Informed Consent for Telehealth Services

1. Nature and Scope of Telehealth

Telehealth involves the use of electronic communication technologies to deliver healthcare services when the patient and the healthcare provider are not in the same physical location. During your telehealth consultation with Bertrand Desilva MD INC. (the “Practice”), you will interact with your provider through a secure, real-time video and audio platform approved by our Practice.

Telehealth is not a separate type of medicine. It is a method of delivering healthcare services using technology. The same standard of care that applies to in-person visits applies to telehealth consultations.

In the context of sleep medicine, telehealth may be used for:

• Initial sleep medicine consultations and evaluation of sleep complaints.
• Review and interpretation of home sleep test (HST) results and in-lab polysomnography (PSG) findings.
• Diagnosis of sleep disorders, including obstructive sleep apnea (OSA), central sleep apnea (CSA), insomnia, hypersomnia, restless legs syndrome, circadian rhythm disorders, and other sleep-related conditions.
• Treatment planning, including CPAP and BiPAP therapy initiation, oral appliance therapy coordination, positional therapy, and behavioral or lifestyle recommendations.
• Follow-up appointments to monitor treatment progress, review compliance data (e.g., CPAP usage reports), adjust therapy settings, and address ongoing concerns.
• Prescription of medications related to sleep disorders, subject to the limitations described in Section 11.
• Coordination with referring physicians, dentists, durable medical equipment (DME) suppliers, and other specialists involved in your care.
• Dental sleep medicine consultations, including evaluation for oral appliance therapy candidacy and coordination with qualified dental providers.
• Second opinions on previously obtained diagnoses, sleep studies, or treatment plans.

2. Your Rights as a Telehealth Patient

As a patient receiving telehealth services from our Practice, you have the following rights under California law and applicable federal regulations:

2.1 Right to Withdraw Consent

You have the right to withdraw your consent for telehealth services at any time, before or during your consultation, without affecting your right to future care or treatment. You may withdraw consent verbally during a session or in writing at any time. Withdrawal of consent will not result in penalties, discrimination, or any adverse impact on your access to care.

2.2 Right to Request In-Person Visit

You have the right to request an in-person visit with a healthcare provider at any time. If your provider determines that telehealth is not clinically appropriate for your condition, they will recommend in-person evaluation and provide appropriate referrals. You will never be denied care solely because you prefer an in-person visit.

2.3 Right to Provider Information

You have the right to receive information about the provider conducting your telehealth visit, including their full name, professional qualifications, credentials, board certifications, licensing jurisdiction, supervising physician (if applicable), and contact information. This information will be provided at or before the time of your appointment.

2.4 Right to Privacy and Confidentiality

You have the right to the same level of privacy and confidentiality during a telehealth visit as you would during an in-person visit. Your telehealth session is protected by HIPAA, the California Confidentiality of Medical Information Act (CMIA), and all other applicable privacy laws. For complete information on how we protect your health information, please review our Privacy Policy.

2.5 Right to Access Your Records

You have the right to access your medical records, including documentation from telehealth visits, in accordance with HIPAA and California law. See our Privacy Policy for details on how to request your records.

2.6 Right to a Second Opinion

You have the right to seek a second opinion from another qualified healthcare provider at any time, whether regarding a diagnosis, treatment recommendation, or any other aspect of your care.

2.7 Right to Understand Costs

You have the right to know the cost of your telehealth consultation before your appointment. Our fees are clearly displayed on our website. You have the right to ask questions about billing, payment, and insurance reimbursement before consenting to services.

2.8 Right to File a Complaint

You have the right to file a complaint if you believe your rights have been violated or if you are dissatisfied with the quality of care received during a telehealth visit. See Section 16 for complaint procedures.

3. Benefits of Telehealth

Telehealth consultations offer several potential benefits:

• Convenience: Attend your appointment from the comfort and privacy of your own home or another private location, without the need to travel to a clinic.
• Improved Access: Access board-certified sleep medicine expertise regardless of your distance from our office, particularly beneficial for patients in underserved, rural, or remote areas of California.
• Reduced Travel: Eliminate travel time, transportation costs, parking expenses, and the need to take extended time away from work or family responsibilities.
• Timely Follow-Up: Facilitate more frequent and timely follow-up visits to monitor treatment progress and make therapy adjustments.
• Continuity of Care: Maintain consistent access to your sleep medicine provider without interruption due to distance, mobility limitations, or scheduling constraints.
• Reduced Exposure: Minimize potential exposure to infectious diseases in clinical waiting areas.
• Comfort and Compliance: Some patients may feel more comfortable and communicate more openly in their own environment, which can improve diagnostic accuracy and treatment compliance.

