Telehealth Consent

Telehealth is a mode of delivering health care services via communication technologies to facilitate diagnosis, consultation, treatment, education, care management, and self-management of a patient’s healthcare. The purpose of this consent form (“Consent”) is to provide you with information about telehealth and to obtain your informed consent to the use of telehealth in the delivery of healthcare and/or mental health services to you by physicians, physician assistants, nurse practitioners, registered dietitians, and/or mental health professionals (“Providers”) using the online platforms owned and operated by OpenLoop and/or its affiliates and/or subsidiaries (the “Service”). In this Consent, the terms “you” and “yours” refer to the person using the Service, or in the case of a use of the Service by or on behalf of an individual minor between the ages of thirteen (13) and eighteen (18) or higher age of majority under applicable state law, “you” and “yours” refer to and include (i) the parent or legal guardian who provides consent to the use of the Service by such minor or uses the Service on behalf of such minor, and (ii) the minor for whom consent is being provided or on whose behalf the Service is being utilized. For Services that require or permit consent from a minor, we apply a separate consent process.

You are reviewing and acknowledging this Telehealth Consent because you are seeking Services from the professional corporation, professional association, or similar professional entity identified to you at the time of your visit (the “Treating PC”), which may be OpenLoop Healthcare Partners, PC or one of its affiliated entities (including but not limited to OpenLoop Healthcare Partners California, PC, OpenLoop Healthcare Partners Colorado, PC, OpenLoop Healthcare Partners New Jersey Professional Corporation, OpenLoop Healthcare Partners, Wisconsin, S.C.), or another professional corporation, professional association, or similar professional entity that is contracted by, or provides services in connection with, OpenLoop Health, Inc., including but not limited to Wasef Health, P.C., Beluga Health, P.A., and Tiger Medical, PLLC. The Treating PC, together with any other professional corporation, professional association, or similar professional entity that is affiliated with, managed by, contracted by, or provides services in connection with OpenLoop Health, Inc., are collectively referred to herein as the “Practice.” You are utilizing telehealth technologies facilitated through the OpenLoop Health Inc. website, iOS mobile app, web mobile app, or any partner platform, mobile app, or web mobile technologies (collectively, the “Platform”). This Telehealth Consent supplements but does not modify or supersede any Terms of Use, Privacy Policy, or Notice of Privacy Practices of your Treating PC, OpenLoop Health Inc., or other healthcare providers offering services via the Platform.

By clicking “I consent”, or by clicking a related box, you agree that you have reviewed this Telehealth Consent or had it explained to you, that you understand the risks and limitations of using telehealth technologies, that you have been given the opportunity to ask questions and that such questions have been answered to your satisfaction, that you have been given the opportunity to exercise your opt-out rights where appropriate, and that you consent to receiving the Services from licensed health care providers employed by or contracted with Practice (“Providers”) who are located at sites remote from you. If you would like to speak to our privacy team, please use the privacy contact information provided to you by your Treating PC at the time of your visit. If such contact information is unavailable, by writing to Privacy Officer, OpenLoop Healthcare Partners, PC, 317 6th Ave. Ste. 400, Des Moines, IA 50309 or sending an e-mail to privacy@openloophealth.com.

By clicking “I consent”, or by clicking a related box, you understand and agree to the following:

