CONSENT TO TELEHEALTH SERVICES

Telehealth services involve the delivery of healthcare through electronic communications, information technology, or other means, connecting a healthcare provider and a patient who are not physically present in the same location. Telehealth services may encompass diagnosis, treatment, follow-up, and patient education, utilizing various methods such as electronic transmission of medical records, photo images, personal health information exchange, audio/video/data communications (including messaging or email), utilization of output data from medical devices, and sound/video files. Please be aware that alternative methods of care, including in-person services, may be available, and you retain the right to choose an alternative option at any time. It is advisable to discuss alternative options with your healthcare provider. Furthermore, you acknowledge the requirement to be physically present within the state where the provider is licensed to practice during the consultation.

Anticipated Benefits:

The use of telehealth services may offer the following potential benefits:

• Increased ease and efficiency in accessing medical care, services, and treatment for conditions managed by your healthcare provider(s).

• Ability to receive medical care, services, and treatment from provider(s) at times convenient for you.

• Facilitation of interaction with provider(s) without the necessity of in-person appointments.

Potential Risks:

• While telehealth services provide potential benefits, it is essential to understand and acknowledge the associated potential risks, which include but are not limited to the following:

• Limitations on the quality, accuracy, or effectiveness of the services received from your healthcare provider.

• Possible bugs or errors in technology that could affect functionality, produce incorrect results, render technology unavailable, produce erroneous records/transmissions/data/content, or cause corruption or loss of records/transmissions/data/content.

• Technological failures or limitations that may impede your healthcare provider's ability to accurately diagnose or treat your condition.

• Inability to conduct certain tests or assess vital signs in-person, potentially preventing diagnosis, treatment, or identification of the need for emergency medical care.

• Possible unavailability of treatment for your specific condition, necessitating the pursuit of alternative healthcare or emergency care services.

• Delays in medical evaluation/treatment due to provider unavailability or deficiencies/failures in technology or electronic equipment.

• Risk of breaches in the privacy of your medical or other information due to potential failures in electronic systems, security protocols, or safeguards.

• Increased susceptibility to unintended disclosure of protected health information (PHI) to third parties when electronically stored and communicated, such as through email communications.

• Limitations on your healthcare provider's diagnosis and treatment options, particularly related to certain prescriptions, based on regulatory restrictions within your state or jurisdiction.

• Potential adverse drug interactions or allergic reactions due to limited access to your complete medical records.

Data Privacy and Protection:

The telehealth systems in use incorporate network and software security protocols designed to protect the privacy and security of your information. These systems implement measures to safeguard data against intentional or unintentional corruption. Personal information identifying you or containing PHI will not be disclosed to any third party without your consent unless authorized by law for consultation, treatment, payment/billing, or certain administrative purposes, or as specified in your healthcare provider's Notice of Privacy Practices. Please note that Sameday does not guarantee the security or privacy of the services used for communication, including email service providers.

Disclosure of Provider Information and Patient Grievances:

All healthcare providers affiliated with the Medical Groups possess the necessary licenses, certifications, or permissions to provide healthcare services within the state where such services are rendered. Upon request at the time of treatment, your treating provider's information, including name, highest academic degree, specialty, license status, license number, and board certification (where applicable), will be made available to you as required. Additionally, you retain the right to report concerns or grievances to the appropriate state medical board or other regulatory bodies. The Medical Group will furnish you with information on how to contact relevant regulatory bodies, as mandated by law, and will prominently display this information.

Disclosure of Risks Regarding Specific Services:

By providing your consent, you affirm that you have thoroughly reviewed the following disclosures and have been informed of and comprehend the risks associated with these particular services. Should you have any questions concerning the items or services, it is advisable to discuss them with your treating healthcare provider or primary care physician.

Limitation of Liability:

Under no circumstances shall Wellbeing Medical Physician Assistant PC, Medical Groups, or Labs (collectively referred to as "Companies") be liable to you or any other person or entity for any damages, including incidental and consequential damages, personal injury or wrongful death, lost profits, or damages resulting from lost or corrupted data or business interruption, arising from the use of or inability to use telehealth services ("Services") or any third-party goods and services (including services by Labs or Medical Providers). This applies whether the claim is based on warranty, contract, tort (including negligence), or any other legal theory, even if Companies were advised of the possibility of such damages. The liability of Companies shall be limited to the actual damages incurred by you, not exceeding U.S. $1,000.

Furthermore, Companies shall not be liable for any personal injury, including death, caused by your use, misuse, or inability to use the Services or any third-party goods and services (including services by Labs or Medical Providers). Any claims arising from your use of the Services or any third-party goods and services must be brought within one (1) year from the date of the event giving rise to such action. You understand and agree that your use of any technology, including the Services, and any third-party goods and services related to Companies is contingent upon your waiver of any right to participate in a class action suit against Companies for losses or damages resulting from your use of such technology, Services, or third-party goods and services.

Please be aware that certain jurisdictions may not allow the exclusion of certain warranties or the limitation or exclusion of liability for incidental or consequential damages. To the extent that Companies may not disclaim any implied warranty or limit their liabilities, the scope, duration, and extent of such warranty, as well as the liability of Companies, shall be limited to the minimum extent permitted by applicable law.

NOTICE OF PRIVACY PRACTICES AND HIPAA COMPLIANCE

This document serves as a notification regarding the usage and disclosure of medical information pertaining to you, and outlines your rights to access this information. Please read this notice carefully. Wellbeing Medical Physician Assistant PC ("PC") and Wellbeings Medical PLLC “PLLC” are legally obligated to protect your Protected Health Information (PHI) and maintain its privacy.

PC and PLLC are mandated by law to safeguard your PHI, which encompasses any information that can identify you, such as details about your past, present, or future health, medical condition, healthcare provision, or related payments. It is required to provide you with this notice, which explains how, when, and why your PHI will be "used" or "disclosed." The term "use" refers to sharing, examining, utilizing, applying, or analyzing your PHI within PC and PLLC's practice, while "disclosure" involves releasing, transferring, providing to, or otherwise revealing your PHI to external parties. PC and PLLC is bound by legal obligations to adhere to the privacy practices detailed in this notice.

However, please note that PC and PLLC reserve the right to modify the terms of this notice and its privacy policies at any time. Any such changes will apply to PHI already in PLLC and PC's possession. In the event of substantial policy alterations, PC and PLLC will promptly revise this notice and make a new copy available upon request.

I. USES AND DISCLOSURES OF YOUR PHI BY PC and PLLC

PC and PLLC may utilize and disclose your PHI for various purposes. While some of these uses and disclosures require your prior authorization, others do not. The following categories outline the different types of PC and PLLC use and disclosures, along with examples for each category:

A. Uses and Disclosures Related to Treatment, Payment, or Health Care Operations Without Prior Consent: PC can use and disclose your PHI without your consent for the following reasons:

Treatment: PC and PLLC can disclose your PHI to licensed healthcare providers, such as physicians, psychiatrists, psychologists, involved in providing you with healthcare services. For instance, if you are receiving treatment from a psychiatrist, PC and PLLC may disclose your PHI to coordinate your care.

Payment: PC and PLLC can use and disclose your PHI to bill and collect payment for the treatment and services provided. For example, PC and PLLC may send your PHI to your insurance company or health plan to obtain payment for healthcare services rendered. PC and PLLC may also disclose your PHI to business associates such as billing companies or claims processing companies involved in healthcare claims processing.

Health Care Operations: PC and PLLC can disclose your PHI for operational purposes. This may include evaluating the quality of healthcare services you received or assessing the performance of healthcare professionals involved in your care. PC and PLLC may also provide your PHI to accountants, attorneys, consultants, and others to ensure compliance with applicable laws.

Other Disclosures: PC and PLLC may disclose your PHI to others without your consent under specific circumstances, such as when emergency treatment is necessary, or when you are unable to communicate your consent due to incapacitation or severe pain, and it is deemed that you would provide consent if able to do so.

B. Certain Uses and Disclosures Without Consent: PC and PLLC can use and disclose your PHI without your consent or authorization for the following reasons:

Legal Requirements: When disclosure is mandated by federal, state, or local laws, judicial or administrative proceedings, or law enforcement. For example, PC and PLLC may disclose information to government agencies and law enforcement personnel as required by law regarding victims of abuse or neglect, or as ordered in a judicial or administrative proceeding.

Public Health Activities: PC and PLLC may need to report information about you to the county coroner, as required for public health activities.

Health Oversight Activities: PC and PLLC may provide information to assist government investigations or inspections of healthcare providers or organizations, as required for health oversight activities.

Research Purposes: PC and PLLC may disclose PHI for medical research purposes, subject to specific circumstances.

Avoiding Harm: In order to prevent or lessen serious harm to individuals, PC and PLLC may disclose PHI to law enforcement personnel or those capable of preventing such harm.

Government Functions: PC and PLLC may disclose PHI of military personnel and veterans in certain situations. Additionally, PC and PLLC may disclose PHI for national security purposes, such as protecting the President or conducting intelligence operations.

