• HIV test results are specially protected and may be disclosed only under specific circumstances.
• Mental health patients have a state-law privacy right in their records.
• Substance abuse counselor records require consent, and state law can be more restrictive than Part 2 in some settings.
• Genetic test results have specific disclosure limits in insurance contexts.

If you are located in Louisiana at the time of your telehealth visit, we will make available to you the name, Louisiana license number, contact information, and specialty or area of practice of your treating provider.

You understand how to receive follow-up care and emergency care, how to request copies of your medical records or request that they be sent to another provider, and how to receive care if technology or equipment fails during your telehealth visit.

You will be informed about the role of any other health care provider or personnel who may be present during your telehealth consultation. You may ask questions about their role before continuing the visit.

If you receive behavioral health services, your provider may develop an emergency plan with you, including how to contact local emergency or crisis resources if needed.

• Maine broadly protects health care information and requires authorization for many disclosures. Patients generally may access records within 21 days.
• Mental health records generally need authorization before being shared outside the practitioner’s or facility’s office in nonemergency situations.
• HIV test results generally require written consent before disclosure.
• If a minor lawfully consents to care, the minor controls authorization for disclosure of those records.
• Maine’s HIE excludes mental health and HIV data by default unless the patient opts in, and SUD records are never included.
• Maine shields lawful reproductive and gender-affirming care from certain out-of-state legal consequences.

If you are located in Maine at the time of your telehealth visit, you understand that telehealth may involve benefits and risks, including improved access to care, confidentiality risks, technological failures, and the possible need for crisis services or in-person care.

Your telehealth session will not be recorded without your permission. If any recording is made, you will be informed how the recording will be stored and disposed of.

If you receive behavioral health or social work services, you may be provided local crisis telephone numbers or local emergency mental health telephone numbers as part of your care plan.

To file a complaint about a provider, visit: https://www.maine.gov/md/discipline/file-complaint.html.

• Mental health records generally require patient authorization or a court order, and only relevant information may be released.
• Maryland restricts HIE and electronic network disclosure of abortion-care codes and other sensitive health services unless the disclosure is for claims or the patient gives written consent to a specific treating provider.
• HIV testing outside a health care facility requires a separate written informed consent form.
• Minors may consent to drug abuse, alcoholism, STI, pregnancy, contraception, and HIV prevention services; abortion information may not be disclosed to a parent without the minor’s consent.
• Medical records are confidential, redisclosure is restricted, and unauthorized disclosure may create civil liability.

If you are located in Maryland at the time of your telehealth visit, you understand that a primary difference between telehealth and in-person care is that your provider may not have direct physical contact with you.

You understand that the quality of transmitted data, images, audio, or other information may affect the quality of services provided. For some services, the knowledge, experience, or qualifications of a consultant providing information to your provider may not be completely known to or understood by your provider.

To file a formal complaint about a provider, visit: https://www.mbp.state.md.us/forms/complaint.pdf.

• Mental health providers generally must get consent before sharing treatment information, even for some uses HIPAA would allow.
• HIV test results require written informed consent before disclosure.
• Genetic test results generally require written consent before disclosure.
• Patients may require insurers to send medical information directly to them rather than the policyholder.

• Mental health and SUD records are confidential and may be disclosed only in limited circumstances.
• HIV/AIDS reports, testing, care, and treatment information are confidential and generally require specific written consent for release.
• Genetic testing requires informed consent.
• An executive order provides shield-type protections for reproductive health care that is lawful in Michigan.

• Minnesota generally requires consent before health records are released, with limited exceptions; patients may sue for unauthorized release.
• Mental health records have additional restrictions, including limits on disclosure to family members.
• Reproductive health records cannot be released based on another state’s subpoena law or court order enforcing that state’s law.
• Minors may consent to pregnancy, STI, alcohol/drug abuse, and certain outpatient mental health services; those records are confidential from parents in key circumstances.

• HIV test results are confidential under state law.
• Substance abuse treatment records of pregnant women are absolutely confidential.
• Minors may consent to care for STIs, substance abuse, and pregnancy, and those records receive confidentiality protections.