• I understand that Practice offers telehealth visits, which are conducted through videoconferencing, telephonic, and asynchronous technology and my Provider will not be present in the room with me.
• I am consenting to Practice importing and accessing my medical records, including laboratory test results, sleep study test results, if applicable, and medication list, including prescription dosages.
• To protect the confidentiality of my health information, I agree to undertake my telehealth visit in a private location, and I understand that my Provider will similarly be in a private location. If any other individuals are present (e.g., for technological or translation assistance), I will be informed of the individual’s presence and such individual’s role, and I will be given the opportunity to consent to such individual’s presence.
• I understand there are potential risks to the use of telehealth technology, including but not limited to interruptions, delays, unauthorized access, other technical difficulties, data processing errors, AI misinterpretation, recording failures, and ambient listening inaccuracies. I understand that either my Provider or I can discontinue the telehealth appointment if the technical connections are not adequate for my visit. I AGREE TO HOLD HARMLESS PRACTICE, OPENLOOP HEALTH, INC., TOGETHER WITH THEIR RESPECTIVE EMPLOYEES, CONTRACTORS, AGENTS, DIRECTORS, MEMBERS, MANAGERS, SHAREHOLDERS, OFFICERS, REPRESENTATIVES, ASSIGNS, PREDECESSORS, AND SUCCESSORS, FOR DELAYS IN SERVICE OR FOR INFORMATION LOST DUE TO SUCH TECHNICAL FAILURES OR FOR ANY ISSUES ARISING FROM THE USE OF AI TECHNOLOGIES, RECORDINGS, OR AMBIENT LISTENING SYSTEMS.
• I understand that my telehealth visit may involve the use of artificial intelligence (AI) technologies for various purposes, including but not limited to transcription of conversations, analysis of medical information, clinical decision support, quality assurance, and improvement of telehealth services. I understand that AI systems may process, analyze, and store information from my telehealth visit, including my voice, image, and medical information shared during the visit. AI processing may occur in real-time during my visit and/or after my visit has concluded. Information processed by AI systems will be protected in accordance with applicable laws and Practice’s privacy policies and procedures. I have the right to request information about what AI technologies are being used during my care and how my information is being processed.
• I understand that, as part of my care, my Provider may use AI tools to assist with analyzing medical data or records, supporting clinical decision making, generating summaries or documentation, or recommending potential diagnoses or treatment options. AI tools are intended to support, not replace, the professional judgment of my Provider. I understand and acknowledge that my Provider will review any AI-assisted outputs before making clinical decisions, and I have the right to ask questions about how AI is used in my care and to request that AI not be used in certain aspects of my treatment, where feasible.
• I understand that my telehealth visit may be recorded (audio and/or video) for purposes, including but not limited to quality assurance, training, clinical documentation, and care coordination. I understand that I will be notified at the beginning of any session that is being recorded. Recordings may be retained for a specified period of time in accordance with applicable laws and regulations, as well as Practice’s retention policies and procedures. I have the right to request access to recordings of my telehealth visits, subject to applicable laws, regulations, and the Practice’s policies and procedures.
• I understand that ambient listening technologies may be used during my telehealth visit to record the encounter, and that such technologies may include third parties contracted by Practice. These ambient listening technologies may be used to capture relevant clinical information that I share during the visit. I can request that ambient listening be disabled during portions of my visit by notifying my Provider. Information captured through ambient listening will be protected in accordance with applicable privacy laws and Practice policies. I have the right to know when ambient listening technologies are active during my visit.
• I understand that in some cases, my Provider might be a nurse practitioner, a physician assistant, registered dietitian, or mental health professionals and not a physician.
• I understand that medication may be prescribed to me for an off-label use, meaning a use not approved by the FDA, and that my provider has discussed the reasons for this recommendation, its potential benefits and risks, and available alternatives with me.
• I understand that I could seek an in-office visit rather than obtain care from a Provider, and I am choosing to participate in a telehealth visit with a Provider. I further understand that my Provider may not have access to a complete copy of my medical records and will not have the ability to perform an in-person examination, which could result in negative health outcomes from the recommended treatment (e.g., adverse drug interactions or allergic reactions). I further understand that while using telehealth technologies may benefit me, no such benefits or specific results are guaranteed, and my condition may not improve.
• Certain technology, including the Services, may be used while still in a beta testing and development phase, and before such technology is a final and finished product. Technology used to deliver care, including the Service, may contain bugs or other errors, including ones which may limit functionality, produce erroneous results, render part or all of such technology unavailable or inoperable, produce incorrect records, transmissions, data or content, or cause records, transmissions, data or content to be corrupted or lost, any or all of which could limit or otherwise impact the quality, accuracy and/or effectiveness of the medical care or other services that you receive from your Provider(s).
• The delivery of healthcare services via telehealth is an evolving field and the use of telehealth or other technology in your medical care and treatment from Provider(s) may include uses of technology different from those described in this Consent or not specifically described in this Consent. No potential benefits from the use of telehealth or other technology or specific results can be guaranteed, including any laboratory test results or related diagnosis or treatment by your Provider(s). Your condition may not be cured or improved, and in some cases, may get worse. There are limitations in the provision of medical care or other services and treatment via telehealth and technology, including the Service, and you may not be able to receive diagnosis and/or treatment through telehealth for every condition for which you seek diagnosis and/or treatment.
• I agree that any information I provide as part of any telehealth visit is accurate, true, and complete.
• I understand that my Provider may determine that a telehealth visit is not appropriate for me due to my particular health concern or for other reasons related to my health status. In such a case: (i) I will receive an alert notifying me that I will be unable to use the Services for the particular issue I submitted; and (ii) I will need to seek any needed care in another way.
• I understand that participating in a telehealth visit is not a guarantee that I will be given a prescription, and that the decision as to whether a prescription is appropriate for my condition will be made in the professional judgment of my Provider.
• I understand there is no guarantee of effectiveness or results of any prescription or telehealth visit.
• I understand that while the Platform may make available access to certain pharmacy or diagnostic laboratory services, I may request to use any pharmacy or laboratory of my preference.
• I understand that I am responsible for payment of any amounts due and owing resulting from my telehealth visit.
• I understand that Providers do not address medical emergencies via the Platform. I understand that the responsibility of my Provider may be to direct me to emergency medical services, such as an emergency room.
• I (we) the parent(s) or legal guardian of a minor, do hereby authorize consent to any medical order, laboratory order, medical diagnosis, or treatment and that I (we) have legal authority to consent to such treatment or order.
• I agree that OpenLoop Health, Inc. is a third party beneficiary of the Telehealth Consent and has the right to enforce it against me.
• I understand and agree that I give permission to Providers to use and disclose my protected health information including my entire medical record. This protected health information is being used or disclosed for the purpose of telehealth treatment.