4. Risks and Limitations

Telehealth, like all forms of healthcare delivery, has certain risks and limitations that you should understand before consenting:

4.1 Technology-Related Risks

• Technical Failures: The quality of your telehealth visit may be affected by poor internet connectivity, hardware malfunctions, software errors, power outages, or platform downtime. These issues may result in interruptions, delays, or degraded audio and video quality. In some cases, a visit may need to be rescheduled or converted to a telephone-only consultation (see Section 7 for our technical failure protocol).
• Security Risks: Despite the use of encryption and HIPAA-compliant platforms, electronic communications carry an inherent risk of interception, unauthorized access, or data breach. No electronic communication system is entirely immune from risk.

4.2 Clinical Limitations

• Inability to Perform Physical Examination: Telehealth does not allow the provider to perform a hands-on physical examination. Certain clinical findings that would be apparent during an in-person visit — such as airway assessment, neck circumference measurement, blood pressure reading, or auscultation — may not be detectable or fully assessable via video.
• Diagnostic Limitations: In some cases, the provider may not be able to make a definitive diagnosis solely through a telehealth visit and may need to order additional diagnostic testing (e.g., home sleep test, in-lab polysomnography, blood work, imaging) or refer you for in-person evaluation.
• Potential Need for In-Person Follow-Up: Based on the information gathered during your telehealth visit, your provider may determine that an in-person examination, additional testing, or referral to another specialist is necessary to complete your evaluation or treatment plan.
• Equipment Limitations: Certain aspects of sleep medicine care — such as CPAP mask fitting, oral appliance fitting, or device troubleshooting — may have limitations in a telehealth setting and may require in-person follow-up or coordination with local DME providers.

4.3 Patient-Side Risks

• Environmental Privacy: We cannot control who may be present in your physical environment during a telehealth session. Others in your household, workplace, or surroundings may be able to see or hear your consultation. You are responsible for ensuring you are in a private setting.
• Device Security: The security of your personal device (computer, phone, tablet) and network connection is your responsibility. An unsecured device or network may increase the risk of unauthorized access to your session.

5. Patient Responsibilities

By consenting to telehealth services, you agree to the following responsibilities:

5.1 Before Your Appointment

• Provide accurate and complete information about your medical history, current symptoms, medications, allergies, and any other information relevant to your care.
• Complete all required intake forms, questionnaires, and documentation prior to your scheduled appointment.
• Verify that your technology (device, camera, microphone, internet connection) meets the requirements described in Section 6.
• Have a valid, government-issued photo identification ready to present at the start of your first telehealth visit for identity verification purposes.
• Ensure you are in a private, quiet, and well-lit location where you can speak freely and be clearly seen and heard by your provider.

5.2 During Your Appointment

• Participate in your telehealth visit from a stationary, private location. Do not participate while driving, operating machinery, or in a public setting where others can overhear your conversation.
• Have relevant medical records, medication bottles, CPAP compliance reports, or other materials available for review if requested by your provider.
• Inform your provider if anyone else is present in the room with you at the start of the session.
• Inform your provider of your current physical location (city and state) at the start of each session for licensing and emergency protocol purposes.

5.3 After Your Appointment

• Follow your provider's treatment recommendations, take prescribed medications as directed, and attend recommended follow-up appointments.
• Contact our office promptly if you experience any adverse reactions to treatments, worsening of symptoms, or new concerns.
• Submit any required documentation, insurance information, or payment in a timely manner.

6. Technology Requirements

To participate in a telehealth consultation, you will need:

• Device: A computer, tablet, or smartphone with a functioning screen capable of displaying video. A device with a screen size of at least 5 inches is recommended for optimal viewing.
• Internet Connection: A reliable, high-speed internet connection (broadband, fiber, or cellular data). A minimum speed of 10 Mbps download and 5 Mbps upload is recommended for optimal video quality. You may test your internet speed at speedtest.net before your appointment.
• Camera and Microphone: A functioning camera and microphone, either built into your device or connected externally. You must grant the telehealth platform permission to access your camera and microphone.
• Speaker or Headphones: Built-in speakers or headphones for audio. Headphones are recommended for additional privacy.
• Browser or Application: A current, supported web browser (such as Google Chrome, Apple Safari, Mozilla Firefox, or Microsoft Edge) or the designated telehealth application, as specified in your appointment confirmation email. Please ensure your browser or application is updated to the latest version.
• Environment: A private, quiet, and well-lit location where you can speak freely and be clearly seen and heard by your provider. Avoid backlighting (e.g., sitting with a bright window behind you) for optimal video quality.

