Consent to Treat and Receive Virtual Care

Effective Date: May 20, 2025

This Consent to Treat and Receive Virtual Care outlines your rights and responsibilities as a patient receiving telemedicine services from Cercanos. Please read it carefully.

1. Scope of Services

You are requesting telemedicine services from Cercanos, which may include primary care, chronic condition management, behavioral health support, nutrition counseling, and wellness and care coaching (“Services”). Telemedicine involves the delivery of healthcare services using interactive audio and/or video technology that enables you to consult with healthcare professionals remotely.

You will be seen by a Cercanos clinician who is licensed to practice in your state or territory, and who will provide a medical evaluation, diagnosis, treatment, and follow-up care via our secure, HIPAA-compliant telehealth platform.

2. Benefits and Risks of Telemedicine

Benefits:

  • Convenient and timely access to medical care from any private location

  • Reduced travel and wait times

  • Enhanced ability to manage chronic conditions remotely

Risks:

  • Potential for technical failures or disruptions (e.g., poor connectivity, dropped sessions)

  • Rare instances of unauthorized access despite safeguards

  • Limited ability to conduct physical examinations, which may impact diagnosis or treatment

  • Incomplete or inaccurate information due to remote communication may increase risk of clinical error

3. Consent to Treatment

By agreeing to this consent, you authorize Cercanos and its affiliated clinicians and care team to:

  • Provide telehealth consultations and treatment via audio, video, or digital communications

  • Access and use your medical history and relevant health information for diagnosis and treatment

  • Document and store information about your consultation in accordance with privacy laws

You understand that you may not receive prescriptions for controlled substances or drugs with abuse potential through Cercanos telemedicine services.

4. Limitations and Appropriateness

Telehealth may not be appropriate for all medical conditions. You understand that:

  • Telemedicine is not a substitute for in-person care in emergency or life-threatening situations

  • Cercanos clinicians may refer you to in-person care, a local provider, or emergency services if medically necessary

If you experience a medical emergency, you should call 911 or go to the nearest emergency room immediately.

5. Privacy and Confidentiality

Your information is protected under applicable laws including HIPAA. Cercanos uses encryption and secure platforms to protect your PHI.

You agree:

  • Not to record your session or share your login credentials

  • To be in a private, secure location during your visit

  • That clinicians will not record sessions without prior written consent

6. Financial Responsibility

You are responsible for any visit fees or service charges not covered by your insurer, unless alternative payment arrangements have been made. You may be required to pay for services prior to or at the time of your visit, depending on your benefit plan.

7. Your Responsibilities

You agree to:

  • Provide complete and accurate health information during each visit

  • Update your medical records as needed, and at least annually

  • Participate in your treatment plan and follow clinical guidance

9. Right to Withdraw Consent

Your use of Cercanos services is voluntary. You may withdraw your consent at any time by ending your session. Doing so will not affect your right to receive future care.

10. Florida Weight Loss Treatment Consent (For Florida Residents Only)

This section applies only to Florida residents receiving care from Cercanos for weight loss treatment.

  1. By providing consent, I acknowledge that weight loss treatments carry potential risks and benefits, which I will discuss with my provider.

  2. Florida Weight Loss Bill of Rights:

Warning: Rapid weight loss may cause serious health problems. Rapid weight loss is weight loss of more than 1½ pounds to 2 pounds per week or weight loss of more than 1 percent of body weight per week after the second week of participation in a weight-loss program. Consult your personal physician before starting any weight-loss program. Only permanent lifestyle changes, such as making healthful food choices and increasing physical activity, promote long-term weight loss. Qualifications of this provider are available upon request.

You have the right to:

  • Ask questions about the potential health risks of this program and its nutritional content, psychological support, and educational components.

  • Receive an itemized statement of the actual or estimated price of the weight-loss program, including extra products, services, supplements, examinations, and laboratory tests.

  • Know the actual or estimated duration of the program.

  • Know the name, address, and qualifications of the dietitian or nutritionist who has reviewed and approved the weight-loss program according to s. 468.505(1)(j), Florida Statutes.

11. Acknowledgment

By continuing with this virtual visit, you acknowledge that:

  • You have read and understand this Consent to Treat and Receive Virtual Care

  • You agree to receive services from Cercanos via telemedicine

  • You understand the limitations, risks, and benefits of virtual care