UltraPharmRx CONSENT TO TELEHEALTH

All capitalized terms used in this Consent to Telehealth but not defined herein have the meanings assigned to them in the Terms and Conditions. For avoidance of any doubt, the terms “UltraPharmRx”, “we”, “us”, or “our” refer to UtraPharmRx and the terms “you” and “yours” refer to the person using the Service.

Telehealth is a way to deliver healthcare services using electronic communications, telecommunications, information technology or other means between a healthcare provider and a patient who are not in the same physical location. It is a convenient way to meet with your healthcare provider from any place, including your home.

Telehealth may be used to deliver clinical health care, including diagnosis, treatment and follow-up; health education; and public health administration. Telehealth is used to for different functions, including:

• Electronic transmission of medical records, photo images, personal health information or other data between you and a health care provider;
• Storage and forwarding of diagnostic images, sound and video files to a health care professional; and
• Audio or video conferencing and/or data communications between you and a health care provider.

The UltraPharmRx Service will incorporate network and software security protocols in all technologies and electronic systems used to deliver telehealth, to protect the privacy and security of health information and data, and will include measures to safeguard your protected health information and data, to ensure its integrity against intentional or unintentional corruption. Your visits with your health care provider are private and will not be recorded.

• As you do not have to go to a clinic or hospital to see your health care provider, it provides an easier, more efficient way for you to access medical care and treatment.
• You can manage your interactions with your health care provider more conveniently and efficiently.
• You can avoid coming in contact with other sick people in a clinic or hospital.

• Seeing your health care provider outside the typical healthcare setting may feel different and you may find it difficult to communicate with and give sufficient information to your health care provider.
• Your health care provider may not be able to provide a diagnosis or treatment because of the inability to conduct physical tests and a close physical examination, which may require an in-person visit.
• The inability to physically examine you may lead to missed signs and symptoms that require emergency medical treatment or further medical testing. Your health care provider may not able to provide medical treatment for your particular condition via telehealth, which may require that you seek alternative care.
• Technological failures may interrupt your tele-visit with your health care provider.
• Technological failures may cause delays in your evaluation and treatment by your health care provider.
• Technological failures may cause distortion of diagnostic images or specimens resulting from electronic transmission issues, unauthorized access to your information, or loss of information due to technology failures. If you are not in a private place during your tele-visit and people are close to you, they may hear something that you wish to keep private.
• Given regulatory requirements in certain jurisdictions, especially pertaining to certain prescriptions, your health care provider’s treatment options may be limited.

By accepting this Consent to Telehealth, you acknowledge, understand and agree to the following:

• 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 UltraPharmRx’s platform by “Providers.”
• I understand the potential risks and benefits of telehealth and will not hold UltraPharmRx responsible for any information lost due to technological failures.
• I understand that while the use of telehealth may provide potential benefits to me, such benefits cannot be guaranteed. My condition may not be cured or improved, and in some cases, may get worse.
• I understand that my health care Provider may determine in his or her sole discretion that my condition is not suitable for treatment using telehealth, and may advise that I 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 telehealth services.
• I understand that my healthcare information may be shared with other individuals in accordance with UltraPharmRx’s Privacy Policy and regulations or laws in the state or territory in which I am located.
• I understand that I have access to all of 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 UltraPharmRx at [email protected] with such instruction. Otherwise, this consent will be considered renewed upon each new telehealth consultation with my health care Provider.
• I agree and authorize my health care Provider to share information regarding the telemedicine exam with other individuals for treatment, payment and health care operations purposes.
• I agree and authorize my health care Provider to release information regarding the telehealth exam to UltraPharmRx and its affiliates.
• I agree and understand that my health care information may be shared in the following circumstances:
  • When a valid court order is issued for medical records.
  • Reporting suspected abuse, neglect, or domestic violence.
  • Preventing or reducing a serious threat to anyone’s health or safety.

UltraPharmRx Asynchronous Telehealth Informed Consent
You are viewing this form because you have elected to engage in asynchronous telehealth visits with an UltraPharmRx health care provider.

BY CHECKING THE “AGREE” BOX, YOU ACKNOWLEDGE THAT YOU HAVE READ AND UNDERSTAND THE TERMS PRESENTED BELOW, AND UNDERSTAND THE RISKS AND BENEFITS OF ASYNCHRONOUS TELEHEALTH, AND BY ACCEPTING THESE TERMS AND CONDITIONS YOU HEREBY GIVE YOUR INFORMED CONSENT TO PARTICIPATE IN ASYNCHRONOUS TELEHEALTH UNDER THESE TERMS.

Telehealth is a way to deliver healthcare services using electronic communications, telecommunications, information technology or other means between a healthcare provider and a patient who are not in the same physical location. It is a convenient way to meet with your healthcare provider from any place, including your home.

