Informed Consent for Telehealth

Last updated: May 9, 2026

Please read this document carefully before your consultation begins.

⚠ THIS SERVICE IS NOT FOR EMERGENCIES

If you believe you are experiencing a medical emergency, do not use this platform. Instead:

  • Call 911 or your local emergency number immediately.
  • Go to the nearest emergency room.
  • Contact your local crisis center.
  • Call or text the 988 Suicide and Crisis Lifeline (call or text 988).
  • Text HOME to 741-741 to reach the Crisis Text Line.

ARSYNL Rx provides clinical infrastructure and care coordination services. We are not a healthcare provider or medical practice. Clinical services are delivered by independent, licensed healthcare providers operating through affiliated professional medical entities in the states where they are licensed. By using the Services and signing this consent, you are consenting to receive healthcare services from those independent providers — not from ARSYNL Rx.

Please read this document carefully. It describes what you can expect from your telehealth consultation, your provider’s credentials, the benefits and risks of telehealth, and disclosures required under the laws of your state of residence. Some states require you to sign or acknowledge this document before your consultation may begin.

Contents

Your Provider’s Credentials

Your provider’s license, credentials, and professional background are available through your patient profile prior to your consultation. If you have questions about your provider’s credentials, please direct them to your provider before the consultation begins. State-specific information about how to verify provider credentials or file a complaint is included in the State Regulations section below.

About Telehealth — Benefits and Risks

Telehealth is the delivery of healthcare services through electronic communications between a licensed provider and a patient who are not in the same physical location. The ARSYNL Rx platform uses encrypted communication protocols designed to protect the confidentiality and integrity of your health information.

Potential benefits include convenient access to licensed providers from your home, timely access to clinical evaluation and care management, and the ability to consult with specialists who may not be locally available.

Potential risks include technical failures — such as dropped connections or poor audio or video quality — that could affect the quality or continuity of the consultation. In rare circumstances, a provider may determine that the information transmitted is insufficient to complete a proper evaluation and may recommend an in-person visit or a rescheduled consultation.

In-person alternatives to telehealth are always available. Choosing telehealth does not prevent you from seeking in-person care at any time.

Controlled Substances — Limited Availability

ARSYNL Rx and its affiliated independent licensed providers do not prescribe controlled substances through this platform, with one narrow clinical exception: testosterone cypionate and testosterone via hypospray formulations (collectively, “Testosterone Therapy”) may be considered for male and female patients where clinically warranted.

Testosterone Therapy is available only when ALL of the following conditions are satisfied:

  • Laboratory results obtained through ARSYNL Rx’s required diagnostic testing protocol have been reviewed by your assigned provider and objectively support a clinical indication for testosterone therapy.
  • Your provider has conducted a complete clinical evaluation — including a thorough review of your medical history, current medications, and relevant risk factors — and has independently determined that testosterone therapy is appropriate for your specific condition.
  • The prescription is issued solely at the professional discretion of your independent licensed provider, in accordance with applicable federal and state law, evidence-based clinical guidelines, and the standard of care.
  • You have been fully informed of the benefits, risks, contraindications, and alternatives to testosterone therapy and have provided separate informed consent for that treatment.

ARSYNL Rx makes no guarantee that Testosterone Therapy will be prescribed. The decision to prescribe rests exclusively with your independent licensed provider. ARSYNL Rx does not direct, influence, or override any prescribing decision made by affiliated providers.

All other controlled substances — including but not limited to opioids, benzodiazepines, stimulants, sedatives, and all other Schedule II–V substances under the Controlled Substances Act — are not available through ARSYNL Rx under any circumstances. If your clinical needs require any other controlled substance, you must seek care from an in-person provider.

Limitation of Liability

ARSYNL Rx is a clinical infrastructure and care coordination platform, not a medical practice or prescriber. All prescribing decisions — including any decision to prescribe or decline to prescribe Testosterone Therapy — are made solely by independent licensed healthcare providers. ARSYNL Rx expressly disclaims any liability arising from a provider’s prescribing decisions, clinical judgments, or any outcome resulting from the use or non-use of Testosterone Therapy.

Confidentiality and When It May Be Shared

Your health information is confidential and handled in accordance with our Privacy Policy, Notice of Privacy Practices, and applicable federal and state laws. In limited circumstances, confidential information may be disclosed without your consent, including:

  • When there is a credible threat of serious harm to you or an identifiable third party.
  • When there is reasonable suspicion of abuse, neglect, or exploitation of a child or vulnerable adult.
  • In response to a valid court order, subpoena, or legal process.
  • To comply with mandatory reporting obligations under applicable law.
  • As otherwise described in our Privacy Policy and Notice of Privacy Practices.

