Telehealth Medical Consent

OUR PROVIDERS DO NOT ADDRESS MEDICAL EMERGENCIES. DO NOT PROCEED WITH CLINICAL SERVICES USING THE Rx Web Meds PLATFORM IF YOU BELIEVE YOU ARE HAVING A MEDICAL EMERGENCY. IF YOU BELIEVE YOU ARE EXPERIENCING A MEDICAL EMERGENCY, YOU SHOULD DIAL 9-1-1 AND/OR GO TO THE NEAREST EMERGENCY ROOM.

IF YOU ARE CONTEMPLATING SUICIDE, CONTACT 911 OR THE NATIONAL SUICIDE PREVENTION LINE BY ONE OF THE FOLLOWING METHODS:

DIAL 1-800-273-TALK

DIAL OR TEXT 988

Go to

988Lifeline.org

to chat LIVE

I. Introduction

You are reviewing and acknowledging this Telehealth Informed Consent because you are seeking Healthcare Services utilizing telehealth technologies by the Beluga Health, P.A facilitated through Rx Web Meds, LLC. website, iOS mobile app, web mobile app or other telehealth technologies collectively the “Rx Web Meds Platform.” This Telehealth Informed Consent does not modify or supersede any Terms of Use, Privacy Policy, or Notice of Privacy Practices of Rx Web Meds or the Providers, rather it supplements these terms and documents.

By creating an account, starting a consult, clicking “I consent to telehealth,” checking a related box to signify your acceptance, or using any other acceptance protocol presented through the Rx Web Meds Platform, you indicate that you have reviewed the risks as described herein of receiving services utilizing telehealth technologies and consent to receiving the services. A record of this Telehealth Informed Consent is maintained in the files and records of the applicable Provider delivering your services, and your on-going participation in services by the Beluga Health, P.A using telehealth technologies serves as an on-going acknowledgement of your acceptance of this Telehealth Informed Consent and updates at such time the representations you provide herein.

Beluga Health, P.A refers to a network of medical professional organizations affiliated with Rx Web Meds, Inc. and its employed and contracted health providers (the “Providers”).

II. What is Telehealth?

Telehealth involves the delivery of health and wellness services using electronic communications, information technology, or other means between a licensed, certified, or registered healthcare professional at one location and a patient in another location about a clinical matter. Telehealth may be used for diagnosis, treatment, follow-up and/or patient education. These telehealth services may involve various modalities, including asynchronous interactions, real-time (synchronous) video and audio encounters, and interactive audio with store and forward. This “Telehealth Informed Consent” informs the patient (“patient,” “you,” or “your”) concerning the treatment methods, risks, and limitations of utilizing telehealth to meet your health and wellness needs.

III. What are the Possible Benefits of Telehealth?

Benefits of telehealth include being easier and more efficient for you to access health and wellness services. You can obtain health and wellness services at times that are convenient for you without the necessity of an in-office appointment, including follow-up care related to your treatment. If you need follow-up care, please contact us through the Rx Web Meds Platform or email us at [email protected]

IV. What are the Possible Risks of Telehealth?

Information transmitted to your health professional may not be sufficient to allow for appropriate health or wellness services to meet your particular need. Some clinical needs may not be appropriate for a telehealth visit and your Provider will make that determination. The technology necessary to interact with your health professional may fail and delay your services. If a technical failure prevents you from communicating with your Providers, you should call the following number:

Phone: (307) 249-3444 Mon - Fri 9:00 am EST - 5:00 pm EST

In rare events, a lack of access to complete medical records, and/or the quality of transmitted data could result in adverse drug interactions, allergic reactions, and/or other clinical judgment errors. You may stop or decline any on-going Healthcare Services provided by Beluga Health, P.A using telehealth technologies at any time, although you acknowledge that applicable fees may apply if a medical consultation has occurred prior to request to cancel services and Beluga Health, P.A has no obligation for your on-going care or selection of separate healthcare services in such circumstances.

I understand that certain diagnostic testing services, including laboratory products and services offered through the Rx Web Meds Platform to support the Healthcare Services of Providers, may contain defects, including ones which may limit functionality or produce erroneous results, any or all of which could limit or otherwise impact the quality, accuracy and/or effectiveness of the medical care or other services that I receive from my Provider(s).

THIRD-PARTY LABORATORY PRODUCTS AND SERVICES To facilitate certain Healthcare Services Providers may require that you complete diagnostic test(s). These diagnostic tests are provided by third-party laboratories, and neither Rx Web Meds, Beluga Health, P.A, nor your Provider(s) can guarantee the accuracy or reliability of these tests. 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.

V. Patient Acknowledgments

By accepting this Telehealth Informed Consent, you acknowledge you understand and consent to the following:

1 You have reviewed this Telehealth Informed Consent carefully, and understand there are risks, limitations, and benefits of utilizing telehealth.

2 You understand that the electronic nature of the telehealth services means that there is a greater risk to the privacy of my health information.

3 In some cases, my Provider may be a nurse practitioner or physician assistant and not a physician.

4 Persons may be present during the telehealth visit other than my Provider in order to operate the telehealth technologies and/or for language translation assistance, if requested. If another person is present during the telehealth visit, I will be informed of the individual’s presence and his or her role.