• Your genetic and neural data require express consent for collection, use, and disclosure. Separate consent is required for third-party transfers, marketing, sale, or disclosure to insurers or employers.
• Records of persons with serious mental illness may be shared only in limited professional circumstances.

If you are located in Nebraska at the time of your telehealth visit and are a Medicaid recipient, you may refuse a telehealth consultation at any time without affecting your right to future care or treatment and without risking the loss or withdrawal of program benefits to which you would otherwise be entitled.

All existing confidentiality protections apply to your telehealth consultation. You have access to medical information resulting from your telehealth consultation as provided by law.

Patient-identifiable images or information from your telehealth consultation will not be shared with researchers or other entities without your written consent.

You have the right to request an in-person consultation immediately after a telehealth consultation. If an in-person consultation is not available, you will be informed.

Your telehealth consultation will not be recorded unless you are informed and any required consent is obtained.

To file a complaint, visit: https://dhhs.ne.gov/Pages/Complaints.aspx.

• Non-HIPAA health apps and wellness companies must obtain consent for collecting or sharing consumer health data and must honor access and deletion rights.
• Providers must get written authorization before sharing records with third parties not involved in care.
• Nevada protects providers from certain out-of-state licensing penalties for reproductive health care that is lawful in Nevada.

• HIV test results require specific informed consent before disclosure.
• State mental health facility and community mental health center records generally require authorization before disclosure.
• A minor’s reproductive health or STD treatment information cannot be disclosed to parents without the minor’s permission when the minor consented to the care.

• Genetic testing and disclosure of genetic information generally require informed consent.
• HIV-related information is highly confidential and generally requires consent before disclosure.
• Mental health service records may require authorization for some uses that HIPAA would otherwise permit.

If you are located in New Jersey at the time of your telehealth visit, you may request that your telehealth encounter be scheduled with a physician where required and available.

You have the right to request a copy of your medical information. Your medical information may be forwarded directly to your primary care provider, health care provider of record, or, at your request, to other health care providers.

• HIV and STI testing and results are confidential and generally cannot be disclosed.
• Children age 14 or older generally control disclosure of their own mental health treatment records.
• Any person, regardless of age, may consent to STI and HIV testing/treatment, and those records are confidential.
• Genetic testing and analysis require informed written consent.
• Counselors and therapists have specific confidentiality obligations.

• Mental health program clinical records generally cannot be disclosed outside the facility except under specific statutory exceptions.
• HIV-related information requires a specific HIV release form and must include a redisclosure warning.
• Certain abortion-related and STI-related minor records cannot be disclosed to a parent or guardian without the minor’s consent.
• Genetic testing and disclosure generally require informed consent.

If you are located in New York at the time of your telehealth visit, you consent to receive services by telehealth after the benefits, limitations, and risks of telehealth have been explained to you. Your consent may be verbal, written, or electronic and will be documented in your record as required.

You understand that telehealth services may be provided only when clinically appropriate. You may decline telehealth services and request in-person services where available and clinically appropriate.

If services are provided by audio-only communication, you consent to receiving services by audio-only communication when clinically appropriate.

Your telehealth session will not be recorded without your written consent. If you receive behavioral health or substance use disorder services, additional program-specific consent requirements may apply.

• Identifying records about reportable communicable diseases, including HIV, are strictly confidential and may be disclosed only under narrow statutory exceptions.
• Records for persons receiving mental health, developmental disability, or substance abuse services generally require written consent before disclosure.
• Minors may consent to care for reportable diseases, pregnancy prevention and diagnosis, and substance abuse; related records have confidentiality protections.

• HIV/AIDS reports are strictly confidential and generally cannot be disclosed by subpoena, search warrant, or discovery.
• Health insurers generally need written, dated consent before sharing identifiable health information.

• HIV test results generally require specific written consent before disclosure.
• Therapist communications are privileged and generally need consent or a court order before disclosure.
• Minors may consent to STI evaluation/treatment and HIV testing/counseling without parental consent.

