Consent to Medical Care & Treatment
I, [Patient Name], consent to receive medical care, evaluation, and treatment through Hundred Health from a licensed healthcare provider (my “Provider”).
Who Provides My Care
Depending on the service I select, my Provider may be a clinician of Hundred Health’s affiliated professional practice, or a licensed clinician furnished through Hundred’s contracted clinical network. In every case, my Provider exercises independent medical judgment and is solely responsible for clinical decisions about my care.
I understand that I will be informed of the name, license type, and licensing state of the Provider responsible for my care, and how to contact or verify that Provider, before or at the time care is provided. My care may be provided without a live visit by a licensed Provider furnished through Hundred’s contracted clinical network, based on the information I submit. I understand a live (synchronous) visit may not occur, and that my Provider may follow up, request additional information, or recommend an in-person evaluation if appropriate. If appropriate a live consultation may be required for an evaluation.
I Understand and Agree That
My care may include examination, assessment, diagnosis, review of labs or imaging, and, where clinically appropriate and legally permitted, treatment and prescribing, based on my Provider’s independent medical judgment.
No specific outcome, result, or prescription is guaranteed, and I may accept or decline any recommendation.
This establishes a provider-patient relationship between me and my Provider (and the professional practice through which my Provider furnishes care). It does not replace my primary care physician or existing medical team. Hundred’s care complements my other care. I should maintain my primary care relationship, and I should never stop or change care, medications, or treatment provided by my other providers except in consultation with the provider who prescribed or recommended it.
Any prescription is issued only after evaluation by my Provider, where clinically appropriate and permitted by applicable state and federal law (including the Ryan Haight Act for controlled substances). The decision to prescribe, decline, or discontinue any medication rests solely with my Provider.
I am responsible for sharing relevant Hundred results and recommendations with my other treating providers, and theirs with Hundred, to support coordinated care.
I have had the opportunity to ask questions about my care, including its benefits, risks, and alternatives, and to ask about the identity, licensure, and privacy practices of my Provider.
I have provided accurate health information to the best of my knowledge and will inform my Provider of changes.
My health information is protected under HIPAA and applicable law, and I acknowledge receipt of (or access to) Hundred’s Notice of Privacy Practices.
I may withhold or withdraw consent at any time without affecting my right to future care.
I am 18 years of age or older (or a legally authorized representative is consenting on my behalf).
Diagnostic & Interpretive Consultations
For consultations limited to reviewing and interpreting my diagnostic results (such as labs, imaging, or genetic testing): I understand this consult is for interpretation, education, and recommendations only, and does not include ongoing treatment or management of any condition. I understand that no test detects every condition, that results may be incomplete, uncertain, or reveal incidental findings, and that any recommended follow-up is my responsibility to pursue with my own care team.
Telehealth Consent
This consent covers telehealth services provided to me through licensed providers and Hundred Health (“my Healthcare Provider”). Telehealth is the delivery of health care using secure electronic and telecommunications technologies between a patient and a provider in different locations. My Healthcare Provider will communicate with me remotely using Doxy.me, a HIPAA-compliant, encrypted audio-video service; the platform vendor only hosts the technology and does not provide medical advice.
This Telehealth Consent works together with my Consent to Medical Care & Treatment. I understand and agree that:
Telehealth is not appropriate for medical emergencies. In an emergency, I will call 911 or go to the nearest emergency department rather than contacting Hundred.
Telehealth care may include evaluation, diagnosis, treatment, ordering and review of tests, and — where clinically appropriate and legally permitted — prescribing, based on my provider’s independent medical judgment.
There are benefits and limitations to telehealth compared with an in-person visit, because I will not be physically in the same room as my provider, and certain conditions may not be appropriately assessed remotely.
Either my Healthcare Provider or I may discontinue a telehealth visit if the remote format is inadequate for my care, and I may be referred for in-person evaluation, labs, or specimen collection.
My health information is protected under HIPAA and applicable law, and industry-standard security protocols safeguard my information, though no internet-based communication is entirely free of privacy or security risk.
I will be informed of anyone else present during a visit and may ask them to leave; I am responsible for a private setting; and I will not record audio or video without my provider’s permission.
I may withhold or withdraw consent to telehealth at any time without affecting my right to future care, and I may request an in-person visit instead.
I am 18 years of age or older (or a legally authorized representative is consenting on my behalf).