Legal

Telehealth Informed Consent

Last Updated: January 2023

Telehealth involves the use of secure electronic communications, information technology, or other means to enable a healthcare provider and a patient at different locations to communicate and share individual patient health information for the purpose of rendering clinical care.

Services Provided Possible Risks Electronic Transmissions Patient Acknowledgments Expected Benefits State-Specific Consents Service Limitations Security Measures

Services

Services Provided

Telehealth services offered by Celly Health Medical Group, P.A., and affiliated medical groups ("Group"), and the Group's engaged providers (our "Providers" or your "Provider") may include a patient consultation, diagnosis, treatment recommendation, prescription, and/or a referral to in-person care, as determined clinically appropriate (the "Services").

Transmissions

Electronic Transmissions

The types of electronic transmissions that may occur using the telehealth platform include, but are not limited to:

Appointment scheduling

Completion, exchange, and review of medical intake forms and other clinically relevant information (health records, images, output data from medical devices, sound and video files, diagnostic and/or lab test results) between you and your Provider via asynchronous communications, two-way interactive audio in combination with store-and-forward communications, and/or two-way interactive audio and video interaction

Treatment recommendations by your Provider based upon such review and exchange of clinical information

Delivery of a consultation report with a diagnosis, treatment and/or prescription recommendations, as deemed clinically relevant

Prescription refill reminders (if applicable)

Other electronic transmissions for the purpose of rendering clinical care to you

Benefits

Expected Benefits

Improved Access to Care

Remain in your preferred location while your Provider consults with you. Our telehealth services are available 24 hours a day, 7 days a week.

Convenient Follow-Up Care

If you need non-emergent follow-up care, contact your Provider via your platform account or reach the Celly Health customer success team at (903) 326-3845 or support@cellyhealth.com

Efficient Care Management

Our team will respond within 24 hours during the week or 48 hours over weekends and holidays.

Limitations

Service Limitations

The primary difference between telehealth and direct in-person service delivery is the inability to have direct, physical contact with the patient. Some clinical needs may not be appropriate for a telehealth visit and your Provider will make that determination.

MEDICAL EMERGENCIES

OUR PROVIDERS DO NOT ADDRESS MEDICAL EMERGENCIES. IF YOU BELIEVE YOU ARE EXPERIENCING A MEDICAL EMERGENCY, DIAL 9-1-1 AND/OR GO TO THE NEAREST EMERGENCY ROOM. DO NOT ATTEMPT TO CONTACT CELLY HEALTH MEDICAL GROUP OR YOUR PROVIDER. AFTER RECEIVING EMERGENCY TREATMENT, VISIT YOUR LOCAL PRIMARY CARE PROVIDER.

Our Providers are an addition to, and not a replacement for, your local primary care provider. Responsibility for your overall medical care should remain with your local primary care provider, if you have one, and we strongly encourage you to locate one if you do not.

Group does not have any in-person clinic locations.

Security

Security Measures

The electronic communication systems we use incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption. All Services delivered through telehealth will be delivered over a secure connection that complies with the requirements of the Health Insurance Portability and Accountability Act of 1996 ("HIPAA").

Risks

Possible Risks

Delays in evaluation and treatment could occur due to deficiencies or failures of the equipment and technologies, or provider availability.

In the event of an inability to communicate as a result of a technological or equipment failure, please contact the Group at support@cellyhealth.com

In rare events, your Provider may determine that the transmitted information is of inadequate quality, necessitating a rescheduled telehealth consult or an in-person meeting with your local primary care doctor.

In very rare events, security protocols could fail, causing a breach of privacy of personal medical information.

Acknowledgments

Patient Acknowledgments

I further acknowledge and understand the following:

Prior to the telehealth visit, I have been given an opportunity to select a provider as appropriate, including a review of the provider's credentials, or I have elected to visit with the next available provider from Group.

If I am experiencing a medical emergency, I will be directed to dial 9-1-1 immediately and my Provider is not able to connect me directly to any local emergency services.

I may elect to seek services from a medical group with in-person clinics as an alternative to receiving telehealth services.

I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time without affecting my right to future care or treatment.

Federal and state law requires health care providers to protect the privacy and the security of health information. I am entitled to all confidentiality protections under applicable federal and state laws. All medical reports resulting from the telehealth visit are part of my medical record.

Group will take steps to make sure that my health information is not seen by anyone who should not see it. Telehealth may involve electronic communication of my personal health information to other health practitioners who may be located in other areas, including out of state. I consent to Group using and disclosing my health information for purposes of treatment, care coordination, reimbursement, and health care operations.

Dissemination of any patient-identifiable images or information from the telehealth visit to researchers or other educational entities will not occur without my consent unless authorized by state or federal law.

There is a risk of technical failures during the telehealth visit beyond the control of Group.

Some parts of the Services involving tests (e.g., labs or bloodwork) may be conducted at another location such as a testing facility, at the direction of my Provider.

Persons may be present during the telehealth visit other than my Provider who will be participating in, observing, or listening to the consultation. I will be informed of any individual's presence and their role.

My Provider will explain my diagnosis and its evidentiary basis, and the risks and benefits of various treatment options.

I have the right to request a copy of my medical records by contacting Group at support@cellyhealth.com. A copy will be provided at reasonable cost.

It is necessary to provide my Provider a complete, accurate, and current medical history. I can log into the Elation Patient Portal at any time to access, amend, or review my health information.

There is no guarantee that I will be issued a prescription. If a prescription is issued, I have the right to select the pharmacy of my choice. Celly Health uses Strive Pharmacy Inc (3906 Cragmont Dr, Tampa, FL 33619, support@strivepharmacy.com, 1-855-405-5993) as a prescription fulfillment service provider.

There is no guarantee that I will be treated by a Group provider. My Provider reserves the right to deny care for potential misuse of the Services or if the provision of Services is not medically or ethically appropriate.

State-Specific

Additional State-Specific Consents

The following consents apply to patients accessing Group's website for the purposes of participating in a telehealth consultation as required by the states listed below:

Alaska If you want to register a formal complaint about a provider, visit the medical board's website.

Iowa If you want to register a formal complaint about a provider, visit the medical board's website.

Idaho If you want to register a formal complaint about a provider, visit the medical board's website.

Indiana If you want to register a formal complaint about a provider, visit the medical board's website.

Kentucky If you want to register a formal complaint about a provider, visit the medical board's website.

Maine If you want to register a formal complaint about a provider, visit the medical board's website or the Maine Board of Osteopathic Licensure's website.

Oklahoma If you want to register a formal complaint about a provider, visit the medical board's website or the Oklahoma Board of Osteopathic Examiners' website.

Rhode Island If you want to register a formal complaint about a provider, visit the medical board's website.

TexasNotice Concerning Complaints (English & Spanish)

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: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018. Assistance: 1-800-201-9353. Website: 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, se pueden presentar en: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018. Ayuda: 1-800-201-9353. Sitio web: www.tmb.state.tx.us

VermontVisit the medical board's website or the Vermont Board of Osteopathic Examiners' website.

I understand that I have a choice in receiving services by audio-only telephone, in person, or through telemedicine, to the extent clinically appropriate. I am choosing to receive my services through telemedicine, but I am not prevented from receiving services in person or through audio-only telephone elsewhere.