If you need assistance setting up your technology or testing your connection before your appointment, please contact our office at least 24 hours in advance.

7. Technical Failure Protocol

If a technical failure occurs during your telehealth session, the following protocol will apply:

1. Brief Interruption (under 2 minutes): Your provider will wait on the platform for you to reconnect. Please refresh your browser or application and rejoin the session using your original link.
2. Extended Interruption (2–5 minutes): If you are unable to reconnect within 2 minutes, our office will attempt to contact you by phone at the number on file to troubleshoot or continue the consultation by telephone if clinically appropriate.
3. Session Cannot Resume: If the session cannot be resumed by video or telephone, our office will contact you within one (1) business day to reschedule at no additional charge. You will not be billed for a session that could not be completed due to technical failure on our end.
4. Telephone-Only Continuation: If both parties agree, a session interrupted by video failure may continue as a telephone-only consultation. Your provider will document this in your medical record. Telephone-only consultations carry additional clinical limitations (no visual assessment), which your provider will explain.

It is your responsibility to ensure your internet connection and equipment are functioning properly before your appointment. If technical failures are attributable to your equipment, internet connection, or environment, standard cancellation and rescheduling policies may apply.

8. Emergency Protocols

8.1 Emergency Preparedness

At the start of each telehealth session, your provider will confirm your current physical location (city and state). This information is necessary so that emergency services can be dispatched to your location if a medical emergency occurs during your session.

8.2 Emergency During a Session

If you experience a medical emergency during a telehealth session:

• Your provider will instruct you (or anyone present with you) to call 911 immediately.
• Your provider will remain on the line until emergency services have been contacted.
• Your provider will provide emergency dispatchers with your location and relevant clinical information to the extent possible.
• Your provider will document the event in your medical record.

8.3 Emergency Resources

If you experience an emergency, call 911 or go to the nearest emergency department.

National Crisis Resources:

• National Suicide Prevention Lifeline: 988 (call or text)
• Crisis Text Line: Text HOME to 741741
• Poison Control: 1-800-222-1222

9. Provider Credentials

9.1 Lead Provider

Telehealth consultations may be conducted by licensed providers affiliated with the Practice

9.2 Additional Providers

Telehealth consultations may also be conducted by licensed providers affiliated with the Practice. All providers:

• Are licensed in the State of California (and may hold additional state licenses).
• Have been credentialed and privileged by our Practice.
• Practice within their scope of licensure and in accordance with California law governing supervisory relationships.
• Are bound by our Practice's Privacy Policy, this Telehealth Consent, and all applicable HIPAA and state privacy regulations.

You will be informed of the specific provider conducting your visit at the time of scheduling. You have the right to request a visit with a specific provider, subject to availability.

10. Recording and Documentation

10.1 Clinical Documentation

Your telehealth visit will be documented in your electronic health record (EHR) in the same manner and with the same level of detail as an in-person visit. Documentation includes clinical notes, diagnoses, treatment plans, prescriptions, referrals, and any orders placed during or as a result of your visit.

10.2 Session Recording

Telehealth sessions are generally not recorded. Clinical information from your visit will be documented in your electronic medical record in the same manner as an in-person visit. Recording will only occur if necessary for clinical or compliance purposes and with your explicit consent.

• You will be notified at or before the start of any session that may be recorded.
• Your explicit verbal or written consent will be obtained before any recording begins.
• If you decline to be recorded, the session will proceed without recording and your care will not be affected.
• Recordings, if made, become part of your medical record and are subject to all protections afforded to Protected Health Information (PHI) under HIPAA, the CMIA, and our Privacy Policy.
• Recordings are stored on HIPAA-compliant, encrypted servers and retained in accordance with our data retention schedule (see our Privacy Policy, Section 9).

10.3 Patient Recording

You may not record the telehealth session (audio, video, screenshot, or screen capture) without the prior written consent of your provider. Unauthorized recording may violate California law (Cal. Penal Code § 632) and may result in termination of the session. If you wish to record a session for personal reference, please request permission from your provider at the start of the visit.

11. Prescribing Practices and Limitations

11.1 General Prescribing

Your provider may prescribe medications related to the diagnosis and treatment of sleep disorders during or following a telehealth consultation. Prescriptions will be transmitted electronically to the pharmacy of your choice, where available, or provided via other secure methods in compliance with applicable law.

