Consent to Telehealth Services

Last revision: September 18, 2026

This Consent to Telehealth Services (“Consent to Telehealth”) should be read together with the Terms and Conditions of Use and the Billing, Refund & Cancellation Policy for the Holistic Medical Services United website, of which it forms a part. In this Consent to Telehealth, “you” and “your” refer to the person receiving telehealth services or, where services are used by or on behalf of a minor, to (i) the parent or legal guardian providing consent for the minor and (ii) the minor for whom consent is provided. The purpose of this form is to obtain your informed consent to participate in telehealth services with Holistic Medical Services United.

What Is Telehealth?

Telehealth allows you to meet with a healthcare provider remotely using a phone, computer, or tablet, without visiting a clinic or hospital.

Telehealth may include:

• Electronic transmission of medical records, photo images, personal health information, or other data between you and your provider
• Interactions with your provider via audio, video, and/or data communications
• Use of data from medical devices, sound, and video files

Possible Benefits of Telehealth

• Easier and more convenient access to care and treatment
• The ability to receive care without traveling to a provider’s office
• Reduced exposure to illnesses that may be present in clinics or hospitals

Possible Risks of Telehealth

• Your provider may not be able to perform certain in-person examinations or tests, which may affect medical decision-making.
• Telehealth may not be suitable for all conditions; in some cases an in-person visit may be necessary.
• Technical difficulties, such as a poor internet connection, may interrupt or delay care.
• Privacy and security risks exist, including the possibility that transmitted information could be intercepted despite security measures.

Will My Telehealth Visit Be Private?

Holistic Medical Services United does not record your visits. You should be in a private space so others cannot overhear your conversation. Your provider will let you know if anyone else is present during the visit. We use secure, HIPAA-compliant telehealth technology to protect your privacy, but no system is entirely risk-free.

Your Rights

• You may withhold or withdraw your consent to telehealth at any time without affecting your right to future care or treatment.
• You have the right to access and review your telehealth records as permitted by law.
• You may request an in-person visit if telehealth is not appropriate for your condition, though in-person care may not always be immediately available.

How Much Does a Telehealth Visit Cost?

• Holistic Medical Services United is a self-pay practice. We do not currently accept or bill insurance, and all telehealth visits are paid directly by the patient according to our Billing, Refund & Cancellation Policy.
• All care at Holistic Medical Services United is delivered by telehealth. There is no separate or additional charge for being seen by video, and your rate is confirmed with you before you book.
• If your provider determines that an in-person visit is also necessary, that care is provided by another practice. Its fees are set by that provider, not by us, and would be payable in addition to the cost of your visit with us.
• Patients who wish to seek reimbursement from their insurer may request an itemized receipt (superbill). We do not guarantee reimbursement and are not responsible for the outcome of any claim you submit.

What If I Change My Mind About Telehealth?

• You may stop using telehealth services at any time, including during a visit.
• If you no longer wish to use telehealth, notify us by email at Hello@holisticmedunited.com.
• If you stop using telehealth, you may still receive in-person care when available.

Acknowledgment and Consent

By booking an appointment or continuing to use Holistic Medical Services United’s telehealth services, you accept this Consent to Telehealth. You acknowledge that you understand and agree to the following:

• Telehealth involves the remote delivery of healthcare services, including assessment, diagnosis, treatment, and education, using electronic communication technologies.
• You have read and understand the risks and benefits of telehealth as described above.
• You voluntarily give informed consent for the use of telehealth by providers at Holistic Medical Services United.
• You understand that your provider may determine telehealth is not suitable for your condition and may recommend in-person care instead.
• You acknowledge that Holistic Medical Services United does not accept insurance, submit claims, or verify coverage, and that you are financially responsible for the full cost of your visit.
• You have the right to withdraw your consent at any time without affecting your future healthcare.