1. If the person or entity receiving this information is not a health care provider or health plan covered by HIPAA, the information described above may be redisclosed to other individuals or institutions and therefore no longer protected by HIPAA.
2. I may refuse to agree to this authorization. My refusal to sign will not affect my payment, ability to obtain treatment, or eligibility for health plan benefits unless this authorization is requested prior to research related to treatment, enrollment in a health plan, or providing health care that is solely for the purpose of giving that information to a third party, such as to a court for a legal proceeding.
3. I may inspect or copy the protected health information to be used or disclosed under this authorization. For protected health information created as part of a clinical trial, your right to access is suspended until the clinical trial is completed.
4. I may revoke this authorization in writing at any time by sending a written notification to the Privacy Officer of my Treating PC using the contact information provided to me at the time of my visit or, if such contact information is unavailable, by writing to Privacy Officer, OpenLoop Healthcare Partners, PC, 317 6th Ave. Ste. 400, Des Moines, IA 50309 or sending an e-mail to privacy@openloophealth.com. Your notice of revocation will not apply to actions taken by Providers prior to the date of receipt of the notice.

• If I was directed to the Services or the Platform by a Partner, I understand and agree that I give permission to Providers to use and disclose my protected health information, including certain personally identifiable health information, such as my name, date(s) of service and prescription order dates, as applicable, to certain Partners, to inform them that I have engaged in use of the Services. This protected health information is being used or disclosed for administrative services and not for treatment. Such disclosure is not a sale of my personal data to any Partner, as defined under state law. I understand that I can revoke this consent at any time by sending a written notification to the Privacy Officer of my Treating PC using the contact information provided to me at the time of my visit or, if such contact information is unavailable, by writing to Privacy Officer, OpenLoop Healthcare Partners, PC, 317 6th Ave. Ste. 400, Des Moines, IA 50309 or sending an e-mail to privacy@openloophealth.com. Your notice of revocation will not apply to actions taken by Providers prior to the date of receipt of the notice.

The following consent applies to patients who receive a prescription from a Provider for compounded medications.

• I understand that the FDA does not approve nor review compounded products for safety, efficacy, or quality.
• I understand that compounding pharmacies must adhere to strict quality control standards to ensure the safety and effectiveness of the medications they prepare. Compounding pharmacies are licensed pharmacies subject to state and federal regulations.
• Safety information about prescribed medications is available at Safety Information.

The following consent applies to patients accessing the Services to receive a telehealth consultation related to mental or behavioral health.

