Telehealth Consent

Informed Consent Regarding Use of Telehealth

Purpose

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 services to you by physicians, physician assistants, nurse practitioners, and/or other licensed healthcare professionals (“Providers”) using the online platform owned and operated by FreeWell Health LLC and/or its affiliated entities (the “Service”). In this Consent, the terms “you” and “yours” refer to the person using the Service, or in the case of use of the Service by or on behalf of an individual minor where permitted by 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.

Use of Telehealth

Telehealth involves the delivery of healthcare services using electronic communications, information technology, or other means between a healthcare provider and a patient who are not in the same physical location. Telehealth may be used for diagnosis, treatment, follow-up, and/or patient education, and may include, but is not limited to, one or more of the following: electronic transmission of medical records, photo images, personal health information, or other data between a patient and a provider; interactions between a patient and provider via audio, video, and/or data communications (such as messaging or email communications); use of output data from medical devices, sound, and video files. Alternative methods of care may be available to you, such as in-person services, and you may choose an alternative at any time. Always discuss alternative options with your Provider.

Anticipated Benefits

The use of telehealth may have the following possible benefits: making it easier and more efficient for you to access medical care or other services and treatment for the conditions treated by your Provider(s); allowing you to obtain medical care or other services and treatment by Provider(s) at times that are convenient for you; and enabling you to interact with Provider(s) without the necessity of an in-office appointment.

Potential Risks

While the use of telehealth in the delivery of care can provide potential benefits for you, there are also potential risks associated with the use of telehealth and other technology. These risks include, but may not be limited to, the following: the quality, accuracy, or effectiveness of the services you receive from your Provider could be limited; technology, 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, including the Service, unavailable or inoperable, produce incorrect records, transmissions, data, or content, or cause records, transmissions, data, or content to be corrupted or lost; failures of technology may also impact your Provider(s) ability to correctly diagnose or treat your condition; the inability of your Provider(s) to conduct certain tests or assess vital signs in-person may in some cases prevent the Provider(s) from providing a diagnosis or treatment or from identifying the need for emergency medical care or treatment for you; your Provider(s) may not be able to provide treatment for your particular condition and you may be required to seek alternative healthcare or emergency care services; delays in medical evaluation/treatment could occur due to unavailability of your Provider(s) or deficiencies or failures of the technology or electronic equipment used; the electronic systems or other security protocols or safeguards used could fail, causing a breach of privacy of your medical or other information; data stored and communicated electronically, for example, through email communications, may be more susceptible to unintended disclosure of protected health information to third parties; given regulatory requirements in certain jurisdictions, your Provider(s) diagnosis and/or treatment options, especially pertaining to certain prescriptions, may be limited; a lack of access to all of your medical records may result in adverse drug interactions or allergic reactions or other judgment errors.

Life Threatening and Other Emergency Situations; Follow-Up Care

If you are experiencing a life-threatening situation such as contemplating suicide, call 911 or the 988 Suicide and Crisis Lifeline at 988.

If the situation is an emergency, call 911. In some situations, telehealth is not an appropriate method of care. If you require immediate or urgent care, you must seek care at an emergency room facility or other provider equipped to deliver urgent or emergent care. Providers may not respond promptly to communications you submit through the Service. If you are not experiencing an emergency or do not require immediate or urgent care, you can communicate with Providers through the secure message service in the Service. If a technical failure prevents you from communicating with your Providers through the Service, you should contact us at support@[DOMAIN].

Data Privacy and Protection

The electronic systems used in the Service will incorporate network and software security protocols to protect the privacy and security of your information and will include measures to safeguard data against intentional or unintentional corruption. Personal information that identifies you or contains protected health information will not be disclosed to any third party without your consent, except as authorized by law for the purposes of consultation, treatment, payment/billing, certain administrative purposes, and as required by law to disclose to other persons and agencies certain information obtained during the provision of services or as otherwise set forth in your Provider's Notice of Privacy Practices. Use of the Service may include email communications to and from you that may include your protected health information. You understand that FreeWell Health does not and cannot guarantee the security or privacy of the services you use to receive communications, including, for example, your email service provider.

Laboratory Products and Services

Certain healthcare services provided to you by Providers via the Service may include laboratory testing. If you are signing this Consent in connection with participating in and receiving the specific lab testing services available through the Service (the “Lab Testing Services”), you are doing so as part of a coordinated offering made available through the Service and certain affiliated and/or third-party laboratories, whereby the Service facilitates access to Providers who can order laboratory tests and provide related counseling, in each case as determined appropriate by such ordering Providers. As part of the Lab Testing Services, you seek and agree to receive the ordering services and oversight support services provided by such Providers, including without limitation, review of test requests, receipt of test results, and related health and wellness counseling. If determined necessary, a Provider will order laboratory blood testing, either using an at-home blood testing kit, which will be mailed to you, or you may need to go, in-person, to a blood collection site to have your blood drawn. You understand the risks involved with blood draws include, but are not limited to, discomfort at the site of the blood draw, possible bruising, redness, and swelling around the site, bleeding at the site, feeling lightheadedness when blood is being drawn, and rarely, an infection at the site of the blood draw. These laboratory tests are provided by affiliated and/or third-party laboratories, and neither FreeWell Health nor your Provider(s) can guarantee the accuracy or reliability of these tests. If you receive laboratory products and/or services from a lab through the Service, these are products and/or services of the lab, with FreeWell Health acting as the collection conduit of the lab. These laboratory tests can provide false negative, false positive, or inconclusive results.

