Informed Consent for Telehealth Services

DO NOT USE THIS SERVICE IF YOU MAY BE EXPERIENCING A MEDICAL EMERGENCY.

In an emergency you can: (i) call 911; (ii) go to the nearest emergency room; (iii) contact your local crisis center; (iv) call or text the 988 Suicide & Crisis Lifeline; or (v) text "GO" to 741-741 to reach the Crisis Text Line.

We are pleased you have chosen MDI Medical Group PC and its affiliated medical practices (the "Practice") for your telehealth care, arranged through Velos Health. This document explains what to expect from your clinician, their credentials, and your treatment by telehealth. After you have read it and had the opportunity to have your questions answered, certain state laws require that you sign and date it before care begins.

Velos Health is not a medical practice and does not provide medical care. Velos operates the website and patient experience, arranges your consultation with the Practice, and arranges pharmacy fulfillment and delivery. Your clinical care is provided by licensed clinicians of the Practice, who exercise independent professional judgment.

YOUR CLINICIAN'S CREDENTIALS. Your clinician's credentials will be made available to you as part of your telehealth visit. If you have questions about them, direct them to your clinician. For states that require it, an explanation of the levels of regulation applicable to telehealth clinicians is in the STATE DISCLOSURES section of this document.

IMPORTANT INFORMATION ABOUT TREATMENT BY TELEHEALTH, INCLUDING RISKS AND BENEFITS. The Practice offers treatment by various types of healthcare providers using telecommunications technology ("telehealth"). Providers include physicians, nurse practitioners, physician assistants and other licensed professionals. Services may include chart review, remote prescribing, scheduling, refill reminders, health information sharing, and non-clinical services such as patient education.

The electronic systems used incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data, to safeguard the data, and to protect its integrity against intentional or unintentional corruption.

Benefits of telehealth include improved access to care by allowing you to remain at home while your clinician consults with you, more efficient evaluation and management, and access to specialist expertise where appropriate. Possible risks include delays in evaluation and treatment caused by deficiencies or failures of equipment and technology, and — in rare cases — transmitted information of inadequate quality, requiring a rescheduled telehealth consultation or a visit with your local primary care doctor.

By signing this form you are representing that you have read this document and understand the information in it.

Consultation and confidentiality

At times your clinician may seek supervision or consultation with other clinicians regarding your treatment, to bring additional perspective and experience to your care. All team members are ethically and legally bound to maintain your privacy and confidentiality, and none of your personal information will be shared or disclosed without your consent.

Exceptions to confidentiality exist in certain situations, including: threat of serious harm to self or others; reasonable suspicion of abuse or neglect of a child, or abuse, neglect or exploitation of an incapacitated or dependent adult; court order or subpoena; your own written permission; supervisory consultations; diagnosis and dates of service shared with an insurer to collect payment; information released as described in any applicable privacy policy; and as otherwise required by law.

Treatment and confidentiality of minors

The Services are not available to anyone under 18. In accordance with state law, consent for the treatment of a minor may only be authorized by a current legal guardian. Where parents are separated, treatment is provided to a minor only with the written consent of both parents. Where parents are divorced, consent may be given by the parent authorized to make medical decisions. Where a court has ordered that medical decisions be made jointly, consent of both parents is required.

Your acknowledgements

By checking the box associated with "Informed Consent," you acknowledge that you understand and agree with the following:

1. You consent to receiving services from the Practice via telehealth technologies. You understand that the Practice and its clinicians offer telehealth-based medical services, but that these services do not replace the relationship between you and your primary care doctor. You also understand that it is up to your clinician to determine whether your specific clinical needs are appropriate for a telehealth encounter.

2. You have been given an opportunity to review your clinician's credentials.

3. You understand that federal and state law requires healthcare providers to protect the privacy and security of health information. You understand that the Practice will take steps to make sure your health information is not seen by anyone who should not see it. You understand that telehealth may involve electronic communication of your personal medical information to other health practitioners who may be located in other areas, including out of state.

4. You understand there is a risk of technical failures during a telehealth encounter beyond the control of the Practice or Velos Health. You agree to hold them harmless for delays in evaluation or for information lost due to such technical failures.