I acknowledge that I may be offered a telehealth consultation related to my mental or behavioral health as part of the Services. This type of telehealth consultation, known as “Teletherapy,” involves the communication of my mental health information to my Provider. Teletherapy has the same purpose or intention as therapy sessions that are conducted in person. However, due to the nature of the technology used, I understand that Teletherapy may be experienced somewhat differently than face-to-face treatment sessions.

I understand that I have the following rights with respect to Teletherapy:

Patient’s Rights, Risks, and Responsibilities:

• I have the right to withhold or withdraw consent for my treatment at any time without affecting my right to future care or treatment.
• The laws that protect the confidentiality of my medical information also apply to Teletherapy. As such, I understand that the information disclosed by me during the course of a Teletherapy session generally is confidential unless an exception to confidentiality applies (e.g., mandatory reporting of child, elder or vulnerable adult abuse; if my Provider believes I may be a danger to myself or others; or if I raise emotional or mental health as an issue in a legal proceeding).
• In addition, I understand that Teletherapy services and care may not be as complete as face-to-face services. I also understand that if my Provider believes I would be better served by another form of therapeutic services (e.g., face-to-face services) I will be referred to a professional who can provide such services in my area.
• I understand that I may benefit from Teletherapy, but that results cannot be guaranteed or assured. I understand that there are potential risks and benefits associated with any form of counseling, and that despite my efforts and the efforts of my Provider, my condition may not improve, and in some cases may even get worse.
• I accept that Teletherapy is not meant to cover emergency situations. If I am having suicidal thoughts or making plans to harm myself, I can call the National Suicide Prevention Lifeline at 1.800.273.TALK (8255) for free 24-hour hotline support. Patients who are actively at risk of harm to self or others are not suitable for Teletherapy services. If this is the case or becomes the case in future, my Provider will recommend more appropriate services.
• I understand that dissemination of any personally identifiable images or information from the Teletherapy interaction to researchers or other entities shall not occur without my written consent.
• I understand that my Provider may need to contact my emergency contact and/or the appropriate authorities in case of an emergency. I agree to inform my Provider of the address where I am located at the beginning of each session and agree to provide the name of a contact person who my Provider may contact on my behalf in an emergency situation.

The following consent applies to patients accessing the Services to receive a telehealth consultation related to Human Immunodeficiency Virus (“HIV”) testing.

HIV is the virus that causes acquired immunodeficiency syndrome (“AIDS”) and can be transmitted through unprotected sex with some who has HIV; contact with blood, including via contaminated hypodermic needles or blood transfusions; by HIV-infected pregnant women to their infants during pregnancy or delivery; or while breastfeeding.

HIV can be detected via an HIV antibody test. The HIV antibody test is a blood test that shows whether you have antibodies to the virus that causes AIDS. A sample of blood will be taken from your arm with a needle. If the first test shows that you have antibodies, a series of tests will then be done on the same blood sample to ensure the first test was correct. A positive result means that you have been exposed to the virus and are infected with HIV. It does not mean that you have AIDS or that you will become sick with AIDS in the future. While HIV can lead to AIDS, this test does not say whether you have AIDS. However, a positive result also means you could pass the virus to other people. There is treatment for HIV that can help you stay healthy. Individuals with HIV and/or AIDS can adopt safe practices to protect uninfected and infected people in their lives from becoming infected or being infected themselves with different strains of HIV.

A negative test means you are unlikely to be infected with the virus. It takes time for the body to produce HIV antibodies. If you have been exposed to HIV recently, you will need to be retested in several months to be sure you’re not infected. Your Provider will explain this to you.

Taking an HIV test is entirely voluntary. If you do not wish to take the test, you may decline and we will not perform the test. This test is not provided on an anonymous basis. Please seek an anonymous test site if you prefer for your HIV test information and results to remain anonymous. Anonymous testing sites are places where you can receive counseling and the HIV test without giving your name or address. You can find the nearest anonymous test site by contacting your local health department.

There are federal and state laws that protect the confidentiality of your HIV test results and related information. Please note, however, that we may disclose your results as required by law for reporting to appropriate public health authorities. There are federal and state laws that prohibit discrimination based on your HIV status and there may be services available to help with any such discrimination.