If you are located in Ohio at the time of your telehealth visit, you understand that your telehealth provider may forward your medical records to your primary care provider or treating provider, with your consent or as permitted by law.

If you receive teletherapy or similar services, you understand that telehealth may affect billing and access to insurance benefits. You should contact your health plan with questions about coverage, co-payments, coinsurance, deductibles, or other financial responsibility.

• Mental health and drug/alcohol abuse treatment information is privileged and confidential. A subpoena alone is not enough to compel disclosure.
• HIV testing requires written consent in many circumstances, and HIV/AIDS is reportable with confidentiality protections.
• Minors may consent to STI treatment and substance abuse treatment; SUD identity cannot be disclosed to parents in some circumstances.

If you are located in Oklahoma at the time of your telehealth visit, you may file a complaint about a provider through the Oklahoma Medical Board at: http://www.okmedicalboard.org/complaint.

Information about the Oklahoma Board of Osteopathic Examiners is available at: https://www.ok.gov/osboe/faqs.html.

• Oregon requires separate authorization checkboxes or initials for HIV/AIDS, mental health, genetic testing, and drug/alcohol information.
• Genetic information is treated as belonging to the person tested and generally requires written authorization for disclosure.
• Minors may consent to reproductive health services at any age, outpatient mental health or chemical dependency treatment at age 14+, and general medical care at age 15+; related records are protected.
• Oregon limits cooperation with out-of-state or federal investigations targeting lawful reproductive and gender-affirming care.
• HIV/AIDS information requires specific written authorization before disclosure.

• Mental health treatment records generally require written consent for release, and privileged communications may not be disclosed without written consent.
• HIV-related information has heightened confidentiality protections and civil enforcement mechanisms.

• Rhode Island generally prohibits providers from releasing identifiable health information to third parties without written consent, subject to limited exceptions.
• Mental health records generally require written consent or a statutory exception before disclosure.
• HIV status generally cannot be disclosed without specific consent.
• Minors may consent to STI testing/treatment, with related confidentiality protections.

If you are located in Rhode Island at the time of your telehealth visit and use e-mail, text, or other text-based technology to communicate with your provider, you understand the types of transmissions that may be permitted and the circumstances when alternative forms of communication or an office visit should be used.

You understand that Story Health Partners uses security measures such as encryption, password protection, secure data files, or other authentication techniques, but that privacy risks may still exist.

You understand that information may be lost due to technical failures. You provide express consent to forward patient-identifiable information to a third party when required for your care or otherwise permitted by law. Failure to comply with agreed communication requirements may result in termination of the e-mail or text-based communication relationship.

• STI-related records, including HIV-related information, are strictly confidential and generally cannot be released by subpoena except under narrow conditions.
• State mental health communications and records are privileged and confidential, subject to limited exceptions.
• Minors may consent to STI/HIV services, with corresponding confidentiality protections.

• Communications with physicians, psychotherapists, psychologists, social workers, and counselors for treatment are privileged.
• Communicable disease reports, including HIV, are strictly confidential.
• Mental health facility records have additional disclosure restrictions.

If you are located in South Dakota at the time of your telehealth visit, you understand the delivery model and treatment methods or limitations associated with telehealth.

Your provider may discuss the diagnosis, the basis for the diagnosis, and the risks and benefits of treatment options with you as part of your telehealth care.

• Tennessee has strict STD/HIV confidentiality rules, including limits on subpoena, court order, discovery, and redisclosure.
• Mental health service records are confidential and may be disclosed only under specified exceptions.
• Tennessee regulates direct-to-consumer genetic testing companies and requires consent for handling genetic data.
• Minors may consent to confidential STD diagnosis and treatment, including HIV, without parental consent.

If you are located in Tennessee at the time of your telehealth visit and are a Medicaid recipient, you understand that you may request an in-person assessment before receiving a telehealth assessment, where available and clinically appropriate.

If your telehealth services relate to workers’ compensation, additional written or electronic consent requirements may apply.