5. You understand that you have the right to withhold or withdraw your consent to the use of telehealth at any time, without affecting your right to future care or treatment. You understand that you may suspend or terminate use of the telehealth services at any time, for any reason or for no reason. You understand that if you are experiencing a medical emergency you will be directed to dial 911 immediately, and that your clinician cannot connect you directly to local emergency services.

6. You understand that alternatives to telehealth consultation, such as in-person services, are available to you. In choosing telehealth, you understand that some parts of your care involving tests may be conducted by individuals at your location or at a testing facility at the direction of your clinician — for example laboratory work.

7. You understand that you may expect the anticipated benefits of telehealth in your care, but that no results can be guaranteed or assured.

8. You understand that your healthcare information may be shared with other individuals for scheduling and billing purposes. Persons other than your clinician may be present during a consultation in order to operate the telehealth technology. You will be informed of their presence and have the right to: (a) omit specific details of your medical history or examination that are personally sensitive to you; (b) ask non-medical personnel to leave; and (c) terminate the consultation at any time.

9. You understand that there is no guarantee that you will be given a prescription. Your clinician may determine that treatment is not appropriate for you.

10. You understand that if you participate in a consultation you have the right to request a copy of your medical records, which will be provided to you at reasonable cost of preparation, shipping and delivery.

11. You have read and understand the disclosures set out for the state in which you are located at the time of the telehealth encounter, in the STATE DISCLOSURES section below.

GLP-1 TREATMENT AND COMPOUNDED MEDICATION CONSENT

You understand that "GLP-1 medications" include:

• FDA-approved, commercially manufactured GLP-1 receptor agonists
• Compounded GLP-1 formulations prepared by a state-licensed compounding pharmacy (503A) or an FDA-registered outsourcing facility (503B), when clinically appropriate

You understand that GLP-1 receptor agonists may:

• Increase insulin secretion
• Reduce glucagon release
• Slow gastric emptying
• Promote satiety and appetite regulation

These medications are intended to be used in combination with nutrition, exercise and lifestyle modification. Individual results vary. No specific outcome is guaranteed.

Potential risks

You understand the potential risks of GLP-1 medications. Certain studies have shown an association between GLP-1 receptor agonists and thyroid C-cell tumors. A causal relationship has not been established in humans.

Other potential risks include, but are not limited to:

• Pancreatitis
• Gallbladder disease
• Kidney injury secondary to dehydration
• Worsening diabetic retinopathy
• Severe gastrointestinal symptoms
• Hypoglycemia, especially if combined with other glucose-lowering agents

If you are prescribed a compounded medication

Your clinician will determine whether an FDA-approved or compounded formulation is appropriate, based on clinical judgment, availability, medical necessity and applicable law. If you are prescribed a compounded GLP-1 medication, you understand and acknowledge that:

• Compounded medications are not FDA-approved for safety, effectiveness or quality in the same manner as commercially manufactured drugs.
• Compounded medications do not undergo FDA review or approval.
• Compounded formulations may differ in concentration, inactive ingredients, delivery system or preparation method.
• Compounded medications are prepared pursuant to a patient-specific prescription by a licensed pharmacy under applicable state and federal compounding regulations.

Common side effects

You understand that common side effects may include, but are not limited to, the following, and you agree to promptly report concerning symptoms to your clinician:

• Nausea
• Vomiting
• Diarrhea
• Constipation
• Reflux
• Abdominal discomfort
• Fatigue

Less common or rare side effects may include, but are not limited to:

• Depression or mood changes
• Hair thinning
• Pancreatitis
• Gallbladder complications
• Severe allergic reactions
• Non-Arteritic Anterior Ischemic Optic Neuropathy (NAION)

When GLP-1 medications should not be used

You understand that you should not use GLP-1 medications if you have or have had any of the following. You agree to provide complete and accurate medical information and to update your clinician about changes in your health.

• Eating disorders

• Severe gastrointestinal disease, such as gastroparesis, unless cleared by a provider

• Chronic or prior pancreatitis

• A personal or family history of medullary thyroid carcinoma (MTC)

• Multiple Endocrine Neoplasia syndrome type 2 (MEN-2)

• Active gallbladder disease, unless cleared by a provider

• Pregnancy or intent to become pregnant

• Breastfeeding

Stop the medication and seek immediate medical attention if you experience

• Severe or persistent abdominal pain
• Symptoms of pancreatitis
• Symptoms of gallbladder disease
• Yellowing of the skin or eyes
• Sudden vision changes
• Decreased urination or swelling of the legs
• Chest pain or shortness of breath
• Signs of an allergic reaction, such as swelling or difficulty breathing

YOUR MEDICATION, PHARMACY AND PLAN

These terms describe how your medication reaches you and what your plan covers. They are arranged by Velos Health and are not clinical decisions made by your clinician.