Florida: Patients that are prescribed GLP-1 medications, such as Semaglutide, for weight-loss – You have been provided with the Weight-Loss Consumer Bill of Rights.

Weight-Loss Consumer Bill of Rights

• 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 THIS PROVIDER ARE AVAILABLE UPON REQUEST.
• YOU HAVE THE RIGHT TO:

1. ASK QUESTIONS 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 DIETITIAN OR NUTRITIONIST WHO HAS REVIEWED AND APPROVED THE WEIGHT-LOSS PROGRAM ACCORDING TO s.468.505(1)(j), FLORIDA STATUTES.

New York: Patients that are prescribed GLP-1 medications, such as Semaglutide, for weight-loss – You have been provided with the Weight-Loss Consumer Bill of Rights.

WEIGHT LOSS AND DIETING INFORMATION

• WARNING! Rapid weight loss may cause serious health problems. Rapid weight loss is weight loss of more than 1 1/2 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 physician before starting any weight loss program or using any diet medications or formulas.
• Long term weight control is the safest and most important goal of any diet program. Permanent lifestyle changes such as eating nutritious foods, calorie control and increasing physical activity help promote long term weight loss according to medical experts.
• Ask the person providing or selling you weight loss advice or diet products, medications or formulas about their qualifications and training in nutrition and health.
• You have the right to:

1. Ask questions about the potential health risks of this program or product, its nutritional content, and its psychological-support and educational components;
2. Know the price of treatment, including the price of any extra products, services, supplements and laboratory tests; and
3. Know the program duration of the program recommended to you. N.Y. Gen. Bus. Law § 642.

The following consent applies to patients accessing the Services to receive a telehealth consultation related to genetic testing.

I acknowledge that I may be offered genetic testing as part of the Services. Testing for genetic conditions can be complex and the specifics of the test, including the methods for collecting a biologic specimen, will vary depending on the condition tested for. There are risks and benefits to genetic testing. If I am offered genetic testing as part of the Services, my Provider will explain the specifics of my particular test to me, and I will have the opportunity to obtain professional genetic counseling prior deciding whether to proceed with testing to fully understand the risks and benefits.

I understand that my substance use disorder treatment is being delivered via telehealth technology, that the Practice has implemented safeguards designed to protect the confidentiality and security of my records consistent with 42 CFR Part 2, and that I am responsible for choosing a private location and secure connection for my telehealth sessions.

I understand that records relating to the identification, diagnosis, or treatment of a substance use disorder created by the Practice are protected by federal law and regulation (42 U.S.C. § 290dd-2 and 42 CFR Part 2) and generally may not be disclosed without my consent.

Each disclosure of my records made with my consent will be accompanied by the following notice, as required by 42 CFR § 2.32, and may not be altered or paraphrased: "This information has been disclosed to you from records protected by federal confidentiality rules (42 CFR Part 2). The federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2."

The following consent applies to patients accessing the Services to receive a telehealth consultation related to peptide therapy.

I understand that peptides are small chains of amino acids linked together that can bind to receptors of the cells in the body. They act as signaling agents to instruct the cells to accomplish various specific functions. The goals of this therapy are to try and prevent, reduce or control the dysfunctions associated with the aging process, through hormonal balancing, control of oxidative stress, and other clinically significant therapeutic agents.

However, I understand that this treatment may be viewed by the mainstream medical community as new, controversial, and unnecessary by the Food and Drug Administration (“FDA”).

Goal: Each peptide has its specific effect and function on the body. My Provider will provide me with information on my specific peptide therapy in an addendum to this Consent.

Risks: At physiologically recommended dosage peptides do not have significant risks/adverse reactions; full medical disclosure should be given by the patient before starting therapy before prescription is sent as specific conditions might apply. Common side effects include reactions at the injection site, such as pain, redness or swelling along with flushing of the face; less than 1% of patients report dizziness, headache, heart palpitations or hyperactivity. These symptoms disappear immediately when the peptides are stopped. Any side effect should be reported immediately to my Provider. Allergic reactions might occur in sensitive individuals. My Provider will provide me with information on risks of my specific peptide therapy in an addendum to this Consent.

Contra-Indications: Most peptides should not be used in patients with cancer. Other precautions might apply to my personal case and should be discussed with my Provider.

