Authorization and Consent to Participate in Remote Health Services
Stayby Remote Health Authorization and Consent
Effective Date: August 13, 2026
The purpose of this form is to obtain your consent to participate in a Remote Health evaluation related to Emotional Support Animal documentation (the “evaluation”) through Stayby, a MyMedsCOM LLC operation.
1. Purpose and Benefits
The purpose and benefit of the evaluation is to provide more timely and available access to telehealth evaluation services with a licensed health care provider.
2. Nature of Evaluation
During the evaluation:
- A licensed clinician will be available to answer questions and conduct the evaluation, and to assist with any routine or emergent needs which may arise in connection with the encounter.
- Non-medical technical personnel may be able to monitor the evaluation in order to assist with any potential or actual electronic transmission and/or communication issues, and to ensure quality compliance.
3. Medical Information and Records
All existing laws regarding your access to medical information and copies of your medical records apply to this evaluation. Additionally, dissemination of any patient-identifiable images or information from this interaction to researchers or other entities shall not occur without your consent, unless authorized under existing confidentiality laws.
4. Modality
Remote evaluation based on an online questionnaire and, when required or permitted by state law and clinical judgment, interactive telehealth communication (such as videoconferencing) with a licensed health care provider.
5. Confidentiality
Reasonable and appropriate efforts have been made to eliminate any confidentiality risks associated with the evaluation. All existing confidentiality protections under federal and applicable state laws apply to information disclosed during this evaluation.
6. Fees
Fees are disclosed to you during your online checkout.
7. Risks and Consequences
The evaluation will be similar to a routine clinical visit, except interactive technology will allow you to communicate with a health professional at a distance and remotely. As with any health care encounter, there are potential risks associated with the use of Remote Health. These risks include, but are not limited to:
- In rare cases, the health professional may determine that the transmitted information is of inadequate quality, thus necessitating an in-person examination or additional evaluation.
- Delays in evaluation could occur due to deficiencies or failures of equipment or connectivity.
- In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information.
- In rare cases, a lack of access to complete medical records may result in incomplete clinical information or other judgment errors.
- Documentation related to an Emotional Support Animal is provided only when the evaluating clinician determines that it is clinically appropriate. No particular clinical determination or housing outcome is guaranteed.
8. Acknowledgments
By authorizing and consenting to Remote Health, you are acknowledging informed consent, and you understand and agree with the following:
- The evaluation may involve electronic communication of your personal medical information to other medical practitioners who may be located in other areas, including out of state.
- You may expect the anticipated benefits from the evaluation, but that no results can be guaranteed or assured.
- Stayby provides a technology platform and does not itself provide medical services or create a patient relationship with you. Clinical care and any documentation decisions are made by independent licensed health care providers.
9. Rights
You may withhold or withdraw consent to the consultation at any time without affecting your right of future care or treatment, or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled.
Agreement
I have been advised of all the potential risks, consequences and benefits of the evaluation. I have had an opportunity to ask questions about this information and all of my questions have been answered. I understand the written information provided above.
Questions about this consent may be sent to hello@stayby.co.