Your pharmacy is assigned, not chosen

If your clinician writes a prescription, it is sent to a licensed pharmacy selected by Velos based on your state, your medication and your dose. You cannot choose your pharmacy.

You will not be switched between pharmacies during a course of treatment. Different pharmacies compound GLP-1 medications at different concentrations and with different inactive ingredients, so switching mid-course would change your injection volume for the same dose. If a change ever becomes necessary, your clinician will review it with you first.

Compounded medication and the FDA

If you are prescribed a compounded medication, it is not FDA-approved. The GLP-1 Treatment and Compounded Medication Consent section above explains what that means. By continuing, you confirm you have read it.

Storage and handling

Your medication requires refrigeration. Storage instructions are supplied with every shipment and in your patient portal.

Once a vial has been punctured for the first time, it must be discarded 28 days later, even if medication remains in it. Vials are deliberately larger than a single month of medication; you draw only the dose you are prescribed and discard the remainder at 28 days. This is a safety requirement, not a dosing error.

Do not use medication that has been left unrefrigerated, appears discolored or contains particles. Contact us instead and we will replace it.

Shipments

Medication ships directly to the address you provide. Multi-month plans ship in batches rather than monthly, so a single shipment may contain more than one vial covering more than one month of treatment.

You are responsible for the accuracy of the shipping address you give us. We cannot replace an order delivered to an address you supplied incorrectly.

Injection and disposal

You will be given instructions for self-injection. You agree to:

• Follow the injection technique and dose your clinician prescribes, measured in units on the syringe supplied;
• Use a new needle for every injection;
• Dispose of used needles and syringes in an approved sharps container, following local requirements; and
• Never share your medication, needles or syringes with another person, and never use medication prescribed for someone else.

Refills require reauthorization

A refill is not automatic. Before each refill you must complete a refill questionnaire so your clinician can review your progress and reauthorize your prescription. This usually happens about every 90 days and applies to every plan, including prepaid multi-month plans.

We will remind you when a questionnaire is due. If you do not complete it, or your clinician does not reauthorize treatment, your next order will not ship.

What your plan covers

Your plan covers a set number of weeks of medication, beginning on the day you are charged: 4 weeks on a monthly plan, 12 weeks on a 3-month plan, 24 weeks on a 6-month plan, and 48 weeks on an annual plan.

If you are late completing a refill questionnaire, your next order is held until it is done, and billing continues on schedule. Once you complete the questionnaire and your clinician reauthorizes your treatment, the held order is released and ships. Your plan period does not extend to make up for the delay, so please complete questionnaires promptly in order to receive everything your plan covers.

Billing, cancellation and refunds are governed by the Velos Health Refunds and Cancellations policy and Terms of Service, both published at veloshealthus.com.

Your responsibilities

You agree to:

• Provide complete and accurate information about your health, your medications and your medical history, and to update your clinician when these change;
• Report concerning symptoms promptly, and seek emergency care for the warning signs listed above;
• Attend any laboratory testing your clinician requests; and
• Maintain a relationship with a primary care provider where possible, and tell them about this treatment.

STATE DISCLOSURES

Alaska. Your primary care provider may obtain a copy of the records of your telehealth encounter. (Alaska Stat. § 08.63.210(C)(2).)

Arizona. All medical records resulting from a telemedicine consultation are part of your medical record. (Ariz. Rev. Stat. Ann. § 36-3602(D).)

California. You have the right to withhold or withdraw consent to the use of telehealth at any time without affecting your right to future care or treatment, or your ability to access covered services from Medi-Cal in the future. You have the right to access Medi-Cal covered services through an in-person visit or through telehealth. Medi-Cal provides coverage for transportation to in-person services when other resources have been reasonably exhausted. (Cal. Welf. & Inst. Code Ann. § 14132.725(d).)

Physicians: All physicians licensed in California are licensed and regulated by the Medical Board of California. To check a licence or file a complaint, visit mbc.ca.gov, email licensecheck@mbc.ca.gov, or call (800) 633-2322.

