Informed Consent for Telehealth Services

LifeMD, Inc. (“LifeMD”) provides a secure platform for working with health providers of the following affiliated medical P.C.s and P.A.s: LifeMD Southern Patient Medical Care, P.C.; LifeMD Atlantic Patient Medical Care, P.C.; LifeMD Kansas Patient Medical Care, P.A., LifeMD Midwest Patient Medical Care, P.C.; LifeMD New England Patient Medical Care, P.A.; LifeMD Puerto Rico Patient Medical Care, P.C.; LifeMD South Central Patient Medical Care, P.A.; New York Patient Medical Care, P.C.; and Puopolo M.D., P.C. d/b/a LifeMD Western Patient Medical Care P.C. (“LifeMD Affiliated PCs”) in the delivery of healthcare services using electronic communications, information technology, and/or remote means of communication (“Telehealth”). The purpose of this form is to obtain your consent to participate in a Telehealth visit with one of LifeMD Affiliated PCs’ health providers via LifeMD’s Telehealth platform.

By affirmatively clicking the box saying that “I agree to the . . . consent to Telehealth,” you understand and agree that

1. Nature of the Telehealth Visit. During the Telehealth visit:
   1. Details of your health information, including but not limited to any and all reports and/or records concerning your medical history, condition, diagnosis, testing, prognosis, treatment, billing information and identity of your health providers (“User Data”), will be discussed with your health provider through the use of interactive video, audio, and telecommunications technology.
   2. Video, audio, and/or digital photographs may be recorded during the Telehealth visit.
   3. Your User Data will continue to be shared via this connection until either you or your health provider terminates this connection.
   4. Non-medical technical personnel may be present during the Telehealth visit to aid with the video transmission. You will be informed of their presence and you may request that non-medical personnel leave the Telehealth visit at any time.
   5. You understand that: (a) the delivery of healthcare services via Telehealth is an evolving field; (b) the Telehealth visit may include technology (and uses thereof) that are not specifically described in this informed consent; and (c) by agreeing, you consent to the uses of those additional technologies.
2. Limits of Telehealth. A health provider will use Telehealth to deliver healthcare services to you. Telehealth may not be as complete as face-to-face treatment and is not intended to replace a full medical face-to-face evaluation by a health provider. You may benefit from Telehealth services; however, results cannot be guaranteed or assured.
3. Telehealth as Appropriate for the Circumstance. It is the health provider’s role to determine whether or not the use of Telehealth and its enabling technologies, capabilities, and limitations is appropriate for the healthcare services you are seeking.
4. Routine Electronic Messages. Health providers will typically respond to routine electronic messages within 24 hours. Patient’s electronic communications through LifeMD’s encrypted platform are securely directed only to the health provider.
5. Medical Information and Records. All existing laws regarding the confidentiality of your User Data apply to this Telehealth visit. Dissemination of any patient-identifiable images or information from this Telehealth interaction to other entities shall not occur without your consent, unless authorized by law.
6. Right to Care. You are under no obligation to use Telehealth and may withdraw at any time. You have the right to access your User Data and copies of your User Data in accordance with federal and state law.
7. Risks. There are potential risks to using Telehealth technology, including interruptions, unauthorized access, confidentiality, and technical difficulties. You or your health provider can discontinue the Telehealth visit if it is felt that the videoconferencing connections are not adequate for the situation. Health providers will attempt to trouble shoot and re-establish Telehealth connection. If unable to re-establish Telehealth connection, or in an emergency, your health provider will attempt to reach you by calling the phone number you have provided. Risks include, but are not limited to, the following:
   1. Information transmitted to your health provider via Telehealth may not in every case be sufficient to allow for appropriate medical decision-making by the health provider.
   2. The inability of your health provider to conduct certain tests or assess vital signs in-person may, in some cases, prevent the health provider from making accurate diagnoses, providing appropriate treatments, or identifying the need for emergency medical care or treatment.
   3. Your health provider may not be able to provide all of the necessary medical treatment for your particular condition via the Telehealth visit, in which case you should rely on alternative and/or specialized medical care.
   4. Delays in medical evaluation/treatment may occur due to unexpected failures in technology associated with providing Telehealth.
   5. Although security protocols and safeguards associated with the Telehealth visit are carefully designed to protect data privacy consistent with legal requirements, such protocols and safeguards may fail, causing a breach in data privacy.
   6. Your health provider’s treatment options may be limited by regulatory requirements in certain states.
8. Sharing Information. LifeMD Affiliated PCs may use and disclose your User Data for purposes of diagnosis, treatment, referral, follow-up, payment, and other administrative purposes as consistent with applicable law. All electronic communication between you and your health provider will be securely stored in one of LifeMD’s encrypted electronic systems. You will hold LifeMD and LifeMD Affiliated PCs harmless for any User Data lost due to technical failures. Further, LifeMD Affiliated PCs retain the right to share User Data pursuant to any legally required reporting. Please note that because the LifeMD Affiliated PCs do not submit claims to health insurance, we are not subject to the federal law governing the use and disclosure of health information, known as the HIPAA rules. You can find further information about our privacy and security practices in our Privacy Policy.
9. Revocation. You make revoke this authorization at any time by informing your health provider during your Telehealth session, contacting LifeMD or LifeMD Affiliated PCs at (866) 351-5097, or contacting your dedicated medical team through your member portal with such instruction; provided, however, that where you revoke this authorization, you will no longer be able to access or use the Telemedicine services provided by LifeMD or Professional Practice. Absent such a revocation, this authorization will be considered renewed upon each new Telehealth visit with a participating health provider.