Informed consent for telehealth
The Health Initiative — Telehealth Puerto Rico · Dr. Diana Krystina Nieves Castro, MD
This document explains how video medical care with us works, what the doctor can do for you, the risks, and your rights. Puerto Rico law asks you to sign it before your first visit (Ley 168-2018, Art. 10, as amended by Ley 68-2020). You can sign it electronically.
Take your time. If you have questions, email [email protected] or call +1 (703) 935-3517 before you sign. At the start of your first visit, the doctor also explains how it works and answers your questions.
You do not have to sign. If you do not sign, we do not do the video visit and we refund you in full, with no charge of any kind. Saying no never takes away your right to get medical care in other ways.
If the patient is under 21, a parent with patria potestad (parental authority) or a court-appointed legal guardian signs. In that case, "you" in this document means the patient and the person signing for them.
This consent is in Spanish and in English, and both versions have equal standing. You sign in the language you choose, and your signed copy shows which one you used.
1. Who cares for you Your doctor is Dr. Diana Krystina Nieves Castro, MD , a general practice physician licensed to practice medicine in Puerto Rico, license no. 24027 , issued by the Junta de Licenciamiento y Disciplina Médica (Puerto Rico's medical board). Her NPI number is 1922842756. You can check her license in the Department of Health registry (opens in a new tab) . She has several years of emergency-department experience.
The service is run by The Health Initiative (THI), a U.S. 501(c)(3) nonprofit organization (EIN 93-2197573). THI takes your payment, arranges your visit and answers your questions. Its mailing address is 10304 Eaton Pl, Suite 100, Fairfax, VA 22030; it is not a care location.
So you know: Dr. Nieves Castro is also the Founding Executive Director of The Health Initiative, the organization that runs this service and receives your payment.
2. How telehealth works with us Telehealth is medical care at a distance. With us, every visit is a real-time video visit between the patient and the doctor. We send you a secure video link. It works on your phone, tablet or computer. We see adults and children of all ages, in Spanish or English.
Through telehealth, the doctor can:
ask about your health, see you on video, evaluate you, diagnose and treat you; prescribe medicines if appropriate, including refills of medicines you already take (non-controlled); give you lab orders and go over the results with you; give you a doctor's note and complete school, university or job forms; teach you about your health and give you a care plan; treat urgent problems that are not emergencies. To do this we also schedule your visits and send you messages about them by email or text message.
3. The doctor decides if your case can be handled by video Telehealth lets you see a doctor without traveling, from anywhere in Puerto Rico. By video, the doctor cannot touch you or do a full physical exam, and that can make a problem harder to find.
So the doctor decides if your problem can be cared for well by video. If your case needs more, she gives you a lab order, recommends an in-person visit or tells you to go to the ER, and explains why. A visit does not guarantee a diagnosis, a prescription, a document or any particular result.
You always have other options: an in-person doctor, your regular doctor, an urgent care center or CDT, or an emergency room.
4. Who you are and where you are The doctor is licensed in Puerto Rico. So the patient must be physically in Puerto Rico for the whole visit. Visitors to the island are welcome too.
At the start, the doctor confirms who the patient is and asks you to show photo ID on camera (the parent's or guardian's if the patient is under 21). The ID is checked by sight only: no photos or screenshots are taken.
She also asks for the exact address where you are, so help can be sent if there is an emergency during the visit. If the patient is not in Puerto Rico or their identity can't be confirmed, the visit does not go ahead and we refund you in full.
5. Emergencies, and what happens if the call drops This service is not for emergencies. In an emergency, call 911 or go to the nearest emergency room. If you are thinking about harming yourself, call or text 988 or call Línea PAS at 1-800-981-0023 , any time. For a possible poisoning, call 1-800-222-1222 .
If the doctor sees an emergency during the visit, she will tell you to call 911 or, if needed, get help sent to the address you gave.
Technology can fail. If the connection drops, the doctor will try to reconnect or call you, or offer you another time. If the visit can't be finished by video, she will tell you what to do and where to get care. If the visit can't take place, we refund you in full.
6. Prescriptions and labs: you choose where If appropriate, the doctor prescribes and we send your prescription to the pharmacy you choose. If you need tests, we give you the order for the lab you choose. No one makes you use a particular pharmacy or lab.
We do not prescribe controlled substances by telehealth. If your treatment needs them, the doctor will tell you where to go.
7. Your privacy: how we protect your information, and the risk that remains To care for you by telehealth, we share your health information electronically: by video, in your record and in the messages about your visit, which reach you by email or text message. By signing, you allow your information to be shared this way for your care, for payment and to run the service, as explained in the privacy notice .
Your record and video visit are held by a HIPAA-compliant electronic health record provider that has signed an agreement (BAA) requiring it to protect your information. We use encrypted connections, password access and identity checks for the staff who access your information.
