Purpose: This form provides information and secures your informed consent to receive medical and mental health care services using telehealth technology. It addresses applicable federal and state-specific requirements governing telehealth.

1. Nature of Telehealth

Telehealth allows health care professionals to evaluate, diagnose, and treat patients at a distance using telecommunications technology. Services may include, but are not limited to:

• Health history review
• Consultations and assessments
• Prescription of medications
• Nutrition and mental health counseling
• Follow-up care coordination

2. Parties Involved

Clinical services are provided by independent, licensed medical providers affiliated with Sheba Health, including Lilac Health PLLC. Sheba Health is a technology and administrative platform and does not itself render clinical care.

3. Potential Benefits

• Improved access to care regardless of location
• Greater efficiency and reduced travel time
• Continuity of care and access to specialists

4. Potential Risks

• Incomplete assessments due to the lack of physical examination
• Delays or limitations due to technical failures
• Potential security breaches or unauthorized access to PHI (Protected Health Information)

5. Privacy and Security

Telehealth services are delivered through secure, HIPAA-compliant systems. Your information is protected as required by:

• The Health Insurance Portability and Accountability Act (HIPAA)
• State-specific privacy laws (e.g., CCPA in California, Oregon Health Information Protection Act)
• Data security best practices

Your provider will maintain confidentiality of your records and will not release information without your written consent unless required by law.

6. Consent and Right to Refuse

By signing this form, you:

• Consent to participate in telehealth visits
• Understand that you may withdraw consent at any time
• Acknowledge telehealth is voluntary and alternative in-person care is available when needed
• Agree that your provider will determine appropriateness of telehealth for your care

7. Emergencies

Telehealth is not intended for emergency care. In a medical emergency, you should dial 911 or go to the nearest emergency room.

8. Provider Licensing Requirements

You confirm that you are physically located in a U.S. state where your provider is licensed to practice at the time of your telehealth session.

9. Communication and Follow-Up

• Communication will occur through secure messaging and scheduled virtual sessions.
• You may contact your provider through the Sheba Health platform for follow-up questions or concerns.

10. Additional State-Specific Disclosures

The following disclosures apply to users accessing the Sheba Health platform for the purposes of participating in a telehealth visit as required by the states listed below:

Florida (Fla. Stat. §46.001)

I have received a copy of the Florida Weight Loss Consumer Bill of Rights, as set forth below: 

Warning: 

• Rapid weight loss may cause serious health problems.  Rapid weight loss is weight loss of more than 1 ½ 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 your weight loss provider are available upon request.

You have a right to:

1. Ask question about the potential health risks of this program and its nutritional content, psychological support, and educational components. 
2. Receive an itemized statement of the actual or estimated price of the weight-loss program, including extra products, services, supplements, examinations, and laboratory tests.
3. Know the actual or estimated duration of the program.
4. Know the name, address, and qualifications of the person who has reviewed and approved the weight loss program according to section 468.505(1)(j), Florida Statutes.

I have been informed that if I want to check the licensing details for a provider I can visit the Florida Department of Health’s website, https://mqa-internet.doh.state.fl.us/MQASearchServices/HealthCareProviders

Illinois (Public Act 102-104)

I have been informed that if I want to register a formal complaint about a provider in the State of Illinois, I should contact the Illinois Department of Financial and Professional Regulation (IDFPR). Complaint forms and instructions are available on the IDFPR website:
https://www.idfpr.com/admin/DPR/DPRcomplaint.asp

New York (N.Y. Pub. Health Law § 2999-cc)

I have been informed that to get information regarding your rights and how to report professional misconduct, I should visit here: https://www.health.ny.gov/professionals/doctors/conduct.

Oregon (ORS 441.224)

I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here: https://www.oregon.gov/omb/investigations/pages/how-to-file-a-complaint.aspx.

Additional consent requirements apply for minors and behavioral health.

Texas (Tex. Occ. Code §1111.001)

I have been informed of the following notice:

NOTICE CONCERNING COMPLAINTS – Complaints about physicians, as well as other licensees and registrants of the Texas Medical Board, including physician assistants, acupuncturists, and surgical assistants may be reported for investigation at the following address: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018, Assistance in filing a complaint is available by calling the following telephone number: 1-800-201-9353, For more information, please visit our website at www.tmb.state.tx.us.  

AVISO SOBRE LAS QUEJAS- Las quejas sobre médicos, asi como sobre otros profesionales acreditados e inscritos del Consejo Médico de Tejas, incluyendo asistentes de médicos, practicantes de acupuntura y asistentes de cirugia, se pueden presentar en la siguiente dirección para ser investigadas: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018, Si necesita ayuda para presentar una queja, llame al: 1-800-201-9353, Para obtener más información, visite nuestro sitio web en www.tmb.state.tx.us   

Vermont

I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here; Or, the Vermont Board of Osteopathic Examiners’ website, here.

11. Revocation of Consent

You may revoke this consent in writing at any time. However, such revocation will not affect actions taken before the revocation.

12. Contact Information

For questions about your rights or telehealth practices, contact:

Sheba Health Telehealth Support
Email: support@shebahealth.com
Phone: (815) 955-8323
Website: www.shebahealth.com

13. Patient Acknowledgment and Signature

By signing below, you confirm that:

• You have read and understand this consent form
• You are located in a state where the provider is licensed
• You agree to receive care through telehealth under the conditions described above

How to Contact Us:

Sheba Health, LLC. 
Attn: Privacy Officer
992 Brook Forest Ave, #1039
Shorewood, IL 60404
Telephone: (815) 955-8323
Email: privacy@shebahealth.co