Shine Thru Health NP – Telehealth & Async Care Consent (Pennsylvania)
By submitting this form, you acknowledge and agree to all terms below. This consent is required under Pennsylvania Telemedicine Act (Act 98 of 2022) and federal telehealth regulations.
1. Nature of Telehealth & Asynchronous Care
You understand that:
- This is a telehealth encounter, conducted through asynchronous (“async”) review of your symptoms, history, and images.
- Because async care does not include a live examination, the provider may:
- Request additional information
- Require a phone or video visit
- Refer you to in-person care
- Decline treatment if telemedicine is not clinically appropriate
- You consent to receive medical advice, assessment, or treatment through telehealth technologies permitted by Pennsylvania law.
2. Pennsylvania Telemedicine Disclosure
Under PA Act 98:
- Telemedicine must meet the same standard of care as in-person care.
- Providers are required to determine if telehealth is appropriate for your condition.
- If your condition requires an in-person exam to safely diagnose or treat, you may be referred accordingly.
You acknowledge this and agree that appropriateness is determined by the licensed provider.
3. Scope of Care & Treatment Limitations
Shine Thru Health NP provides care only for non-emergent, low-acuity conditions appropriate for telehealth.
Examples include (but are not limited to):
- Respiratory illness (mild)
- Skin concerns
- Urinary symptoms (uncomplicated)
- GI issues
- Viral symptoms
- Medication refills (non-controlled)
- Allergies
- Minor infections
You understand:
- No diagnosis or prescription is guaranteed.
- Telehealth may not replace physical examination when needed.
You may be instructed to obtain labs, imaging, testing, or in-person evaluation.
4. No Controlled Substances (PA-Compliant)
You acknowledge that Shine Thru Health NP:
- Does NOT prescribe controlled substances via this service under PA law and DEA regulations.
- This includes all Schedule II–V medications, such as:
- Stimulants
- Sedatives
- Benzodiazepines
- Narcotics/opioids
- Sleep medications
- Testosterone and other controlled hormone therapies
Only non-controlled, medically appropriate medications will be considered.
5. Risks, Benefits & Alternatives
Telemedicine carries risks, including but not limited to:
- Misdiagnosis or delayed diagnosis due to technology limitations
- Incomplete information compared to in-person exams
- Equipment/connection issues
- The need for conversion to audio or video
- The possibility that telemedicine may not produce the same results as an in-person visit
Benefits include:
- Convenience
- Faster access
- Secure communication
- Reduced need for travel
Alternatives include in-person care through urgent care, your PCP, or emergency services.
6. Communication & Follow-Up (24–48 Hours)
- Async visits are reviewed within 24–48 hours.
- If you selected “Async + Call/Video,” you will be provided with a time and telehealth link (Doximity).
- If your async case requires a live visit to be completed safely, you may be upgraded to a follow-up visit with your consent.
You agree to respond promptly to communication from your provider.
7. Accuracy & Patient Responsibility
You confirm that:
- All information you submit is complete, accurate, and truthful.
- You will report any change or worsening in symptoms.
- You are physically located in Pennsylvania at the time of this submission, as required by law.
- You are the individual seeking care (not completing the form for another adult unless legally permitted).
Providing inaccurate or incomplete information may impact the provider’s ability to safely treat you.
8. Payment, Billing, Membership, and Refund Terms
You acknowledge:
- Payment is collected at submission unless you use a valid Member Access Code.
- Fees cover clinical evaluation, not a medication guarantee.
- No refunds are issued after your case has been reviewed or clinical work has begun.
- Members must enter the correct passcode to waive payment; misuse may lead to dismissal from the membership program.
- The provider may decline treatment if telehealth is not appropriate; this does not guarantee a refund.
9. Privacy & HIPAA Disclosure
You consent to:
- The use and disclosure of your Protected Health Information (PHI) for treatment, billing, and healthcare operations.
- Secure electronic communication, including email notifications sent from np@shinethruhealth.com or CharmHealth EHR.
- Storage of your health information within CharmHealth, a HIPAA-compliant EHR.
Your provider will maintain your privacy as required by HIPAA and Pennsylvania confidentiality laws.
10. Emergency & Urgent Situations
You acknowledge that this service must not be used for emergency symptoms, including:
- Chest pain
- Severe shortness of breath
- Fainting
- Severe allergic reactions
- Suicidal thoughts
- Uncontrolled bleeding
- Sudden neurological changes
- Any rapidly worsening condition
Call 911 or go to the nearest emergency department immediately for any emergency.
11. Consent to Treat
By checking the consent box and submitting this form, you confirm:
- You have read, understand, and agree to the above statements.
- You consent to receive medical evaluation and treatment via telehealth from licensed Pennsylvania Nurse Practitioner.
- You understand that you may withdraw consent at any time, although completed services remain billable.
- You agree to the secure exchange of medical information electronically.