Fees and Payment

All services are provided on a cash-pay basis. ARSYNL Rx does not accept health insurance, Medicare, or Medicaid. Fees are due at the time of service. If you believe you have been charged incorrectly, notify us in writing at support@arsynlrx.com within 15 calendar days of the charge. Failure to notify us within this window constitutes acceptance of the charge.

Diagnostic and Laboratory Testing

Some services may require at-home diagnostic or laboratory tests provided by independent third-party laboratories. Neither ARSYNL Rx nor your provider can guarantee the accuracy or reliability of third-party laboratory results. Laboratory tests can produce false positive, false negative, or inconclusive results that may affect your provider’s ability to make an accurate diagnosis or treatment recommendation.

By acknowledging this document electronically or signing below, you confirm that you understand and agree to the following:

  • You consent to receiving healthcare services through telehealth technologies from the independent licensed providers affiliated with ARSYNL Rx. These telehealth services complement but do not replace your relationship with your primary care provider.
  • Your provider will determine whether your clinical needs are appropriate for a telehealth encounter and may refer you to in-person care if necessary.
  • You have been given the opportunity to review your assigned provider’s credentials before the consultation begins.
  • Federal and state laws protect the privacy and security of your health information. Telehealth may involve electronic transmission of your health information to providers located in a different state.
  • Technical failures may occur during a telehealth encounter. You agree to hold ARSYNL Rx and affiliated providers harmless for delays or loss of information resulting from technical failures beyond their reasonable control.
  • You may withdraw your consent to telehealth services at any time without affecting your right to seek future in-person or telehealth care. If you experience a medical emergency during a telehealth consultation, dial 911 immediately.
  • In-person alternatives are available and your choice to use telehealth does not foreclose access to in-person care.
  • Others may be present during the consultation to support platform operations. You will be informed of any such individuals and may request that they leave the session or that certain information be withheld.
  • With the sole exception of Testosterone Therapy (testosterone cypionate and hypospray formulations) where laboratory results and clinical criteria are met at your provider’s independent discretion, controlled substances are not available through ARSYNL Rx. All other Schedule II–V controlled substances are not prescribed through this platform under any circumstances.
  • You have the right to request a copy of your medical records at any time. Records will be provided at reasonable cost reflecting preparation and delivery expenses.
  • You have read and understand the state-specific disclosures applicable to your state of residence set forth in the State Regulations section below.

State Regulations

The following disclosures are required under the laws and regulations of specific states. Please read the disclosure applicable to your state of residence at the time of your telehealth encounter.

Alabama

You understand that your provider may forward a copy of your medical records to your primary care physician. (Ala. Code § 34-24-503).

Alaska

Your primary care provider may obtain a copy of records from your telehealth encounter. (Alaska Stat. § 08.63.210(C)(2)).

Arizona

All medical records resulting from a telemedicine consultation are part of your medical record. (Ariz. Rev. Stat. Ann. § 36-3602(D)).

California

You have the right to withhold or withdraw consent to telehealth at any time without affecting your right to future care. All physicians practicing in California are licensed and regulated by the Medical Board of California. To verify a physician’s license or file a complaint, visit www.mbc.ca.gov, email licensecheck@mbc.ca.gov, or call (800) 633-2322. (Cal. Bus. & Prof. Code § 2290.5; Cal. Welf. & Inst. Code Ann. § 14132.725(d)).

Colorado

You understand that your provider may share your health information as necessary to provide coordinated care, and that you have the right to access your telehealth records. (6 Colo. Code Regs. § 1011-3).

Connecticut

Your primary care provider may obtain a copy of records from your telehealth encounter, and you may revoke your consent at any time. (Conn. Gen. Stat. Ann. § 19a-906).

District of Columbia (D.C.)

You have been informed of alternate methods of communication with your physician for urgent matters. All relevant communications with the physician, including electronic communications, shall be documented and filed in your medical record. (D.C. Mun. Regs. tit. 17, §§ 4618.9–4618.10).

Delaware

You have been informed of the risks, benefits, and limitations of telemedicine, including the limitations of telemedicine in an emergency situation. (24 Del. Code § 1769D).

Florida

Patients prescribed GLP-1 medications for weight loss have been provided with the Florida Weight-Loss Consumer Bill of Rights. See Appendix below.

Georgia

You have been given clear and appropriate instructions on how to obtain emergent follow-up care if needed. (Ga. Comp. R. & Regs. 360-3-.07(7)).

Hawaii

You understand that your provider is required to document your telehealth encounter in your medical record in the same manner as an in-person encounter, and that you have the right to access those records. (Haw. Rev. Stat. § 453-1.3).

Idaho

To file a formal complaint about a provider, visit https://dopl.idaho.gov/filing-a-complaint/. Your informed consent for telehealth services will be obtained as required by applicable law. (Idaho Stat. § 54-5708).