Connecticut. Your primary care provider may obtain a copy of the records of your telehealth encounter, and you may revoke your consent at any time. (Conn. Gen. Stat. Ann. § 19a-906.)

District of Columbia. You have been informed of alternate forms of communication between you and a physician for urgent matters. (D.C. Mun. Regs. tit. 17, § 4618.10.) Relevant communications with the physician, including those by electronic methods, are documented and filed in your medical record. (§ 4618.9.)

Florida. Patients prescribed GLP-1 medications for weight loss have been provided with the Weight-Loss Consumer Bill of Rights, below.

Georgia. You have been given clear, appropriate and accurate instructions on follow-up in the event of needed emergent care related to the treatment. (Ga. Comp. R. & Regs. 360-3-.07(7).)

Idaho. To register a formal complaint about a provider, visit dopl.idaho.gov/filing-a-complaint. Your informed consent for the use of telehealth services shall be obtained as required by law. (Idaho Code § 54-5708.)

Indiana. If a prescription is issued to you, and subject to your consent, the prescriber shall notify your primary care provider of any prescriptions issued, if their contact information is provided by you. This does not apply if the practitioner uses an electronic health record system your primary care provider can access, or has established an ongoing relationship with you through at least two consecutive telehealth encounters. (Ind. Code Ann. § 25-1-9.5-7.) If you are a Medicaid patient, you have the right to choose between an in-person visit and a telehealth visit.

Iowa. To file a complaint, complete the medical board complaint form and email it to ibmcomplaints@iowa.gov. (Iowa Admin. Code 653-13.11(147,148,272C)(13.11(18)).) As appropriate, your provider will identify the medical home or treating physician for you where in-person services can be delivered in coordination with telemedicine, and will provide a copy of the medical record to them. (13.11(11).)

Kansas. If you have a primary care provider or other treating physician, the person providing telemedicine services must send a report to them within three business days of the encounter. (Kan. Stat. Ann. § 40-2,212(2)(d)(2)(A).)

Kentucky. To register a formal complaint about a provider, visit kbml.ky.gov. If you request it, your physician must share the medical record with your primary care physician and other relevant members of your care team.

Louisiana. You understand the role of other health care providers who may be present during the consultation other than the telehealth provider. (46 La. Admin. Code Pt XLV, § 7511.)

Maine. To register a formal complaint about a provider, visit maine.gov/md/complaint/file-complaint. (Code Me. R. tit. 02-373 Ch. 11, § 3.)

Nebraska. If you are a Medicaid recipient, you may refuse the telehealth consultation at any time without affecting your right to future care or risking loss of program benefits. All existing confidentiality protections apply. You have access to all medical information resulting from the consultation. Dissemination of patient-identifiable images or information to researchers or other entities requires your written consent. You have the right to request an in-person consult immediately after the telehealth consult, and will be informed if one is not available. (Neb. Rev. Stat. Ann. § 71-8505; 471 Neb. Admin. Code § 1-006.05.)

New Hampshire. The telehealth provider may forward your medical records to your primary care or treating provider. (N.H. Rev. Stat. § 329:1-d.)

New Jersey. You have the right to request a copy of your medical information, and it may be forwarded to your primary care provider or, on request, to other providers. If you do not have a primary care provider, the provider may advise you to contact one and may assist you in locating one within reasonable proximity. (N.J. Rev. Stat. Ann. § 45:1-62.)

New York. Patients prescribed GLP-1 medications for weight loss have been provided with the Weight-Loss Consumer Bill of Rights, below. (N.Y. Gen. Bus. Law § 642.)

Ohio. The telehealth provider may forward your medical records to your primary care or treating provider. (Ohio Admin. Code 4731-37-01(C)(4).)

Oregon. If you have a concern or complaint about the providers caring for you, you may contact a board agency to assist you. Your provider may ask if you need more detail. (ORS 17-52-677.07.) Complaints may be filed with the Oregon Medical Board, 1500 SW 1st Ave., Suite 620, Portland, OR 97201-5847, (971) 673-2702, complaintresource@omb.oregon.gov.

Rhode Island. If you use email or text-based technology to communicate with your provider, you understand the types of transmissions permitted and the circumstances when alternate forms of communication or office visits should be used. You have discussed security measures, including encryption of data, password-protected screen savers and data files, and other reliable authentication techniques, as well as potential risks to privacy. Failure to comply with this agreement may result in the telehealth provider terminating the relationship. (Rhode Island Medical Board Guidelines.)