You understand that laws in certain states may necessitate a delay prior to release of certain testing results to permit an opportunity for the ordering healthcare provider to review results with the patient. You hereby elect to exercise your direct right of access to test results under federal law. You knowingly waive any release requirement and affirm your desire to receive testing results as soon as the testing report is complete and available for release.

All tests and results are confidential, but will be disclosed, as appropriate and to the extent of information needed, by and among the Service, its affiliated Providers, and the laboratory that processes your sample. Neither the Service nor its affiliated Providers will otherwise disclose your results except as authorized by you or as may be required or permitted by law. You are responsible for sharing any results with your primary care or other personal physician and for initiating follow up with such physician for care, diagnosis, or medical treatment.

The Service is not a laboratory and is not responsible for the retention of your specimen following the Lab Testing Services. Contact the testing laboratory if you have questions about how your sample will be retained or disposed.

You understand that laboratory testing is voluntary and you may choose not to have your sample tested. You have read and you understand the information provided in this consent, and all your questions have been answered.

Open Payments Notice

For informational purposes only, a link to the federal Centers for Medicare and Medicaid Services Open Payments web page is provided here. 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. The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. It can be found at https://openpaymentsdata.cms.gov.

Your Acknowledgments

By clicking “I Agree,” checking a related box to signify your acceptance, using any other acceptance protocol presented through the Service, or otherwise affirmatively accepting this consent, you are agreeing and providing your consent with respect to the following:

• Healthcare services provided to you by Providers via the Service will be provided by telehealth. In some cases, your treating Provider may be a nurse practitioner or physician assistant and not a physician, and you agree to be treated by non-physician providers, if applicable, by using the Service.
• Certain technology, including the Service, 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 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).
• Certain diagnostic testing services, including laboratory products and services offered through the Service, may contain defects, including ones which may limit functionality or produce erroneous results.
• 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 testing 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.
• There are potential risks to the use of telehealth and other technology, including but not limited to the risks described in this Consent.
• You have the opportunity to discuss the use of telehealth, including the Service, with your Provider(s), including the benefits and risks of such use and the alternatives to the use of telehealth.
• You understand that there will be no recording of any online treatment sessions by your Provider(s) or you.
• Your Provider(s) will assess your medical condition and, in their sole discretion, may determine it is medically appropriate to diagnose and/or treat your condition via telehealth and whether you maintain sufficient knowledge and skills in the use of technology appropriate to diagnosing and/or treating your condition via telehealth. By continuing to use the Service, you concur with your Provider's medical assessment and agree to receive a diagnosis and/or treatment via telehealth technology.
• You have the right to withdraw your consent to the use of telehealth in the course of your care, without prejudice to any future care or treatment and without risking the loss or withdrawal of any health benefits to which you are entitled, but you understand that the Providers who utilize the Service do not offer in-person treatment. Any withdrawal of your consent will be effective upon receipt of written notice to your Providers, except that such withdrawal will not have any effect on any action taken by FreeWell Health or your Provider(s) in reliance on this Consent before it received your written notice of withdrawal. Any withdrawal of your consent will not affect any other provision of this Consent, and you will continue to be bound by this Consent.
• You understand that the use of the Service involves electronic communication to and from you of your personal medical information in connection with the provision of telehealth services, including through email.
• You understand that it is your duty to provide FreeWell Health and your Provider(s) truthful, accurate, and complete information, including all relevant information regarding care that you may have received or may be receiving from healthcare providers including emergency contact information for your local healthcare providers.
• FreeWell Health has a financial relationship with the entity that employs or contracts with your Provider. You are free to obtain your medical examination from another healthcare provider that is not associated with FreeWell Health. FreeWell Health will use its pharmacy partners to fulfill your order directly to your door. You are free to obtain your prescription from any pharmacy of your choice by contacting our support team. Prescriptions may be filled by and transferred between any pharmacy partners on your behalf.
• You must pay the full amount of the costs associated with use of the Service, including any prescription you may receive, and you will not attempt to submit a claim to Medicare, any other federal payor, or any state or private insurer.
• If you have a concern about a medical professional, you may contact the Medical Board in your state regarding your concerns.
• Special Notice to California Clients. Physicians and midwives are licensed and regulated by the Medical Board of California. To confirm a license or file a complaint, go to www.mbc.ca.gov or call (800) 633-2322.

Contacting Us

If you have any questions about this Telehealth Consent, please contact us: