Telehealth Consent Form

CONSENT TO TELEHEALTH, TREATMENT-SPECIFIC CONSENT, CONSENT TO TEXT OR EMAIL COMMUNICATION, AUTHORIZATION TO USE AND DISCLOSE MY MEDICAL INFORMATION, and ASSIGNMENT OF BENEFITS

IMPORTANT: OUR HEALTHCARE PROVIDERS DO NOT ADDRESS MEDICAL EMERGENCIES. IF YOU BELIEVE YOU ARE HAVING A MEDICAL EMERGENCY, YOU SHOULD DIAL 911 OR GO TO THE NEAREST EMERGENCY ROOM.

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 ACKNOWLEDGE THAT YOU HAVE READ, ACCEPTED, AND AGREED TO BE BOUND BY THIS CONSENT.

Consent to Telehealth

Telehealth is a mode of delivering health care services via communication technologies to facilitate diagnosis, consultation, treatment, education, care management, and self-management of an individual's healthcare. The purpose of this consent form 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 doctors, physician assistants, nurse practitioners, and/or mental health professionals ("Providers") using the online platforms owned and operated by Fountain of Youth and/or its affiliates and subsidiaries.

You are reviewing and acknowledging this Telehealth Consent Form because you are seeking Services from Fountain of Youth utilizing telehealth technologies.

Treatment-Specific Consent

By clicking "I consent to telehealth" you understand and agree to the following:

1. I understand that Fountain of Youth offers telehealth visits, which are conducted through videoconferencing, telephonic, and asynchronous technology and my Provider will not be present in the room with me.
2. I am consenting to Fountain of Youth importing and accessing my medical records and medication list, including prescription records.
3. 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.
4. 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, documentation inaccuracies, recording failures, and ambient listening inaccuracies.
5. I understand that my telehealth visit may involve the use of automated 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.
6. I understand that, as part of my care, my Provider may use automated tools to assist with analyzing medical data or records, supporting clinical decision making, generating summaries or documentation, or recommending potential diagnoses or treatment options. These tools are intended to support, not replace, the professional judgment of my Provider.
7. I understand that my telehealth visit may be recorded (audio and/or video) for purposes including but not limited to quality assurance, provider training, clinical documentation, and care coordination.
8. I understand that ambient listening technologies may be used during my telehealth visit to capture relevant clinical information.
9. I understand that in some cases, my Provider might be a nurse practitioner or a physician assistant and not a doctor.
10. 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.
11. I understand that while using telehealth technologies may benefit me, no such benefits or specific results are guaranteed, and my condition may not improve.
12. I agree that any information I provide as part of any telehealth visit is accurate, true, and complete.
13. 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.
14. 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.
15. I understand that while the Platform may make available access to certain pharmacy or diagnostic lab services, I may request to use any pharmacy or lab of my preference.
16. I understand that I am responsible for payment of any amounts due and owing resulting from my telehealth visit.
17. I understand that Providers do not address medical emergencies via the Platform.

Compounded Medications Consent

If you receive a prescription for compounded medications:

• I understand that the FDA does not approve nor review compounded products for safety, effectiveness, 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.

Authorization to Bill Insurance and Assignment of Benefits

By clicking "I accept," I confirm that the above information is true, correct, and complete to the best of my knowledge. I authorize Fountain of Youth and its affiliated entities to bill my insurance company directly and I further authorize any third-party payer through which I have benefits to make payment directly to Fountain of Youth. I understand that I am financially responsible for any balance.

Consent to Text or Email Communication

By clicking "I accept," I authorize Fountain of Youth to contact me via phone call, SMS/text message, or email for:

• Appointment reminders
• Member feedback requests
• General health and wellness information

I understand that:

• These communications may be generated in part by automated systems.
• Standard messaging and data rates may apply.
• I may opt out of receiving such communications at any time.
• Using these communication methods presents a potential security risk of unauthorized access to protected health information (PHI).

Your Rights

• 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 telehealth.
• I may refuse to agree to this authorization. My refusal to sign will not affect my ability to obtain treatment unless this authorization is requested prior to providing health care.
• I may revoke this authorization in writing at any time by sending a written notification to our Privacy Office.

State-Specific Disclosures

The following additional consents may apply based on your state of residence:

• California: To get information regarding your rights and how to report professional misconduct, visit the Medical Board of California website.
• Texas: Complaints about doctors may be reported to the Texas Medical Board at 1-800-201-9353 or www.tmb.state.tx.us.
• New York: To get information regarding your rights and how to report professional misconduct, visit the New York State Department of Health website.

For additional state-specific information, please contact our support team.

Contact Information

Fountain of Youth
Email: support@fountainofyouths.com