South Carolina. Your medical records may be distributed in accordance with applicable law to other treating practitioners. You understand the value of having a primary care medical home and, if requested, we can provide assistance in identifying options. (S.C. Code Ann. § 40-47-37.) If you are a Medicaid beneficiary, you may withdraw your consent at any time.

South Dakota. You have received disclosures regarding the delivery models and treatment methods or limitations. You have discussed with the telehealth provider the diagnosis and its evidentiary basis, and the risks and benefits of various treatment options. (S.D. Codified Laws § 34-52-3.)

Tennessee. You may request an in-person assessment before receiving a telehealth assessment if you are a Medicaid recipient.

Texas. Your medical records may be sent to your primary care physician within 72 hours. (Tex. Occ. Code Ann. § 111.005.)

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 to: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018. Assistance in filing a complaint is available at 1-800-201-9353. For more information visit tmb.state.tx.us.

Aviso sobre las quejas. Las quejas sobre médicos, así como sobre otros profesionales acreditados e inscritos del Consejo Médico de Tejas, incluyendo asistentes de médicos, practicantes de acupuntura y asistentes de cirugía, se pueden presentar en la siguiente dirección para ser investigadas: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018. Si necesita ayuda para presentar una queja, llame al 1-800-201-9353. Para obtener más información, visite tmb.state.tx.us.

Utah. You are able to (i) access, supplement and amend your patient-provided personal health information; (ii) contact your provider for subsequent care; (iii) obtain on request an electronic or hard copy of your medical record documenting the telemedicine services, including the informed consent provided; and (iv) request a transfer to another provider of your medical record documenting the telemedicine services. (Utah Admin. Code r. 156-1-602.)

Vermont. You have the right to receive a consult with a distant-site provider and will receive one upon request immediately or within a reasonable time after the results of the initial consult. Receiving telehealth services by store-and-forward technologies does not preclude you from receiving real-time telemedicine or face-to-face services with the distant provider at a future date. (Vt. Stat. Ann. § 9361.) To register a formal complaint about a provider, visit healthvermont.gov or sos.vermont.gov/opr.

Virginia. You acknowledge that you have received details on security measures taken with the use of telemedicine services, such as encrypting date of service, password-protected screen savers, encrypting data files, and other reliable authentication techniques, as well as potential risks to privacy notwithstanding such measures. You agree to hold harmless the Practice for information lost due to technical failures, and you provide express consent to forward patient-identifiable information to a third party. (Virginia Board of Medicine Guidance Document 85-12.)

WEIGHT-LOSS CONSUMER BILL OF RIGHTS

Provided to patients in Florida and New York, and to any patient on request.

A. WARNING: RAPID WEIGHT LOSS MAY CAUSE SERIOUS HEALTH PROBLEMS. Rapid weight loss is weight loss of more than 1½ to 2 pounds per week, or weight loss of more than 1 percent of body weight per week after the second week of participation in a weight-loss program.

B. CONSULT YOUR PERSONAL PHYSICIAN BEFORE STARTING ANY WEIGHT-LOSS PROGRAM.

C. ONLY PERMANENT LIFESTYLE CHANGES, such as making healthful food choices and increasing physical activity, promote long-term weight loss.

D. QUALIFICATIONS OF THIS PROVIDER ARE AVAILABLE UPON REQUEST.

E. YOU HAVE THE RIGHT TO:

1. Ask questions about the potential health risks of this program and its nutritional content, psychological support and educational components;
2. Receive an itemized statement of the actual or estimated price of the weight-loss program, including extra products, services, supplements, examinations and laboratory tests;
3. Know the actual or estimated duration of the program; and
4. Know the name, address and qualifications of the dietitian or nutritionist who has reviewed and approved the weight-loss program, in accordance with s. 468.505(1)(j), Florida Statutes.

CONSENT

You have read this document carefully, and understand the risks and benefits of telehealth services and of GLP-1 treatment. You have had your questions regarding the services answered, and you hereby give your informed consent to participate in a telehealth consultation under the terms described here.

By typing your name into the appropriate field on your questionnaire for this Informed Consent for Telehealth Services, you state that you have read, understood and agree to the terms of this document.