11.2 Controlled Substances

The prescribing of controlled substances (Schedules II–V) via telehealth is subject to federal and state regulations, including the Ryan Haight Online Pharmacy Consumer Protection Act (21 U.S.C. § 829) and California Health and Safety Code Section 11150 et seq.:

• Your provider will comply with all applicable DEA regulations regarding telehealth prescribing of controlled substances, including any requirements for in-person evaluation, valid DEA registration, and state-specific telehealth prescribing rules.
• Certain controlled substances may not be prescribed via telehealth without a prior in-person examination, depending on the substance and current federal and state regulations. Your provider will inform you if an in-person visit is required before a controlled substance can be prescribed.
• Telehealth prescribing flexibilities granted during the COVID-19 public health emergency may be subject to change. Our Practice will comply with the most current regulations in effect at the time of your visit.

11.3 Durable Medical Equipment (DME)

Prescriptions for durable medical equipment (e.g., CPAP machines, BiPAP machines, oral appliances, pulse oximeters) may be issued following a telehealth consultation. DME is typically provided through third-party suppliers and may involve separate charges, insurance processing, and delivery timelines that are outside our Practice's direct control.

12. Cross-State Telehealth

12.1 Licensing Requirements

Our providers are licensed to practice medicine in the State of California and may hold additional licenses in other states. If you are physically located outside of California at the time of your telehealth appointment, you must inform our office at the time of scheduling and your provider at the start of the session.

12.2 State-Specific Regulations

Different states have varying telehealth regulations, scope-of-practice rules, prescribing laws, and privacy requirements. We are only authorized to deliver care to you via telehealth in states where your provider holds an active, unrestricted license. If we are unable to provide care due to licensing restrictions:

• We will inform you as soon as possible, preferably before your scheduled appointment.
• We will not bill you for a session that cannot proceed due to our licensing limitations.
• Where possible, we will assist with referrals to qualified providers in your state.

12.3 Your Responsibility

It is your responsibility to inform us of your physical location at the time of each telehealth visit. Providing a false or inaccurate location may impact the legality and validity of your visit, any prescriptions issued, and our ability to coordinate emergency services if needed.

13. AI and Automated Systems Disclosure

Our Practice may use artificial intelligence (AI) and automated technologies in connection with the delivery of telehealth and related services. These may include:

• AI-Powered Phone Systems: Automated phone agents that may answer calls, schedule appointments, collect preliminary information, or route your call to the appropriate team member. You will be clearly notified when you are interacting with an AI system rather than a human.
• Automated Appointment Reminders: Text messages, emails, or phone calls generated by automated systems to remind you of upcoming appointments or follow-up actions.
• Clinical Decision Support: AI-assisted tools that may help your provider analyze sleep study data, identify patterns, or AI-assisted tools that may help organize or analyze data related to sleep studies. All clinical decisions are made by your licensed provider, not by AI. AI tools are used as supplementary aids only.
• Chatbots and Virtual Assistants: If deployed on our website or patient portal, AI-powered chatbots may help you with scheduling, general questions, or navigation. Chatbots do not provide medical advice and are not a substitute for consultation with your provider.

13.1 Your Rights Regarding AI

• You have the right to know when you are interacting with an AI or automated system.
• You have the right to request to speak with a human at any time during an interaction with an AI system.
• AI systems will not make clinical decisions about your diagnosis or treatment. All clinical decisions are made by licensed healthcare providers.
• Interactions with AI systems may be recorded, transcribed, and stored in accordance with our Privacy Policy (Section 8) and applicable law.

14. Minors and Legal Guardians

14.1 Consent for Minors

If the patient is under the age of eighteen (18), a parent or legal guardian must:

• Provide informed consent for telehealth services on behalf of the minor patient by reviewing and agreeing to this document.
• Be present and visible on camera during the telehealth consultation, unless otherwise directed by the provider or permitted by California law.
• Provide accurate identification for both themselves and the minor patient.
• Serve as the primary point of contact for scheduling, follow-up, and billing.

14.2 Minors' Rights Under California Law

In accordance with California law, minors twelve (12) years of age and older may consent to certain types of healthcare services on their own, including mental health treatment and certain other categories of care. If applicable, our Practice will honor these rights. Your provider will discuss any relevant minor consent provisions with you and the minor patient as appropriate.

14.3 Custody and Access

In cases involving shared custody, we will follow applicable court orders regarding medical decision-making authority. If there is a custody dispute affecting medical consent, please provide our office with relevant legal documentation before the appointment.

