Consent for Telehealth Services
Informed Consent Regarding Use of Telemedicine Services Appendix Health, PLLC, doing business as Heart Hippo, and affiliates (including Appendix, Inc., doing business as Heart Hippo, collectively "Heart Hippo")
This Consent for Telehealth Services ("Consent") is presented to you at checkout and at other points throughout your use of the Heart Hippo website (the "Site"). By selecting the confirmation checkbox at checkout, by signing electronically as described below, or by visiting, accessing or using the Site to receive telehealth services, you accept this Consent in its entirety.
Adults Acting on Behalf of Minor Patients
If the patient receiving telehealth services in connection with this Consent is a minor (under eighteen (18) years of age, or otherwise under the age of majority in his or her jurisdiction), this Consent is being given by the minor's parent or legal guardian. By executing this Consent, you represent and warrant that you:
(i) are the parent or legal guardian of the minor patient and have the legal authority to consent to the minor's medical care; (ii) have reviewed this Consent in its entirety, understand it, and accept it on the minor's behalf; (iii) will provide complete and accurate medical information about the minor patient; and (iv) acknowledge that all references herein to "you," "the patient," or similar terms refer to the minor patient when this Consent is being given on the minor's behalf, except where context plainly refers to the consenting parent or legal guardian.
If you are an adult patient signing for yourself, this section does not apply to you.
PURPOSE
The purpose of this Consent is to provide you with information about telemedicine and to obtain your informed consent to participate in a telemedicine health service as part of your medical care.
NATURE OF TELEMEDICINE
Telemedicine involves the use of electronic communications to enable a health care provider and a patient at different locations to share medical information for the purpose of evaluation, diagnosis, consultation, or treatment of the patient. The delivery of healthcare via telemedicine allows the patient and provider to establish a relationship, much as they would during a traditional face-to-face appointment. For example, your telemedicine encounter may include interaction through and with the use of the internet, audio communications, medical imaging, medical tests, and related technologies known as "store-and-forward" technologies, in each case for the purposes of making appropriate diagnoses.
BENEFITS
The benefits of telemedicine include improved access to medical services and care, including the expertise of specialists and consultants that may not otherwise be available to you. Telemedicine also permits increased efficiency in evaluations, diagnoses, consultations, and treatment.
POTENTIAL RISKS
The potential risks associated with the use of telemedicine are rare, but such risks include delays in medical evaluation and treatment due to equipment failures or information transmission deficiencies (such as poor image resolution); breach of privacy of protected health information due to security breaches or failures; and adverse drug interactions, allergic reactions, complications, or other errors due to the patient's failure to provide complete medical information or records.
INDEMNIFICATION
YOU AGREE TO INDEMNIFY AND HOLD HARMLESS HEART HIPPO AND ITS EMPLOYEES, AGENTS, DIRECTORS, OFFICERS, MANAGERS, SHAREHOLDERS, REPRESENTATIVES, ASSIGNS, PARENTS, PREDECESSORS, AND SUCCESSORS FROM AND AGAINST ANY AND ALL LOSS, DAMAGE, EXPENSE, LIABILITY, CLAIM, OR DEMAND WHATSOEVER, ARISING OUT OF OR RELATED TO ANY FAILURE OF TECHNOLOGY OR EQUIPMENT IN CONNECTION WITH THE PROVISION OF TELEMEDICINE, WHETHER OR NOT ANY SUCH LOSS, DAMAGE, EXPENSE, LIABILITY, CLAIM, OR DEMAND ARISES FROM OR RELATES TO HEART HIPPO'S NEGLIGENCE.
ALTERNATIVES
Alternative methods of care may be available to you, such as in-person services. Your provider will explain any such options to you, and you may choose an alternative at any time.
FOLLOW-UP CARE; EMERGENCY SITUATIONS
In some situations, telemedicine is not an appropriate method of care. If there is an urgent situation, if you have an adverse reaction, if a technical failure prevents you from communicating with your telemedicine provider, or if you believe telemedicine will not provide sufficient safety and quality, you should contact Heart Hippo as indicated below. If the contacts listed below are unavailable, you must seek care at an emergency room facility or other provider equipped to deliver urgent or emergent care. If the situation is an emergency, call 911. Heart Hippo does not provide emergency medical services and is not appropriate for urgent or emergent medical care.
Contact Email: hello@hearthippo.com
YOUR PRIVACY RIGHTS
Heart Hippo uses network and software security protocols to protect the confidentiality of your patient health information, including, for example, your medical record, EMR, imaging, and personal financial data. These protocols are designed to safeguard the data and to ensure its integrity against corruption. Personal information that identifies you or contains protected health information will not be disclosed to any third party without your consent, except as authorized by law for the purposes of consultation, treatment, payment/billing, and certain administrative purposes, or as otherwise set forth in Heart Hippo's Notice of Privacy Practices and Privacy Policy.