Illinois

You have been informed of the right to request an in-person evaluation, and the provider has used clinically appropriate telehealth technology. (225 Ill. Comp. Stat. 60/49.5).

Indiana

If your provider issues a prescription, the prescriber will notify your primary care provider of any prescriptions issued unless: (A) your primary care provider has access to a shared electronic health record system; or (B) the prescriber has established an ongoing relationship with you through at least two prior telehealth encounters. Indiana Medicaid patients have the right to choose between in-person and telehealth care. (Ind. Code Ann. § 25-1-9.5-7).

Iowa

To file a complaint with the Iowa Medical Board, email ibmcomplaints@iowa.gov. Your provider will identify an in-person medical home or treating physician with whom telemedicine services can be coordinated when appropriate. (Iowa Admin. Code § 653-13.11).

Kansas

If you have a primary care provider, your telehealth provider is required to send a report of treatment rendered during this encounter to that provider within three business days. (Kan. Stat. Ann. § 40-2,212(2)(d)(2)(A)).

Kentucky

To file a formal complaint about a provider, visit https://kbml.ky.gov/board/Pages/default.aspx. Upon your request, your physician must share your medical record with your primary care physician and other relevant members of your care team. (Kentucky Board of Medical Licensure Opinion on Telemedicine, as amended September 15, 2022).

Louisiana

You have been informed of the role of any other healthcare providers who may be present during the consultation. (46 La. Admin. Code Pt XLV, § 7511).

Maine

To file a formal complaint about a provider, visit https://www.maine.gov/md/complaint/file-complaint. (Code Me. R. tit. 02-373 Ch. 11, § 3.).

Maryland

You understand that your provider must maintain a complete medical record of your telehealth consultation and provide you with a copy upon request. (Md. Code Ann., Health Occ. § 14-302.1).

Michigan

You understand that your provider must document the telehealth encounter in your medical record and that you have the right to access those records. (Mich. Comp. Laws § 333.16171).

Minnesota

You have been informed that you have the right to receive a summary of the telehealth visit, and that your provider may forward a copy of your medical records to your primary care provider. (Minn. Stat. § 62A.673).

Mississippi

You understand that your provider must maintain appropriate documentation of your telehealth visit and that you have the right to access your records. (Miss. Code Ann. § 83-9-351).

Missouri

You understand that your provider must document the telehealth encounter in your medical record consistent with the documentation required for in-person encounters. (Mo. Code Regs. Ann. tit. 20, § 2150-4.200).

Montana

You understand that the telehealth provider is subject to the same standards of practice as apply to in-person healthcare encounters, and that you have the right to access your medical records. (Mont. Code Ann. § 37-3-102).

Nebraska

If you are a Nebraska Medicaid recipient, you may refuse the telehealth consultation at any time without affecting your right to future care or any Medicaid benefits. You have the right to access all resulting medical records and no patient-identifiable information will be shared with researchers without your written consent. (Neb. Rev. Stat. Ann. § 71-8505; 471 Neb. Admin. Code § 1-006.05).

New Hampshire

Your telehealth provider may forward your medical records to your primary care or treating provider. (N.H. Rev. Stat. § 329:1-d).

New Jersey

You have the right to request a copy of your medical information. Your medical information may be forwarded to your primary care provider or other treating provider of record. If you do not have a primary care provider, your telehealth provider may assist you in identifying one. (N.J. Rev. Stat. Ann. § 45:1-62).

New Mexico

You understand that your provider must maintain a medical record for your telehealth visit and that you have the right to access that record. (N.M. Admin. Code § 16.10.5.9).

New York

Patients prescribed GLP-1 medications for weight loss have been provided with the New York Weight-Loss Consumer Bill of Rights. See Appendix below. (N.Y. Gen. Bus. Law § 642).

North Carolina

You understand that the telehealth provider must establish a proper provider-patient relationship and that you have the right to receive a copy of your medical records upon request. (N.C. Gen. Stat. § 90-18.3).

North Dakota

You understand that your telehealth provider is subject to the same standard of care as would apply to an in-person encounter. (N.D. Cent. Code § 23-01-46).

Ohio

Your telehealth provider may forward your medical records to your primary care or treating provider. (Ohio Admin. Code § 4731-37-01(C)(4)).

Oklahoma

You understand that your provider must document the telehealth encounter in your medical record and that you have the right to access your records and to request a copy for your primary care provider. (Okla. Admin. Code § 435:10-7-14).

Oregon

To file a complaint about your provider, contact: Oregon Medical Board, 1500 SW 1st Ave., Suite 620, Portland, OR 97201-5847. Phone: 971-673-2702. Email: complaintresource@omb.oregon.gov. (ORS § 17-52-677.07).

