SymplyV Telehealth Services

Consent, Notices & Acknowledgement Form
Important Notice

By selecting "I Accept," you confirm that you have read, understood, and agree to these terms. Without acceptance, you cannot access SymplyV's telehealth services. Your acceptance extends to any authorized party clicking "I Accept" on your behalf.

Telehealth Service Agreement
I agree to receive healthcare services from SymplyV and Symplicity Healthcare ("Practice") practitioners through telehealth, understanding that:

• Practitioners will be located remotely from my location

• Services, diagnoses, treatments, and prescriptions are provided at the practitioner's discretion

• Practitioners determine if conditions are appropriate for telehealth

• Services are delivered through real-time interactive video and/or audio conferencing
   

Your Rights

You have the right to:

• Withdraw consent at any time

• Seek in-person care when necessary

• Access your health information as per applicable laws

• Receive the same privacy protections as in-person care

• Seek immediate in-person care if urgent needs arise
   

Privacy & Information Sharing

We maintain your privacy by ensuring:

• All telehealth interactions are protected by medical privacy laws

• Video feeds are not recorded or retained

• Your information may be shared for treatment, payment, and healthcare operations

• Information shared with non-covered entities requires your written consent

 
Notice of Privacy Practices

I acknowledge that:

• I have received the Practice's Privacy Notice

• Practice may share my information with other healthcare providers, insurers, and [Client]

• My information may be shared across state lines with other medical practitioners

• Practice cannot control third-party use of shared information

• Information sharing includes FPK Services, laboratories, and pharmacies
   

Financial Terms
 

• A flat fee applies to each telehealth visit

• Payment is required before receiving services
   

Communication Consent
I authorize SymplyV and Symplicity Healthcare to:

• Use my email for health-related and limited marketing communications

• Contact me at my provided phone number regarding account balances

• Share information between SymplyV, Symplicity Healthcare, and myself
   

I understand that:

• My email will not be sold or used for unauthorized purposes

• I can opt-out of marketing communications after initial contact

• Treatment is not conditional on providing these authorizations
   

Accuracy Statement I confirm that:

• The information I've provided is accurate

• I release SymplyV, Symplicity Healthcare, and their staff from errors in my submissions

• I have read and understood these terms

• My questions have been answered satisfactorily
   

Contact Information
For privacy practices information: Symplicity Healthcare 3301 Green Street Suite 343 Claymont, Delaware
By accepting, you agree to participate in telehealth services under these terms and any additional requirements provided to you.