ACKNOWLEDGMENTS
By signing this form, I understand the following:
Telemedicine is the use of electronic information and communication technologies by a health care provider to deliver services to an individual when such individual is located at a different site than the provider. I understand that I need to provide a full and accurate medical history, including any pre-existing conditions, to my telemedicine provider so that my provider can accurately determine what services I need. I further understand that my provider will determine whether telemedicine is appropriate for me at this time, based on the condition being diagnosed and/or treated. I understand that I may benefit from telemedicine, but that results cannot be guaranteed. My provider will inform me who will be present at the provider's location during the delivery of the telemedicine services, and I have the right to exclude anyone from being present, if I so choose. I further understand that I have the right to object to the use of a telemedicine service without prejudice to any future care or treatment and without risking the loss or withdrawal of any health benefits to which I am entitled. If there are costs to me associated with my telemedicine encounter, a health care professional will discuss those costs with me prior to the start of my session. Further, I understand and agree that I must pay the full amount of the costs associated with this telemedicine consultation, including any prescription I may receive, and I will not attempt to submit a claim for the telemedicine consultation fee to Medicare, any other federal payor, or any state or private insurer. I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine, and I agree that Heart Hippo may provide my confidential personal health information to other medical providers who may be located in other areas, including on rare occasions to providers outside the State, as necessary. I have the right to inspect and obtain copies of all information received and recorded during any telemedicine session, subject to the policies of the physicians, physician assistants, nurse practitioners and facilities involved in my care. I may be charged a fee for copies of my records in accordance with applicable State rules. I have read and understand the information above and all of my questions have been answered to my satisfaction.
I consent to a Heart Hippo physician, physician assistant, or nurse practitioner providing services to me via telemedicine.
I consent to Heart Hippo sending my patient health information to me via email and text message communications.
DEVICE FULFILLMENT AND MONITORING
Cardiac monitoring services made available through Heart Hippo are fulfilled using the Zio® patch, a wearable cardiac monitor manufactured by iRhythm Technologies, Inc. ("iRhythm"). After your telehealth visit, the Zio® patch is shipped directly to you for in-home application. You will wear the device for the prescribed monitoring period (typically up to fourteen (14) days), after which you return the device to iRhythm using the prepaid return packaging included with the device.
iRhythm processes the raw cardiac waveform data captured by the device and prepares a monitoring report. A Heart Hippo-affiliated clinician then reviews the report and communicates findings, clinical impressions, and any recommended next steps to you through your Heart Hippo account or other secure communication channels.
I understand that the Zio® patch is provided through iRhythm as Heart Hippo's monitoring partner, that the device must be applied, worn, and returned in accordance with the instructions provided, and that timely return of the device is necessary in order for monitoring data to be processed and reviewed.
ELECTRONIC SIGNATURE
By selecting the confirmation checkbox presented to you at checkout, or by otherwise affirmatively assenting to this Consent through any electronic mechanism made available on the Site, you understand and consent to the foregoing acknowledgments and disclosures, including the Heart Hippo Terms of Service, Privacy Policy, and Notice of Privacy Practices, each of which is hereby incorporated by reference. For purposes of this Consent, YOUR ACT OF SELECTING THE CONFIRMATION CHECKBOX, OR OF OTHERWISE AFFIRMATIVELY ASSENTING TO THIS CONSENT THROUGH ANY ELECTRONIC MECHANISM MADE AVAILABLE ON THE SITE, SHALL CONSTITUTE AND IS YOUR ELECTRONIC SIGNATURE TO THIS CONSENT.
I understand and agree to the foregoing acknowledgments and disclosures. I adopt my electronic confirmation as my signature, and I authorize Heart Hippo to process the documents and signatures provided herewith and to create, store, and communicate electronic records thereof.
Consumer Notices
CALIFORNIA
NOTICE AND ACKNOWLEDGMENT OF RECEIPT AND UNDERSTANDING NOTICE TO PATIENTS
Medical doctors are licensed and regulated by the Medical Board of California.
To check up on a license or to file a complaint go to <www.mbc.ca.gov>, email: licensecheck@mbc.ca.gov, or call (800) 633-2322.
Additional information can be found at https://www.mbc.ca.gov/licensing/Notice-to-Consumers.aspx
The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. It can be found at https://openpaymentsdata.cms.gov.
TEXAS
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 to:
Texas Medical Board
Attention: Investigators
333 Guadalupe, Tower 3, Suite 610
P.O. Box 2018, MC-263
Austin, TX 78768-2018
Assistance in filing a complaint is available by calling 1-800-201-9353. For more information, visit <www.tmb.state.tx.us>
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>.
KANSAS
It is unlawful for any person who is not licensed under the Kansas Healing Arts Act to open or maintain an office for the practice of the healing arts in this State.
This office is maintained under the authority of a person who is licensed to practice the healing arts of Kansas.
Questions and concerns regarding this professional practice may be directed to:
Kansas State Board Of Healing Arts
800 SW Jackson, Lower Level-Suite A
Topeka, Kansas 66612
Phone: (785) 296-7413
Toll Free: 1 (888) 886-7205
Fax: (785) 296-0852
Website: <www.ksbha.org>
This Consent was last modified on May 22, 2026.