I have received enough information about these treatment goals and risks to make my decision to start the treatment. I understand that my provider will monitor my treatment in an effort to prevent adverse reactions but cannot guarantee that I will not experience any side effects to the treatment. I understand that, as with any health treatment, there is no guarantee that I will obtain satisfactory results through the use of this therapy. I understand that the use of this treatment does not preclude me from using other treatments as well.

I have sufficient information to give this informed consent. I further acknowledge that I understand that compounded peptides are not approved by the FDA for any particular indication.

I have been informed of the fact that my insurance company will consider this treatment technique as an “experimental or investigational” service and reimbursement will likely be denied.

I acknowledge that I have had the opportunity to ask any questions of my physician with respect to the proposed therapy and the procedures to be utilized, and that all of my questions have been answered to my full satisfaction.

I have informed my physician of any known allergies to drugs or other substances, and of any past reaction to injections. I have also informed my physician of all current medications and supplements.

Certain healthcare services provided to you by Providers via the Service may require that you complete an at-home diagnostic specimen collection. These diagnostic specimen collection kits are provided by third-parties, and neither OpenLoop Health, Inc. and its affiliates and subsidiaries (collectively, “OpenLoop”), nor your Provider(s) can guarantee the accuracy or reliability of these test results. These laboratory tests can provide false negative, false positive, or inconclusive results that could impact your Provider(s) ability to correctly diagnose or treat your medical conditions. A failure or defect of these tests could also impact your Provider(s) ability to correctly diagnose or treat your medical conditions.

By clicking “I consent”, or by checking a related box, I confirm that the above information is true, correct, and complete to the best of my knowledge. I authorize my Treating PC and the Practice to bill my insurance company directly and I further authorize any third-party payer through which I have benefits to make payment directly to the Treating PC or Practice, as applicable. I understand that I am financially responsible for any balance. I also authorize the Treating PC, Practice, or my insurance company to use and disclose any healthcare information for the purpose of obtaining payment for services and determining insurance benefits. Services provided by outside companies (i.e., laboratories, pathology, radiology, sleep study device manufacturer) may be billed separately by those companies.

By clicking “I consent,” or by checking a related box, I authorize Practice to contact me via phone call, SMS/text message, or email at the contact information I have provided, for the purposes of:

• Appointment reminders
• Medication fulfillment and shipment updates
• Refill reminders
• Communications related to my care or payment for care
• Patient feedback requests
• General health and wellness information

I understand and agree to the following:

• These communications may be generated in part by automated systems or artificial intelligence (AI).
• Standard messaging and data rates may apply.
• This authorization will remain in effect for future communications unless I revoke it in writing.
• I may opt out of receiving such communications at any time by following the opt-out instructions provided in each message or by contacting Practice directly.
• Using these communication methods presents a potential security risk of unauthorized access to protected health information (PHI).
• I accept this risk and consent to receiving communications through these methods.

If you prefer not to receive appointment reminders or health information email, please notify your Treating PC in writing using the privacy contact information provided to you at the time of your visit.

The following consents apply to patients accessing the Services for the purposes of participating in a telehealth visit within the states listed below, as required by state law:

Alaska: I understand that my primary care provider may obtain a copy of my records of my telehealth encounter.

California Patients: The Open Payments database is a federal tool used to search payments made by drug and device companies to physician and teaching hospitals. It can be found at https://openpaymentsdata.cms.gov.

For informational purposes only, a link to the federal Centers for Medicare and Medicaid Services (CMS) Open Payments web page is provided above. The federal Physician Payments Sunshine Act requires that detailed information about payment and other payments of value worth over ten dollars ($10) from manufacturers of drugs, medical devices, and biologics to physicians and teaching hospitals be made available to the public.

Treatment Records: I understand that If I live in one of the following states, my primary care provider or other treating physician may obtain a copy of my telehealth treatment records with my consent, and Practice may securely send a copy of my telehealth treatment records to my primary care provider or other treating physician. If I need help sending my telehealth treatment records to my primary care provider I can contact call 1-855-597-1248 If I would like Practice to do so, I can contact call 1-855-597-1248 and provide information necessary for Practice to securely send my records.

Connecticut: I understand that my primary care provider may obtain a copy of my records of my telehealth encounter.