Pennsylvania

You understand that your provider must maintain a complete medical record of your telehealth encounter consistent with in-person medical records requirements, and that you have the right to receive a copy of your records upon request. (49 Pa. Code § 16.95).

Rhode Island

If you communicate with your provider via email or text, you have been informed about applicable security measures including data encryption and password protection, as well as the potential privacy risks associated with electronic communications. (Rhode Island Medical Board Guidelines).

South Carolina

Your medical records may be shared with other treating healthcare practitioners as permitted by applicable law. We can assist you in identifying a primary care medical home upon request. South Carolina Medicaid beneficiaries may withdraw consent at any time. (S.C. Code Ann. § 40-47-37).

South Dakota

You have received disclosures regarding the delivery models and treatment limitations applicable to your care. Your provider has discussed the diagnosis and its evidentiary basis and the risks and benefits of available treatment options with you. (S.D. Codified Laws § 34-52-3).

Tennessee

Tennessee Medicaid recipients may request an in-person assessment prior to receiving a telehealth assessment. (TN Dept. of Mental Health and Substance Abuse Services, Office of Crisis Services Telecommunications Guidelines, p. 8 (2012)).

Texas

Your medical records may be transmitted to your primary care physician within 72 hours. (Tex. Occ. Code Ann. § 111.005).

NOTICE CONCERNING COMPLAINTS: Complaints about physicians and other Texas Medical Board licensees may be directed to: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018. Complaint assistance: 1-800-201-9353. Website: www.tmb.state.tx.us.

Utah

You have the right to: (i) access, supplement, and amend your personal health information; (ii) contact your provider for ongoing care; (iii) obtain a copy of your medical record documenting the telemedicine services; and (iv) request transfer of your medical record to another provider. (Utah Admin. Code r. 156-1-602).

Vermont

You have the right to receive a follow-up consultation with your distant-site provider upon request. To file a complaint about a provider, visit http://www.healthvermont.gov/health-professionals-systems/board-medical-practice/file-complaint. (Vt. Stat. Ann. § 9361; Vt. Board of Medical Practice Policy on Telemedicine, March 1, 2023).

Virginia

You have been informed of security measures used in this telehealth encounter including data encryption, password-protected systems, and other authentication techniques, as well as residual privacy risks that may exist despite those measures. You agree to hold ARSYNL Rx and affiliated providers harmless for information lost due to technical failures and provide express consent to transmission of patient-identifiable information to third parties as necessary for your care. (Virginia Board of Medicine Guidance Document 85-12).

Washington

You have additional rights regarding your consumer health data under the Washington My Health My Data Act. Please review our My Health My Data Privacy Policy. You may withdraw consent to telehealth services at any time without affecting your right to future care. (RCW Chapter 70.372; Wash. Admin. Code § 246-922-790).

West Virginia

You understand that your telehealth provider must maintain a medical record for your visit consistent with in-person documentation requirements, and that you have the right to access and receive copies of those records. (W. Va. Code § 30-3-13a).

Wisconsin

You understand that your provider must document the telehealth encounter in your medical record and that you have the right to access your records upon request. (Wis. Stat. § 448.9645).

Wyoming

You understand that your telehealth provider is subject to the same standard of care as applies to in-person encounters, and that you have the right to access and receive a copy of your medical records. (Wyo. Stat. Ann. § 33-26-102).

Appendix — Weight-Loss Consumer Bill of Rights (Florida and New York)

For patients prescribed GLP-1 medications (including compounded or branded semaglutide or tirzepatide) for weight loss in Florida or New York, the following statutory disclosures apply:

  • WARNING: Rapid weight loss may cause serious health problems. Rapid weight loss is defined as loss of more than 1.5 to 2 pounds per week, or more than 1 percent of body weight per week after the second week of a weight-loss program.
  • Consult your physician before beginning any weight-loss program or taking any weight-loss medications.
  • Long-term weight control through permanent lifestyle changes — including nutritious eating and regular physical activity — is the safest and most sustainable approach to weight management.
  • You have the right to ask about your provider’s qualifications and training in nutrition, obesity medicine, and metabolic health.
  • You have the right to: (a) ask questions about the health risks associated with this program and its psychological and educational support components; (b) receive an itemized list of the actual or estimated costs of the program, including products, services, supplements, and lab tests; (c) know the expected duration of the program; and (d) know the identity and qualifications of any dietitian or nutritionist who has reviewed and approved the program.

Acknowledgment and Signature

By signing below or acknowledging electronically through the ARSYNL Rx platform, you confirm that you have read and understood this document, have had an opportunity to ask questions, and freely give your informed consent to receive telehealth services from the independent licensed providers affiliated with ARSYNL Rx under the terms described herein.

Questions? Contact us at support@arsynlrx.com.