Telehealth Consent and Open Payments Notice

Texas laws define telemedicine as remote medical services provided to a patient by a physician who is licensed in Texas. With this, it should be noted that in order for the proper conduct of telemedicine, the physician must be within the vicinity of the state of Texas. This however requires that in the practice, the patient should also be within the state of Texas for the proper conduct of the service.

In order for the service of telemedicine to take place, please go through and understand each item in this informed consent form. If you have questions, please do not hesitate to let us know and we will be more than happy to answer them for you.

• Consent

  I voluntarily give my consent to engaging in telemedicine with the physician(s) for the purpose of treatment and diagnosis.I understand that telemedicine involves the use of audio, video, and/or data communication for consultation, diagnosis, treatment, or education purposes.I understand that telemedicine has its limitations and shall not be equal to a face-to-face consultation as the doctor cannot use the senses of touch or smell which may be needed during consultation and diagnosis, and that there is no assurance guaranteed to the benefits of telemedicine.I understand that with telemedicine, communication interruptions may arise which may not be the fault of the doctor nor mine. I understand that this instance may cause delay or problems in communication that may prevent proper engagement.I understand that I have the right to withhold or withdraw my consent from this telemedicine agreement and that such will not affect my right to further future care or treatment that of which I am entitled.I understand the laws in place that protect my privacy and that such privacy and confidentiality, particularly relating to health, such as that of HIPAA, likewise apply in telemedicine. Any dissemination of information that may personally identify my person shall require my prior written consent.I understand that these confidentiality rights is not absolute. Any matter that may involve abuse, harm, or violence towards a child, an elder, or any person shall permit the doctor to report to proper authorities if he or she do so believe the possibility of such event to happen or may have happened.

• By signing and submitting this form I hereby declare that I have read and I fully understand all the information provided above. This information was discussed with me by my doctor or his or her representative, and all questions I have raised were answered to me to my full satisfaction. That I am located or living in the state of Texas and during my telemedicine visits, will be within the state of Texas

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 device, 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 and mental health 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. Your treating Provider for therapy services will be a mental health professional, such as a licensed counselor. 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, including ones which may limit functionality, produce erroneous results, render part or all of such technology unavailable or inoperable, produce incorrect records, transmissions, data or content, or cause records, transmissions, data or content to be corrupted or lost, any or all of 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, any or all of 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). 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 your 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 Klouds, Inc 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 Klouds, Inc 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 and/or mental health providers including emergency contact information for your local healthcare and/or mental health providers. You understand that each of 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 using telehealth technology, including the Service. 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 understand that each of your Provider(s) may determine in their sole discretion that your condition is not suitable for diagnosis and/or treatment using telehealth technology, including the Service, and that you may need to seek care and treatment from a specialist or other healthcare or mental health provider, outside of such telehealth technology.