District of Columbia: I have been informed of alternate forms of communication between me and a physician for urgent matters. Relevant communications with the physician, including those done via electronic methods shall be documented and filed in my medical record.

Georgia: I have been given clear, appropriate, accurate instructions on follow-up in the event of needed emergent care related to the treatment.

Indiana: If a prescription is issued to me, and subject to my consent the prescriber shall notify my primary care provider of any prescriptions the prescriber has issued for me if the primary care provider's contact information is provided by me. This requirement does not apply if: (A) The practitioner is using an electronic health record system that my primary care provider is authorized to access. (B) The practitioner has established an ongoing provider-patient relationship with me by providing care to me at least 2 consecutive times through the use of telehealth services. If the conditions of this clause are met, the practitioner shall maintain a medical record for me and shall notify my primary care provider of any issued prescriptions.

Kansas: I understand that if I have a primary care provider or other treating physician, the person providing telemedicine services must send a report to such primary care or other treating physician of the treatment and services rendered to me during the telemedicine encounter within three days of me providing consent to the person providing telemedicine services to send such report.

New Hampshire: I understand that my primary care provider or treating provider may obtain a copy of my records of my telehealth encounter.

New Jersey: I understand I have the right to request a copy of my medical information, and I understand my medical information may be forwarded directly to my primary care provider or health care provider of record, or upon my request, to other health care providers. If I do not have a primary care provider or other health care provider of record, the health care provider engaging in telemedicine or telehealth may advise me to contact a primary care provider, and, upon request by me, may assist me with locating a primary care provider or other in-person medical assistance that, to the extent possible, located within reasonable proximity to me.

Ohio: I understand that my primary care provider may obtain a copy of my records of my telehealth encounter.

Rhode Island: If I use e-mail or text-based technology to communicate with my provider, then I understand the types of transmissions that will be permitted and the circumstances when alternate forms of communication or office visits should be utilized. I have also discussed security measures, such as encryption of data, password protected screen savers and data files, or utilization of other reliable authentication techniques, as well as potential risks to privacy. I acknowledge that my failure to comply with this agreement may result in the telehealth provider terminating the relationship.

South Carolina: I understand that my medical records may be distributed only with my consent and in accordance with applicable laws and regulations to other treating health care practitioners.

South Dakota: I have received disclosures regarding the delivery models and treatment methods or limitations. I have discussed with the telehealth provider the diagnosis and its evidentiary basis, and the risks and benefits of various treatment options

Texas: I understand that with my consent my medical records may be sent to my primary care physician within 72 hours after receiving Services.

Utah: I am able to a (i) access, supplement, and amend my patient-provided personal health information; (ii) contact my provider for subsequent care; (iii) obtain upon request an electronic or hard copy of my medical record documenting the telemedicine services, including the informed consent provided; and (iv) request a transfer to another provider of my medical record documenting the telemedicine services.

Virginia: I acknowledge that I have received details on security measures taken with the use of telemedicine services, such as encrypting date of service, password protected screen savers, encrypting data files, or utilizing other reliable authentication techniques, as well as potential risks to privacy notwithstanding such measures. I agree to hold harmless OpenLoop for information lost due to technical failures; and I provide my express consent to forward patient-identifiable information to a third party.

Vermont: I understand that I have the right to receive a consult with a distant-site provider and will receive one upon request immediately or within a reasonable time after the results of the initial consult. I understand that receiving telehealth services via store-and-forward technologies by OpenLoop does not preclude me from receiving real-time telemedicine or face-to-face services with the distant provider at a future date.

Billing

Patients residing in New Jersey, New York, and Rhode Island have the right under each states respective billing laws to request an itemized price list for laboratory results.

Formal Complaints

California: 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 physician assistant board’s website here or use the QR coder here: .

Georgia: 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.

Idaho: 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.

Indiana: 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.

Iowa: 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.

Kentucky: 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.

Maine: 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.

New York: I have been informed that to get information regarding my rights and how to report professional misconduct, I should visit here.

Oklahoma: 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 Oklahoma Board of Osteopathic Examiners’ website, here.

Oregon: 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.

Rhode Island: 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.

Texas:

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.

Wyoming: 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.