Workers' Compensation: PC and PLLC may provide PHI to comply with workers' compensation laws.

Appointment Reminders and Health-Related Benefits or Services: PC and PLLC may use PHI to provide appointment reminders or offer information about treatment alternatives, other healthcare services, or benefits.

C. Certain Uses and Disclosures Allowing Objection: PC and PLLC may disclose your PHI to family, friends, or other individuals involved in your care or payment, unless you object. In emergency situations, consent may be obtained retroactively.

D. Other Uses and Disclosures Requiring Prior Written Authorization: For any situation not covered in Sections III A, B, and C, PC will request your written authorization before using or disclosing your PHI. If you choose to authorize the disclosure of your PHI, you may later revoke this authorization in writing, except if PC and PLLC have already taken action based on your authorization.

II. YOUR RIGHTS REGARDING YOUR PHI

You have the following rights concerning your PHI:

A. Requesting Limits on Uses and Disclosures: You may ask PC and PLLC to limit the usage and disclosure of your PHI. While PC and PLLC will consider your request, it is not legally obligated to accept it. If PC and PLLC agree to your request, any limitations will be documented in writing and adhered to, except in emergency situations. However, certain uses and disclosures that PC and PLLC is legally required or allowed to make cannot be limited.

B. Choosing Alternate Methods of Communication: You have the right to request that PC and PLLC send information to an alternative address (e.g., work address instead of home address) or through alternate means (e.g., email instead of regular mail). PC and PLLC must comply with your request as long as it can easily provide the PHI to you in the requested format.

C. Accessing and Obtaining Copies of Your PHI: In most cases, you have the right to review and obtain copies of your PHI held by PC and PLLC, provided you make a written request. If PC and PLLC does not possess your PHI but knows where it can be obtained, it will guide you accordingly. PC and PLLC will respond to your request within 30 days of receipt. In certain situations, PC and PLLC may deny your request, in which case it will provide a written explanation for the denial and inform you of your right to have the denial reviewed. Instead of providing the requested PHI, PC and PLLC may offer a summary or explanation of the information, provided you agree to this alternative and the associated costs in advance.

D. Requesting an Accounting of Disclosures: You have the right to receive a list of instances in which PC and PLLC has disclosed your PHI. This list will exclude uses or disclosures to which you have already consented, such as those made for treatment, payment, or healthcare operations directly to you or your family. The list will also exclude disclosures made for national security purposes, to corrections or law enforcement personnel, or those made before April 15, 2003.

PC and PLLC will respond to your request for an accounting of disclosures within 60 days and provide the list for the last six years unless you specify a shorter timeframe. The list will include the date of disclosure, the recipient of the PHI (including their known address), a description of the information disclosed, and the reason for the disclosure. PC and PLLC will provide the list at no cost, but multiple requests within a year may incur reasonable fees.

E. Correcting or Updating Your PHI: If you believe there is an error or omission in your PHI, you have the right to request its correction or amendment by PC and PLLC. You must submit the request in writing, along with your reasons. PC and PLLC will respond within 60 days and may deny your request in writing if the PHI is deemed correct, complete, not created by PC and PLLC, not allowed to be disclosed, or not part of its records. In case of denial, PC and PLLC will explain the reasons and your right to submit a written statement of disagreement. If you choose not to do so, you can request that your original request and the denial be included with any future disclosures of your PHI. If your request is approved, PC and PLLC will make the necessary changes, inform you of the update, and notify relevant parties who require the modified PHI.

You have the right to receive a copy of this notice by email. However, even if you consent to electronic notice, you retain the right to request a paper copy.

III. FILING A COMPLAINT ABOUT PRIVACY PRACTICES

If you believe that PC and PLLC has violated your privacy rights or disagree with a decision regarding access to your PHI, you may file a complaint with the designated person listed in Section VI below. Alternatively, you can submit a written complaint to the Secretary of the Department of Health and Human Services at 200 Independence Avenue S.W., Washington, D.C. 20201. PC will not retaliate against you for filing a complaint about its privacy practices.

IV. CONTACT PERSON FOR INFORMATION AND COMPLAINTS

If you have any questions about this notice, complaints about PC's and PLLC’s privacy practices, or wish to understand the process for filing a complaint with the Secretary of the Department of Health and Human Services, please contact:

Jessica Brewer

Email: jessica@wellbeingmedical.com

V. EFFECTIVE DATE OF THIS NOTICE

This notice became effective on Apr 24, 2023.