Even so, no technology is completely secure. There is a risk that the confidentiality of your information could be lost: there can be technical failures, interruptions or unauthorized access, despite these measures. Email and text messages, such as your visit reminders, are less secure than the record. You can help too: have the visit in a private place, on a device you control and on a network you trust.
8. We do not record visits Visits are not recorded , in video or audio. We ask that you do not record them either. The doctor does write what happens at each visit in your record, as she would for an in-person visit.
9. Other people at the visit If anyone else will be present on the doctor's side and can see or hear you, she will tell you at the start and ask your permission. You should also tell her who is with you. You can ask for someone to leave, or for part of the visit to be private. The doctor notes in your record who was present.
10. Prices, payment and refunds We charge when you request the visit, by credit or debit card, through Stripe. We do not bill insurance; if you ask, we give you an itemized receipt (superbill). The price is the same for all ages:
Doctor visit: US$79. Includes a doctor's note if you need one. Follow-up visit (refills of medicines you already take, or review of lab results from an earlier visit with us): US$49. School, university or job forms, and the lab order for the certificado de salud (does not include forms that need a vision exam): US$35. If, in a follow-up or forms visit, the doctor finds you need a full doctor visit, she explains why and only with your permission do you pay the difference up to US$79. Full refund if the visit can't take place: for example, if your location in Puerto Rico can't be confirmed, if a minor's parent or guardian is not there, or if no doctor is available. Full refund if you cancel before the visit, if you do not sign this consent, or if you withdraw it before the doctor starts to evaluate you. 11. Your right to say no You can refuse care by telehealth. You can also withdraw this consent at any time , even during a visit. Just tell the doctor or email [email protected] .
Refusing or withdrawing your consent does not take away your right to get medical care in other ways. If you do not sign, or you withdraw it before the doctor starts to evaluate you, we refund you in full. Withdrawing does not change what was already done before.
13. What we ask of you So the doctor can help you well, we ask you to:
give true and complete information about your health, your medicines and allergies, your identity and where you are; have the visit in a private place, with good light and a good connection; tell the doctor if you don't understand something or don't agree with the plan; follow the care plan you agree on with her, or tell her if you can't; get in-person or emergency care when the doctor tells you to. 14. Follow-up and your regular doctor At the end of the visit, the doctor explains the plan and when to come back. If you need follow-up, you can request another visit with us or see another doctor in person.
If you have a regular doctor, we encourage you to share your visit summary with them. If you ask us in writing, we send it to them. If we ever stop caring for you, we will give you reasonable notice so you can find another doctor.
15. Mandatory reporting of abuse Health professionals in Puerto Rico are required by law to report any suspected abuse or neglect of a child under 18 to the authorities (Ley 57-2023). The doctor will meet that duty, and it comes before confidentiality.
16. How long this consent lasts This consent covers your first visit and later visits. At the start of each visit, the doctor will ask if you still agree to care by video, and note it in your record.
We will ask you to sign again if we change this document and at least every 12 months.
17. Your copy and where we keep this document When you sign, you can download, save and print your PDF copy. You can also ask for a free copy, on paper or as a PDF, at any time at [email protected] .
We keep the signed document privately in a clinic Google Workspace account covered by a health-information protection agreement (BAA), shared with no one. The doctor notes in your medical record that you signed it, with its reference number. We keep it at least as long as your medical record is kept.
To be able to prove that you signed, your copy records the date and time, your IP address, the type of browser you used, and a code that identifies the exact version of this document.
If the patient is under 21 We see children of all ages. In Puerto Rico the age of majority is 21. For a patient under 21, the telehealth rule requires written authorization from whoever holds patria potestad (parental authority) or from a court-appointed guardian. This applies to every visit type, including birth control and STI visits. If the patient is under 21:
A parent with patria potestad, or a legal guardian, signs this consent before the visit and states their relationship to the patient. A parent who signs states that they hold patria potestad and that no court has taken it away or limited it. A legal guardian states that they have the court order appointing them. That person stays on camera for the whole visit, except for any time alone with a teenager that they agree with the doctor, and, at the start, shows official photo ID. The doctor confirms the patient's name and date of birth. For now we do not accept other adults in their place, such as grandparents, aunts, uncles or caregivers, even with an authorization. If the authorized person is not there or their identity can't be verified, the visit does not go ahead and we refund you in full. With a teenager, the doctor may talk with the patient alone for part of the visit, only if the parent or guardian agrees. The doctor keeps that conversation private during the visit, but she notes in the record what matters for the patient's health, and the parent or guardian can ask for the record. The doctor must also act if there is a risk that the patient will harm themselves or others, and if she suspects abuse.
The same applies to a patient aged 21 or over who has a court-appointed guardian: the guardian signs, stays on camera and shows photo ID.
