CONSENT TO TELEHEALTH SERVICES

Last updated: November 1st, 2023

Medvidi Health, P.C., a California professional corporation (a “Medical Group”) provides mental health care services via telehealth (“Telehealth Services”). By agreeing to the terms set forth herein (this “Telehealth Consent”), you consent to the applicable Medical Group providing services to you pursuant to these terms.

The terms “you” and “yours” refer to the person using the Telehealth Services. The purpose of this form is to obtain your consent to participate in the applicable Medical Group’s Telehealth Services.

PLEASE READ THE CONSENT TO TELEHEALTH SERVICES CAREFULLY BEFORE CLICKING THE “AGREE” BOX AND USING TELEHEALTH SERVICES. BY CLICKING THE “AGREE” BUTTON DISPLAYED TO UTILIZE TELEHEALTH SERVICES, YOU CONSENTING TO THE PROVISION OF TELEHEALTH SERVICES AND CONFIRM YOU HAVE READ THE “CONSENT TO TELEHEALTH SERVICES”.

IF YOU DO NOT CONSENT TO TELEHEALTH SERVICES, DO NOT SELECT THE “AGREE” BUTTON.

Telehealth involves the delivery of healthcare services using electronic communications, information technology or other means between a healthcare provider (“Provider”) and a patient who are not in the same physical location. Telehealth may be used for diagnosis, treatment, follow-up and/or member education, and may include, but is not limited to:

• Electronic transmission of medical records, photo images, personal health information or other data between a member and a Provider;
• Interactions between a member and a Provider via audio, video and/or data communications; and
• Use of output data from medical devices, sound, and video files.

The electronic systems used in the Telehealth Services will incorporate network and software security protocols to protect the privacy and security of Personally Identifiable Information, health information, and will include measures to safeguard the data to ensure its integrity against intentional or unintentional corruption.

You may discuss these risks and benefits with your Medical Group Provider and will be given an opportunity to ask questions about telehealth services.

Possible Benefits of Telehealth

• Can be efficient for you to get medical care and treatment.
• You can receive medical care and treatment at times that are convenient for you.
• You can talk to and see a provider without the necessity of going to a physical office.

Possible Risks of Telehealth

• Information transmitted to your Provider(s) may not be sufficient to allow for appropriate medical decision making by the Provider(s).
• 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 may not able to provide medical treatment for your condition via telehealth and you may be required to seek alternative care.
• Delays in medical evaluation/treatment could occur due to failures of the technology and none of the foregoing can guarantee that their services will be always provided without error or interruption that you may wish to use those services.
• Security protocols or safeguards could fail causing your information to be accessed by unauthorized people or entities. While we use state-of- the-art security, no system can 100% guard against risks of intentional intrusion or inadvertent disclosure of information. When using the Telehealth Services, information may be transmitted over media that are beyond the control of the Medical Group, and that may not be secure. For example, you may receive email, text, or telephone communications in connection with your use of Telehealth Services, all of which are inherently unsecured and subject to disclosure to or access by third parties (e.g., if Your phone is used by someone else, you do not keep your phone or email information up to date with the Medical Group and communications are misdirected, or the network or systems of a telecommunications provider are hacked).
• Given regulatory requirements in certain jurisdictions, your Provider(s) treatment options, especially pertaining to certain prescriptions may be limited.

Will my telehealth visit be private?

• We will not record visits with your provider.
• If people are close to you, they may hear something you did not want them to know. You should be in a private place, so other people cannot hear you.
• Your provider will tell you if someone else from their office can hear or see you.
• We use telehealth technology that is designed to protect your privacy.
• If you use the Internet for telehealth, use a network that is private and secure.
• There is a very small chance that someone could use technology to hear or see your telehealth visit.

Your Rights

You may withhold or withdraw your consent to a telemedicine consultation at any time before and/or during the consult without affecting your right to future care or treatment, or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled.

By accepting this Consent to Telehealth, you acknowledge your understanding and agreement to the following:

• By using the Telehealth Services provided by Medvidi, I agree to telehealth services. I understand that telehealth involves the delivery of health care services, including assessment, treatment, diagnosis, and education, using interactive audio, video, and data communications.
• I have read this special Consent to Telehealth carefully, and understand the risks and benefits of the use of telehealth in the medical care and treatment provided to me through MedVidi’s platform by “Providers.”
• I give my informed consent to the use of telehealth by providers affiliated with Medvidi.
• I understand that the delivery of healthcare services via telehealth is an evolving field and that the use of telehealth in my medical care and treatment may include uses of technology not specifically described in this consent.
• I understand that while the use of telehealth may provide potential benefits to me, as with any medical care service no such benefits or specific results can be guaranteed. My condition may not be cured or improved, and in some cases, may get worse.
• I understand that the level of care provided by my provider is to be the same level of care that is available to me through an in-person medical visit. I also, understand that “Providers” may determine in his or her sole discretion that my condition is not suitable for treatment using telehealth, and that I may need to seek medical care and treatment in-person or from an alternative source.
• I understand that the same confidentiality and privacy protections that apply to my other health care services also apply to these telehealth services.
• I understand that I have access to all my health and wellness information pertaining to the telehealth services in accordance with applicable laws and regulations.
• I understand that I can withhold or withdraw this consent at any time by emailing Medvidi with such instruction. Otherwise, this consent will be considered renewed upon each new telehealth consultation with “Providers.”
• I understand expressly assume the risk of any unauthorized disclosure or intentional intrusion, or of any delay, failure, interruption, or corruption of data or other information transmitted in connection with the use of any Telehealth Services.
• I agree and authorize my health care provider to share information regarding the telehealth exam with other organizations or individuals for treatment, payment, and health care operations purposes.
• I understand that I do not need to consent to telehealth services, only if I want to use telehealth services provided by Medvidi.
• I understand that in case of an emergency, I will dial 911 or go directly to the nearest hospital emergency room.
• I agree and authorize my health care provider to release information regarding the telehealth exam to Medvidi and its affiliates.

My health care provider has previously discussed with me the information provided above. I have had an opportunity to ask questions about this information and all my questions have been answered. I have read and agreed to a telemedicine consultation.

By clicking the acceptance box, I consent to receive telehealth services, or in the case of a use of the service by or on behalf of a minor, I am the parent or legal guardian of said minor and provide consent on behalf of said minor. I understand and agree that I am signing this Consent electronically and that (a) I have read this Telehealth Consent carefully, (b) I understand the risks and benefits of the Service and the use of telehealth in the medical care and treatment provided to me by Provider(s) using the Service, and (c) I have the legal capacity and authority to provide this consent for myself.