Asynchronous telehealth is a way to deliver telehealth using asynchronous communication. Asynchronous communication often referred to as “store-and-forward” communication, is communication that between participants that doesn’t happen at the same time. An example of asynchronous communication is a telehealth encounter with a health care provider that involves sending photos, video, or other communications via email or text message. “Asynchronous” means “not occurring at the same time” and is different from “synchronous” telemedicine, which generally includes visits conducted in real-time between patients and health care Providers through audio- or video-based technology including live phone calls or video-conferencing. Health care Providers may use asynchronous telehealth to aid in diagnoses and medical consultations when live communication or face-to-face contact is not possible or necessary.

UltraPharmRx’s platform (“Platform”) allows for the following asynchronous telehealth services: 1) text-based health care provider-patient interactions through short message service (“SMS”) and multimedia messaging service (“MMS”) communications; and 2) secure information collection through asynchronous store-and-forward patient questionnaires.

• Asynchronous telehealth allows you and your health care provider to interact at a time that suits your schedule.
• You and your health care provider can access telehealth from where and when you want, at different times.
• Because you are not limited by the scheduled time of an in-person or synchronous video or audio visit, you can give your health care provider more detailed information than you would if you were feeling the pressure under a timed visit.

• Your visit with your health care provider may be delayed due to technological deficiencies, disruptions, or failures, which may include poor data quality, Internet outages, or other service interruption issues. You may have to reschedule the visit with your health care provider should these interruptions occur.
• Security protocols could fail, causing a breach of privacy of your personal health information.
• Your health care provider may not be able to fully assess your condition without access to your complete medical history, which may require you to seek alternative care.
• Your health care provider does not have access of your complete medical records. To reduce the chances of negative outcomes such as drug interactions and/or allergic reactions, you should disclose a full list of your medical history including diagnoses, treatments, medications/supplements, and allergies to your health care provider.
• Asynchronous telehealth services are NOT emergency services and your Personal Data (as defined in the UltraPharmRx Privacy Policy) WILL NOT BE MONITORED AT ALL TIMES. If you think you are experiencing a medical emergency, you should CALL 911 IMMEDIATELY.

THE CARE YOU RECEIVE WILL BE AT THE SOLE DISCRETION OF THE HEALTH CARE PROVIDER WHO IS TREATING YOU, WITH NO GUARANTEE OF DIAGNOSIS, TREATMENT, OR PRESCRIPTION. THE HEALTH CARE PROVIDERR WILL DETERMINE WHETHER OR NOT THE CONDITION BEING DIAGNOSED AND/OR TREATED IS APPROPRIATE FOR THE CARE PROVIDED THROUGH AN ASYNCHRONOUS TELEHEALTH ENCOUNTER VIA THE PLATFORM.

ASYNCHRONOUS TELEHEALTH MAY NOT BE AVAILABLE TO YOU AS MANY STATES LEGISLATE AGAINST ITS USE.

By accepting this Consent to Asynchronous Telehealth, you acknowledge, understand and agree to the following:

• I have read this special Consent to Asynchronous Telehealth carefully, and understand the risks and benefits of the use of telehealth in the medical care and treatment provided to me through UltraPharmRx’s platform by “Providers.”
• I have the same privacy rights via asynchronous telehealth that I would have during an in-person visit. Dissemination of any identifiable images or protected health information from the asynchronous telehealth visit to researchers or other third-parties will not occur without my written consent. For more information about how UltraPharmRx protects your privacy, please read the UltraPharmRx Privacy Policy.
• Asynchronous telehealth may involve electronic communication of my protected health information to health care Providers who may be located in other areas, including out of state.
• I understand that I may expect the anticipated benefits from the use of asynchronous telehealth, but that no results can be guaranteed or assured.
• I understand that all information submitted to UltraPharmRx via text message and entered by my health care provider in the UltraPharmRx Platform will be part of my medical record and available to me by emailing [email protected] This information will have the same restrictions on dissemination without my consent.
• I understand that my health care provider’s initial text message to me will include his/her name and credentials, and this will be recorded in the UltraPharmRx Platform as part of my medical record.
• I understand that I can withhold or withdraw this consent at any time by emailing UltraPharmRx at [email protected] with such instruction. Otherwise, this consent will be considered renewed upon each new asynchronous telehealth consultation with my health care provider.
• I understand that this consent is not a condition of purchase.
• I understand that my health care information may be shared with other individuals in accordance with the UltraPharmRx Privacy Policy and regulations or laws in the state or territory in which I am located.
• I agree and understand that my health care information may be shared in the following circumstances:
  • When a valid court order is issued for medical records.
  • Reporting suspected abuse, neglect, or domestic violence.
  • Preventing or reducing a serious threat to anyone’s health or safety.

Call/Email/Text Messaging Consent: I expressly consent to allow UltraPharmRx or its health care Providers to call, email, or text me (via SMS and/or MMS) with or regarding Personal Data (as defined in the UltraPharmRx Privacy Policy), appointments, or similar matters related to my telehealth encounters using the contact information I have provided. I understand and agree that any calls or texts to me may be placed using an auto-dialer or a pre-recorded or artificial voice, even if my number is on a do-not-call list, and that my phone carrier’s normal rates may apply. This Asynchronous Telehealth Informed Consent is valid during your entire treatment with UltraPharmRx.