15. Financial Responsibility

By consenting to telehealth services, you acknowledge and agree to the following financial terms:

15.1 Payment

Full payment for your telehealth consultation is required at the time of booking unless other arrangements have been made in advance. We accept major credit cards, debit cards, and other payment methods as indicated on our website.

15.2 Fee Transparency

Our consultation fees are clearly displayed on our website. You will know the exact cost of your visit before booking. If additional services are recommended during your visit that would involve separate charges, your provider will inform you before proceeding.

15.3 Insurance

We may provide a detailed receipt or superbill that you can submit to your insurance company for potential out-of-network reimbursement. We do not guarantee that your insurance will reimburse you for telehealth services. It is your responsibility to verify your insurance coverage, including any telehealth- specific benefits or limitations, before your appointment.

15.4 Additional Services

Diagnostic tests (such as home sleep tests), durable medical equipment (such as CPAP machines), oral appliances, lab work, and prescriptions are not included in the consultation fee and may involve separate charges from third-party providers, suppliers, laboratories, or pharmacies. Our Practice is not responsible for charges assessed by third parties.

15.5 Cancellation and No-Show Policy

• Cancellation: If you need to cancel or reschedule your appointment, please notify our office at least 24 hours before your scheduled visit. Cancellations made with less than 24 hours' notice may be subject to a cancellation fee.
• No-Show: If you do not appear for your scheduled telehealth appointment and do not contact our office, you may be charged a no-show fee.
• Late Arrival: If you join your telehealth session more than 10 minutes after the scheduled start time, your provider may need to shorten the session or reschedule. Late arrivals do not extend the scheduled session time.
• Technical Failure: If a session cannot be completed due to technical failure, the provisions of Section 7 apply. You will not be charged for sessions that could not be completed due to technical issues on our end.

Cancellation and no-show fee amounts are posted on our website. Fees are subject to change with notice.

15.6 Refund Policy

If you are dissatisfied with the billing for a telehealth service, or if you believe you were charged in error, please contact our office within thirty (30) days. We will review your concern and issue a refund or adjustment if warranted.

16. Complaints and Grievances

If you have concerns about the quality of care received during a telehealth visit, the conduct of a provider, or any aspect of our telehealth services, you may:

You will not be penalized, retaliated against, or treated differently for filing a complaint.

17. Governing Law

This Informed Consent for Telehealth Services shall be governed by and construed in accordance with the laws of the State of California, including but not limited to California Business and Professions Code Section 2290.5, the California Confidentiality of Medical Information Act (Cal. Civ. Code § 56 et seq.), and applicable federal law, including HIPAA and the HITECH Act. Any disputes arising from or related to telehealth services provided by our Practice shall be subject to the jurisdiction of the courts of the State of California, County of Orange.

18. Relationship to Other Documents

This Informed Consent for Telehealth Services is part of a suite of legal and compliance documents governing your relationship with our Practice. By consenting to telehealth services, you also acknowledge the following related documents:

• Privacy Policy and Notice of Privacy Practices: Describes how we collect, use, protect, and disclose your health and personal information.
• Terms of Service: Governs your use of our website and digital services.

In the event of a conflict between this Telehealth Consent and our Privacy Policy, the more protective provision shall apply with respect to your health information. In the event of a conflict between this Telehealth Consent and the Terms of Service, this Telehealth Consent shall control with respect to the delivery of clinical care.

19. Consent Acknowledgment

19.1 Electronic Signature Acknowledgment

If you are providing consent electronically (via our website, patient portal, or electronic form), you acknowledge that your electronic signature, click-through acceptance, or typed name constitutes a valid and binding signature under the Electronic Signatures in Global and National Commerce Act (E-SIGN Act, 15 U.S.C. § 7001 et seq.) and the California Uniform Electronic Transactions Act (Cal. Civ. Code § 1633.1 et seq.), with the same legal effect as a handwritten signature.

20. Language Access and Accommodations

If you have limited English proficiency, you may be entitled to language assistance services, including qualified interpreters and translated documents, at no cost to you. If you require disability-related accommodations for your telehealth visit (e.g., closed captioning, sign language interpretation, screen reader compatibility), please contact our office at least 48 hours before your appointment so we can make appropriate arrangements.

We are committed to ensuring that our telehealth services are accessible to individuals with disabilities in compliance with the Americans with Disabilities Act (ADA) and Section 508 of the Rehabilitation Act.

Contact Information

If you have questions about this consent form, our telehealth services, or any aspect of your care, please contact us: