All use and disclosure will follow HIPAA privacy and security rules. More information about these uses and disclosures, and my rights to request more information from Tembo Health about these uses is available in Tembo’s Notice of Privacy Practices.
Section 5 – Assignment of Benefits and Payment for Services
I agree to assign the payment of authorized medical benefits to Tembo Health for treatment and services and treatment that Tembo has provided to me. I authorize the payment of services under the terms of my health coverage directly to Tembo Health and authorize Tembo Health to be considered my authorized representative with respect to all payments and/or claims related to medical care and treatments furnished to me by Tembo.
I certify that the information that I have given to Tembo to authorize payment is correct and accurate, and that Tembo may rely on that information for submission to health insurance carriers, government-sponsored health care programs, and/or other third-party payors.
I understand that Tembo will bill my health insurance carriers, government-sponsored health care programs, and/or other third-party payors at my direction for the services and will bill me personally for any deductible, co-payment, or outstanding balance associated with the services that is not covered by those payors. I acknowledge I may also be billed fees associated with canceling/missing an appointment, visit, or service with a provider, including services that are incomplete due to the failure of telemedicine technologies or if my condition may not be treated completely through telemedicine.
Section 6 — Communication Preferences
Communication by Phone, Email and Secure Messaging
I consent to Tembo contacting me or my representative by:
- Phone
- Email
- Secure electronic systems (e.g., patient portal)
These communications may include appointment reminders, care updates, and information needed to coordinate services. They do not include marketing messages. I may change my communication preferences at any time by contacting Tembo.
Communication by Text Messaging
Additionally, I consent to Tembo contacting me or my representative via text messaging. I understand that text messaging will only be used for informational purposes and that I may revoke this consent at any time, in any reasonable manner (for example, by replying “STOP,” “QUIT,” “END,” “REVOKE,” “OPT-OUT,” “CANCEL,” or “UNSUBSCRIBE”, to any text message that I receive from Tembo). Standard messaging rates may apply to communications sent by text message.
Communications Privacy
If I choose to allow communication by email or text messaging, I understand that Tembo may text and email me about my health information, including information about healthcare and services available to me. I realize that text messages and email are not completely secure because messages might be sent to the wrong person or number or improperly accessed after being sent or while in storage or transmission. I accept this risk and permit Tembo to send this information via text message and email.
Section 7 — Supporting Clinical Research
A. Use of Anonymized Health Data
Tembo may use my anonymized health information to support research and healthcare improvement. This means:
- All personal identifiers (name, address, date of birth, etc.) are removed, and the data will be de-identified in accordance with the HIPAA rules
- Anonymized data cannot be linked back to me, and the groups that Tembo shares it with will not have the ability to re-identify the data
- Information may be used to study dementia care, treatment effectiveness, and patient outcomes
- Research may be conducted or sponsored by academic centers, healthcare organizations, pharmaceutical companies, or medical device companies
- Results may be published, but I will never be personally identified
- I understand that I may withdraw my consent for my data to be included in these activities at any time. However, because my data will have been anonymized and not re-identifiable, my withdrawal of consent will not affect the availability or use of any data de-identified prior to my withdrawal of consent.
B. Clinical Trial Identification & Outreach
Based on my health profile, Tembo may identify whether I might be eligible for clinical trials or research studies.
If I consent, Tembo or its research partners may contact me or my representative to share information about relevant opportunities.
Participation in any trial is voluntary and requires separate consent. My agreement to participate in clinical trial identification and outreach does not guarantee the availability of or my participation in any clinical trial that may be identified by Tembo or its research partners.
Section 8 — Voluntary Participation
My participation in Tembo services is voluntary.
I may withdraw consent at any time, and doing so will not affect my care, insurance benefits, or relationship with my other clinical providers.
I may also change my choices about clinical trial outreach at any time.
Section 9 — Legally Authorized Representative (LAR)
Because many people receiving dementia care cannot legally consent for themselves, if desired, you may submit a form signed by a Legally Authorized Representative (LAR), such as:
- A person with Durable Power of Attorney for Healthcare
- A Healthcare Proxy
- A Court-Appointed Guardian
- Another individual legally permitted to make healthcare decisions under state law
By providing a form signed by any Legally Authorized Representative, the Legally Authorized Representative affirms they have the authority to act on the participant’s behalf, and complies with any requirements of applicable state law. Tembo reserves the right to review signed Legally Authorized Representative forms, and may reject such forms in its sole discretion. However, I agree to release Tembo from liability and to indemnify, defend and hold Tembo harmless from its good faith reliance of signed Legally Authorized Representative forms submitted by me or my Legally Authorized Representatives.
Section 10 — Consent & Signature
By signing below, I acknowledge:
- I have read and understand this consent form
- I authorize Tembo Health to provide the services described
- I authorize the use and sharing of health information as outlined
- I understand my participation is voluntary and may be withdrawn at any time
- I have received an electronic copy of Tembo’s HIPAA Notice of Privacy Practices (or had the opportunity to review it online) and received a paper copy if I asked for it.