• Texas applies medical privacy rules to more entities than HIPAA and generally requires authorization for electronic disclosure outside the covered entity, with exceptions for treatment, payment, operations, or law.
• Mental health communications and records are confidential and privileged; the state authorization form requires a separate checkbox for mental health records.
• HIV/AIDS test results are confidential and generally require written authorization naming who may receive the results. Wrongful disclosure can create criminal and civil liability.
• Minors may consent to STI treatment, drug or chemical addiction/dependency care, and counseling for suicide prevention, addiction, or abuse; providers may, but need not, inform parents.
• Genetic information requires separate authorization on the Texas standard form.

If you are in Texas at the time of your telehealth visit, you consent to receive telemedicine medical services or telehealth services from Story Health Partners before those services are provided. You consent to treatment, data collection, and data sharing for treatment, payment, health care operations, and other purposes described in our Notice of Privacy Practices. Your consent may be documented electronically, verbally, or in writing, as permitted by applicable law.

You understand that your medical records may be sent to your primary care physician or another provider involved in your care, with your consent or as permitted by law.

Notice Concerning Complaints
Complaints about physicians and certain other licensees may be reported to the Texas Medical Board at: 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 at 1-800-201-9353. More information is available at www.tmb.state.tx.us.

Aviso Sobre Las Quejas
Las quejas sobre médicos y otros profesionales autorizados pueden presentarse ante el Texas Medical Board. Si necesita ayuda para presentar una queja, llame al 1-800-201-9353. Para obtener más información, visite www.tmb.state.tx.us.

• Communications with psychotherapists are privileged and may be disclosed only under recognized professional standards or with consent.
• A minor who has or believes they have an STI may consent to testing and treatment without parental consent.

If you are located in Utah at the time of your telehealth visit, you understand any additional fees charged for telehealth services, if any, and how payment will be made if those fees are charged separately from fees for related in-person services.

You understand to whom your health information may be disclosed and for what purposes, and you have received information about any consent governing the release of patient-identifiable information to third parties.

You understand your rights with respect to your health information, the appropriate uses and limitations of telehealth services, and the limitations of telehealth in emergency situations.

You understand that Story Health Partners uses privacy and security measures designed to support applicable legal and industry standards, but that privacy risks and technical failures may still occur. You understand that information may be lost due to technical failure.

You have been provided with Story Health Partners’ website and contact information. To the extent available and clinically appropriate, you may select your provider and pharmacy of choice.

You may access, supplement, and amend patient-provided personal health information; contact your provider for subsequent care; request an electronic or hard copy of your medical record documenting telehealth services and consent; and request transfer of your medical record to another provider.

• Mental health records are confidential and generally require written consent or a court order before disclosure.
• HIV-related information has stricter consent standards than general medical information.
• Direct-to-consumer genetic testing companies must obtain separate consent for each use of genetic data and honor access, deletion, and revocation rights.
• Vermont restricts geofencing near health care facilities and limits sale of consumer health data, including reproductive, sexual, and gender-affirming care data.
• Covered entities and business associates face limits on disclosing PHI related to legally protected reproductive and gender-affirming care.
• Minors age 12 and older may consent to some mental health or substance abuse treatment and keep those records confidential.

If you are located in Vermont at the time of your telehealth visit, you consent to receive care through telemedicine technology. This consent may be oral, written, or electronic and will be documented in your medical record.

You understand the opportunities and limitations of telehealth, including that telehealth may improve access to care but may not be appropriate for every medical condition. You will be informed if another individual participates in or observes your telehealth consultation, and your permission will be obtained for that person’s participation or observation.

If you receive audio-only telephone services, you consent to receiving services by audio-only telephone when clinically appropriate. You understand that you may choose telemedicine, audio-only telephone, or in-person care to the extent clinically appropriate; that audio-only services may not be covered by all health plans; and that audio-only services may affect your financial responsibility.

Neither you nor Story Health Partners may record a telehealth consultation unless recording is permitted by applicable law and all required consents are obtained.

