Consent to Telemedicine Services

ReviveHealth, Inc.

Last Updated: 7/25/2025

Thank you for choosing Revive Healthcare, P.C. ("ReviveHealth"). ReviveHealth provides virtual healthcare services through licensed healthcare providers. You are viewing this form because you have elected to receive these services through ReviveHealth. The provider(s) you engage with via ReviveHealth are licensed providers in your state.

By clicking "I Agree," I ACKNOWLEDGE I HAVE READ AND UNDERSTAND THE TERMS PRESENTED BELOW, AND UNDERSTAND THE RISKS AND BENEFITS OF TELEHEALTH, AND BY ACCEPTING THESE TERMS OF USE I HEREBY GIVE MY INFORMED CONSENT TO PARTICIPATE IN TELEHEALTH UNDER THESE TERMS.

What is Telehealth?

Telehealth is the delivery of healthcare services, including examination, consultation, diagnosis, and treatment, through electronic communication technologies when you (the patient) are located in a different location than your healthcare provider.

ReviveHealth allows you to receive medical and/or mental health treatment from a qualified provider without having to travel to another location or schedule a separate appointment. This helps you avoid long waiting times that you might otherwise experience at an in-person visit.

Synchronous vs. Asynchronous Telehealth

ReviveHealth providers may deliver both asynchronous and synchronous telehealth.

Asynchronous telehealth is the delivery of telehealth through asynchronous

communication. Asynchronous communication is often referred to as "store-and- forward" communication, where patients and providers transmit information to each other to be viewed and responded to later. Healthcare providers may use asynchronous telehealth to aid in diagnoses and medical consultations when live communication or face-to-face contact is not possible or necessary. For example, asynchronous telehealth involves sending photos, video, or other communications via email or text message. "Asynchronous" means "not occurring at the same time" and is different from "synchronous" telehealth, which generally includes visits conducted in real-time between patients and healthcare providers through audio and/or video means (e.g., live phone calls or video-conferencing).

If you choose to receive mental health treatment through ReviveHealth, you will communicate with your provider via audio telephone calls or video. For medical visits with a provider, you will have the option to communicate via asynchronous text message or synchronous telephone or video chat. If your provider determines the method you choose is insufficient to address your condition(s), your provider may request you use a different method of communication better suited to your needs.

What are the Possible Risks Associated with Telehealth?

As with any healthcare service, there are potential risks associated with receiving care via telehealth. ReviveHealth believes that the likelihood of these risks materializing is very low, but we want to make sure you understand them before using our services.

These risks may include, without limitation, the following:

  • Delays in medical evaluation and consultation or treatment may occur due to deficiencies or failures of the equipment or the Internet, which may include poor data quality,Internet outages, or other service interruption issues. You may reschedule your visit with your healthcare provider should these interruptions occur.
  • Security protocols could fail, causing a breach of privacy of personal medical information.
  • Because ReviveHealth does not have access to your complete< medical records, if you do not disclose to your healthcare provider a full list of your medical history including diagnoses, treatments, medications/supplements, and allergies, adverse treatment, drug interactions or allergic reactions, or other negative outcomes may occur.
  • The ReviveHealth™ telehealth services are NOT emergency services and your Personal Data (as defined in the ReviveHealth Terms of Use and Privacy Policy) WILL NOT BE MONITORED 24/7. If you think you are experiencing a medical emergency, CALL 911 IMMEDIATELY.

The care you receive through ReviveHealth will be at the sole discretion of the healthcare provider who is treating you, with no guarantee of diagnosis, treatment, or prescription. Your provider will determine whether or not the condition being diagnosed and/or treated is appropriate for the care provided through a telehealth encounter via the ReviveHealth platform.

Your Rights and Acknowledgements:

These risks may include, without limitation, the following:

  • You have the same privacy rights via telehealth that you have during an in-person visit. Dissemination of any identifiable images or information from your visit to researchers or other entities will not occur without your written consent. For more information about how we protect your privacy, please read the Terms of Use and Privacy Policy.
  • You understand that all information submitted to a provider via text message and entered by your< healthcare provider into the ReviveHealth platform will be part of your medical record. You can receive a copy of your medical records by logging into your ReviveHealth member portal and downloading your records, or by contacting ReviveHealth customer service at 888-220-6650. This information will have the same restrictions on dissemination without your consent.
  • Telehealth, via synchronous and asynchronous communication, may involve electronic communication of your personal medical information to healthcare providers who may be located in other areas, including outside of your state.
  • You understand that you may anticipate benefits from the use of telehealth, but that no results can be guaranteed or assured.
  • You understand you may withdraw your consent at any time by contacting eviveHealth customer service at 888-220-6650.
  • You understand that your healthcare information may be shared with other individuals in accordance with the Terms of Use and Privacy Policy and regulations or laws in the state or territory in which you are located.
  • You understand that healthcare information is gathered from Electronic Medical Records through Health Gorilla and aggregated and shared with your current healthcare providers to access your most recent medical and Rx history, with ReviveHealth, for proper assessment, treatment, and diagnosis. ReviveHealth is here to support care for all our patients and all their healthcare providers.
  • You further understand that your healthcare information may be shared in the following circumstances:
    • When a valid court order is issued for medical records.
    • Reporting suspected abuse, neglect, or domestic violence.
    • Preventing or reducing a serious threat to anyone's health or safety, including your own.
    • From our Revive Care partners to the ReviveHealth Care Team to coordinate any additional care requirements you may need.

Call/Email/Text Messaging Consent: You expressly consent to allow ReviveHealth or its healthcare providers to call, email, or text you (via SMS) with or regarding Personal Data (as defined in the ReviveHealth Terms of Use and Privacy Policy ), appointments, or similar matters related to your telehealth encounters using the contact information you have provided. Any calls or texts to you may be placed using an auto-dialer or a pre-recorded or artificial voice, even if your number is on a do-not-call list. Your phone carrier's normal rates may apply. This is consent, not a condition of purchase. You may revoke this consent at any time by emailing us at info@revive.health

This Telehealth Informed Consent is valid during your entire relationship with ReviveHealth or until it is withdrawn.