5 I understand that information I provide as part of any telehealth offering is viewed as accurate, true, and complete.

6 I understand that in certain instances, and in compliance with applicable law, my Provider may determine that it is appropriate to provide my Healthcare Services asynchronously via store-and-forward technology. In such instances, my Provider and I will communicate electronically through the Rx Web Meds Platform and not via telephone or video. I agree that if my provider makes that determination, I would like to receive Healthcare Services in this manner.

7 I understand that there is no guarantee that I will be given a prescription and that the decision of whether a prescription is appropriate will be made in the professional judgment of my Provider. I understand that while the use of telehealth may provide benefits to me, no such benefits or specific results can be guaranteed, and my condition may not improve.

8 I understand there is a risk of technical failures during the telehealth encounter beyond the control of Beluga Health, P.A and my Provider(s). I AGREE TO HOLD HARMLESS Beluga Health, P.A AND ITS EMPLOYEES, CONTRACTORS, AGENTS, DIRECTORS, MEMBERS, MANAGERS, SHAREHOLDERS, OFFICERS, REPRESENTATIVES, ASSIGNS, PREDECESSORS, AND SUCCESSORS, INCLUDING Rx Web Meds AND ITS EMPLOYEES, CONTRACTORS, AGENTS, DIRECTORS, MEMBERS, MANAGERS, SHAREHOLDERS, OFFICERS, REPRESENTATIVES, ASSIGNS, PARENTS, PREDECESSORS, AND SUCCESSORS FOR DELAYS IN EVALUATION OR FOR INFORMATION LOST DUE TO SUCH TECHNICAL FAILURES.

9 I understand that certain diagnostic testing services, including laboratory products and services offered through the Rx Web Meds Platform to support the Healthcare Services of Providers, may contain defects, including ones which may limit functionality or produce erroneous results, any or all of which could limit or otherwise impact the quality, accuracy and/or effectiveness of the medical care or other services that I receive from my Provider(s).

10 I understand the Rx Web Meds Platform makes available a specific set of services and I may need to seek other resources for my other health needs. There is no guarantee that I will be approved for treatment by a Provider. My Provider reserves the right to deny care for any reason if, in the professional judgment of my Provider, the provision of the services, including when provided via telehealth is not medically or ethically appropriate. I understand that the Providers, and not Rx Web Meds or the Beluga Health, P.A, are responsible for the quality and appropriateness of the care they render to me and make all decisions regarding clinical care in their independent discretion without the influence of Rx Web Meds or the Beluga Health, P.A. I agree to only seek relief against the Provider for any liabilities pertaining to medical or clinical issues arising as a direct result of medical or clinical services accessed through Rx Web Meds.

11 I understand that by using the Rx Web Meds Platform I am not always speaking or messaging with my Provider in real-time, and there may be a delay before my messages or information is reviewed. I understand that I must check the Rx Web Meds Platform or my mobile device for messages because this is the way that my Provider will communicate important information to me. I understand that if I do not check the Rx Web Meds Platform regularly, then my services may be delayed.

12 I understand that I have the opportunity to discuss the use of telehealth, including the Healthcare Services, with my Provider(s), including the benefits and risks of such use and the alternatives to the use of telehealth. I have the right to withdraw my consent to the use of telehealth in the course of my care, without prejudice to any future care or treatment and without risking the loss or withdrawal of any health benefits to which I am entitled, but I understand that the Providers who provide Healthcare Services via the Rx Web Meds Platform do not offer in-person treatment.

13 I understand that I have access to my medical record pertaining to the Healthcare Services of Providers utilizing the Rx Web Meds Platform in accordance with applicable laws and regulations and that my primary care provider, or other treating provider, may obtain copies of my health and wellness information with my consent.

14 I understand that while the Rx Web Meds Platform may make available access to pharmacy or diagnostic lab services that are coordinated with the Healthcare Services, I am able to request any pharmacy or lab of my preference.

15 I agree that Rx Web Meds is a third-party beneficiary of the Telehealth Patient Consent and has the right to enforce it against you.

VI. Additional State-Specific Disclosures

The following disclosures apply to users accessing the Rx Web Meds Platform for the purposes of participating in a telehealth visit as required by the states listed below:

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:

https://medicalboard.iowa.gov/consumers/filing-complaint

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:

https://kbml.ky.gov/grievances/Pages/default.aspx

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:

https://www.maine.gov/md/complaint/file-complaint

New York

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

https://www.health.ny.gov/professionals/doctors/conduct

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:

https://www.oregon.gov/omb/investigations/pages/how-to-file-a-complaint.aspx

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:

https://health.ri.gov/complaints/

Texas

I have been informed of the following notice:

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:

http://www.healthvermont.gov/health-professionals-systems/board-medical-practice/file-complaint

; or Board of Osteopathic Examiners can be found at:

https://sos.vermont.gov/opr/complaints-conduct-discipline/

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:

http://wyomedboard.wyo.gov/consumers/file-a-complaint

Other State Specific Information Regarding Telehealth Services For the following states:

California, Massachusetts, Rhode Island, and Vermont

CA Cal. Bus. & Prof. Code § 680.5(e).;

MA Mass. Board of Registration in Medicine Policy 15-05 (2015) (p.7);

RI R.I. Board of Medical Licensure and Discipline Telemedicine Guidelines.;

VT Vt. Board of Medical Practice Policy on Telemedicine.

The following health group provides Telehealth Services

Beluga Health, P.A is the provider