If services are delivered by store-and-forward technology, you understand that you may refuse to receive services in that format and may request services through real-time telemedicine or an in-person visit.

• Psychotherapy notes generally require written authorization before disclosure, subject to narrow exceptions.
• HIV test results are confidential, and wrongful disclosure may trigger fines and a private damages action.
• Virginia requires explicit affirmative consent before certain reproductive or sexual health information is collected, shared, sold, or disseminated by covered non-HIPAA entities; provider NPPs also reflect restrictions on using PHI to investigate reproductive care without specific authorization.
• Virginia recognizes a privacy right in health records and limits disclosure to statutory or HIPAA-permitted circumstances.

If you are located in Virginia at the time of your telehealth visit, you understand that Story Health Partners uses security measures such as encryption, password protection, secure data files, and other reliable authentication techniques when providing telemedicine services.

You understand that privacy risks may remain despite those measures and that information may be lost due to technical failures.

You provide express consent for Story Health Partners to forward patient-identifiable information to third parties when required for your care or otherwise permitted by law.

• Mental health admission and treatment records are confidential and may be disclosed only under specific statutory circumstances.
• STD and HIV records may not be disclosed or compelled except as specifically allowed by law; if the patient is 14 or older, disclosure to parents is prohibited without authorization.
• Minors age 13+ may consent to outpatient mental health and SUD treatment; minors age 14+ may consent to STI testing and treatment; related records are protected.
• Washington protects reproductive and gender-affirming care records from certain out-of-state investigations and legal process.
• Health apps, websites, and non-HIPAA entities need opt-in consent to collect or share consumer health data, including reproductive, sexual, gender-affirming, biometric, and genetic data. Patients may request deletion and sue for violations.

If you are located in Washington at the time of your telehealth visit, you consent to be billed, or for your health plan to be billed, for telehealth services where consent is required before billing.

If you receive audio-only telemedicine services, your consent may apply for up to 12 months. If audio-only services continue beyond that period, consent may be requested again for the next applicable period.

You may revoke consent for audio-only telemedicine billing verbally or in writing. Revocation applies prospectively and will be documented in your record.

• Mental health treatment records and even the fact of treatment are confidential; a subpoena alone is not enough to compel disclosure.
• HIV test identity and results are protected and may be disclosed only to a limited set of persons; court proceedings about disclosure are generally private.

If you are located in West Virginia at the time of your telehealth visit, you consent to the use of telemedicine technologies.

If you receive another service requiring written informed consent, your electronic signature may be used to document that consent.

You understand the types of services that may be provided through telehealth, the limitations of those services, precautions to take in the event of technological failure or emergency, and any other information required for the specific service you receive.

• Wisconsin provides strong confidentiality for all patient health care records and generally requires informed consent for release.
• Records for mental illness, developmental disabilities, alcoholism, or drug dependence have strict confidentiality protections and specific informed-consent rules.
• HIV test results are strictly confidential and may be disclosed only with specific written consent or narrow statutory exceptions.
• Minors who consent to certain substance use or STI treatment have confidentiality protections for those records.

• Wyoming hospitals generally need written patient authorization before disclosing health care information, and patients may seek damages or injunctive relief for violations.
• STD reports must be made to health authorities, but reported information is confidential.

If you are located in Wyoming at the time of your telehealth visit, you consent to the use of telehealth technology. For services that require written informed consent, your electronic signature or other written confirmation may be used to document that consent.

You understand the limitations of telehealth services, including that remote care may not be appropriate for every condition and that technology failures may interrupt care or affect transmission of information.

You understand that Story Health Partners uses security measures such as encryption, password protection, secure data files, authentication techniques, and HIPAA-aligned safeguards, but that privacy risks may still exist.

If any part of your telehealth service will be photographed, recorded, videotaped, stored electronically, or otherwise retained beyond the medical record, you will be informed and your consent will be obtained where required.

You and your provider may establish steps for emergency services based on local resources and may identify emergency contact information if clinically appropriate.