Telehealth Informed Consent

1. Consent to Telehealth

Telehealth is a mode of delivering health care services via communication technologies to facilitate diagnosis, consultation, treatment, education, care management, and self-management of a patient's healthcare. The purpose of this consent form ("Consent") is to provide you with information about telehealth and to obtain your informed consent to the use of telehealth in the delivery of healthcare and/or mental health services to you by physicians, physician assistants, nurse practitioners, and/or mental health professionals ("Providers") using the online platforms owned and operated by OpenLoop and/or its affiliates and/or subsidiaries (the "Service").

You are reviewing and acknowledging this Telehealth Consent Form because you are seeking Services from OpenLoop Healthcare Partners, PC and its affiliated entities (including but not limited to OpenLoop Healthcare Partners California, PC, OpenLoop Healthcare Partners Colorado, PC, OpenLoop Healthcare Partners New Jersey Professional Corporation, OpenLoop Healthcare Partners, Wisconsin, S.C) (collectively, the "Practice") utilizing telehealth technologies facilitated through the OpenLoop Health Inc. website, iOS mobile app, web mobile app, or any partner platform, mobile app, or web mobile technologies (collectively, the "Platform").

By clicking "I consent to telehealth" you indicate that you have reviewed this Telehealth Consent Form or had it explained to you, that you understand the risks and limitations of using telehealth technologies, that you have been given the opportunity to ask questions and that such questions have been answered to your satisfaction.

If you would like to speak to our privacy team, please call 1(844) 819-7956 or email us at privacy@openloophealth.com

2. Treatment-Specific Consent

By clicking "I consent to telehealth", you understand and agree to the following:

1. I understand that Practice offers telehealth visits, which are conducted through videoconferencing, telephonic, and asynchronous technology and my Provider will not be present in the room with me.
2. I am consenting to Practice importing and accessing my medical records and medical list, including prescription records.
3. To protect the confidentiality of my health information, I agree to undertake my telehealth visit in a private location, and I understand that my Provider will similarly be in a private location.
4. I understand there are potential risks to the use of telehealth technology, including but not limited to interruptions, delays, unauthorized access, other technical difficulties, data processing errors, AI misinterpretation, recording failures, and ambient listening inaccuracies. I AGREE TO HOLD HARMLESS PRACTICE AND ITS MANAGEMENT COMPANY, OPENLOOP HEALTH, INC., TOGETHER WITH THEIR EMPLOYEES, CONTRACTORS, AGENTS, DIRECTORS, MEMBERS, MANAGERS, SHAREHOLDERS, OFFICERS, REPRESENTATIVES, ASSIGNS, PREDECESSORS, AND SUCCESSORS, FOR DELAYS IN EVALUATION OR FOR INFORMATION LOST DUE TO SUCH TECHNICAL FAILURES OR FOR ANY ISSUES ARISING FROM THE USE OF AI TECHNOLOGIES, RECORDINGS, OR AMBIENT LISTENING SYSTEMS.
5. I understand that my telehealth visit may involve the use of artificial intelligence (AI) technologies for various purposes, including but not limited to transcription of conversations, analysis of medical information, clinical decision support, quality assurance, and improvement of telehealth services.
6. I understand that, as part of my care, my Provider may use AI tools to assist with analyzing medical data or records, supporting clinical decision making, generating summaries or documentation, or recommending potential diagnoses or treatment options. AI tools are intended to support, not replace, the professional judgment of my Provider.
7. I understand that my telehealth visit may be recorded (audio and/or video) for purposes, including but not limited to quality assurance, provider training, clinical documentation, and care coordination. I understand that I will be notified at the beginning of any session that is being recorded.
8. I understand that ambient listening technologies may be used during my telehealth visit to record the encounter. I can request that ambient listening be disabled during portions of my visit by notifying my Provider.
9. I understand that in some cases, my Provider might be a nurse practitioner or a physician assistant and not a physician.
10. I understand that I could seek an in-office visit rather than obtain care from a Provider, and I am choosing to participate in a telehealth visit with a Provider.
11. I understand that participating in a telehealth visit is not a guarantee that I will be given a prescription, and that the decision as to whether a prescription is appropriate for my condition will be made in the professional judgment of my Provider.
12. I understand that while the Platform may make available access to certain pharmacy or diagnostic lab services, I may request to use any pharmacy or lab of my preference.
13. I understand that I am responsible for payment of any amounts due and owing resulting from my telehealth visit.
14. I understand that Providers do not address medical emergencies via the Platform. I understand that the responsibility of my Provider may be to direct me to emergency medical services, such as an emergency room.
15. I (we) the parent(s) or legal guardian of a minor, do hereby authorize consent to any medical order, laboratory order, medical diagnosis, or treatment and that I (we) have legal authority to consent to such treatment or order.

3. Additional Treatment-Specific Consent (Compounded Medications)

The following consent applies to patients who receive a prescription from a Provider for compounded medications:

1. I understand that the FDA does not approve nor review compounded products for safety, effectiveness, or quality.
2. I understand that compounding pharmacies must adhere to strict quality control standards to ensure the safety and effectiveness of the medications they prepare. Compounding pharmacies are licensed pharmacies subject to state and federal regulations.

4. Laboratory Products and Services

Certain healthcare services provided to you by Providers via the Service may require that you complete an at-home diagnostic test. These diagnostic tests are provided by third-party laboratories, and neither OpenLoop Health, Inc. and its subsidiaries (collectively, "OpenLoop"), nor your Provider(s) can guarantee the accuracy or reliability of these tests.

These laboratory tests can provide false negative, false positive, or inconclusive results that could impact your Provider(s) ability to correctly diagnose or treat your medical conditions. A failure or defect of these tests could also impact your Provider(s) ability to correctly diagnose or treat your medical conditions.

5. Authorization to Bill Insurance and Assignment of Benefits

By clicking "I accept", I confirm that the above information is true, correct, and complete to the best of my knowledge. I authorize OpenLoop Healthcare Partners, PC and its affiliated entities (OpenLoop Healthcare Partners California, PC, OpenLoop Healthcare Partners Colorado, PC, OpenLoop Healthcare Partners New Jersey Professional Corporation, OpenLoop Healthcare Partners, Wisconsin, S.C., OpenLoop Healthcare Partners Puerto Rico, P.C., Reliant MD Medical Associates PLLC) (collectively, the "Practice") to bill my insurance company directly and I further authorize any third-party payer through which I have benefits to make payment directly to Practice.

I understand that I am financially responsible for any balance. I also authorize Practice or my insurance company to use and disclose any healthcare information for the purpose of obtaining payment for services and determining insurance benefits. Services provided by outside companies (i.e., lab, pathology, radiology) are billed separately by those companies.

6. Consent to Text or Email Usage

By clicking "I accept," I authorize Practice to contact me via phone call, SMS/text message, or email at the contact information I have provided, for the purposes of:

• Appointment reminders
• Patient feedback requests
• General health and wellness information

I understand and agree to the following:

• These communications may be generated in part by automated systems or artificial intelligence (AI)
• Standard messaging and data rates may apply
• This authorization will remain in effect for future communications unless I revoke it in writing
• I may opt out of receiving such communications at any time by following the opt-out instructions provided in each message or by contacting Practice directly
• Using these communication methods presents a potential security risk of unauthorized access to protected health information (PHI)
• I accept this risk and consent to receiving communications through these methods

If you prefer not to receive appointment reminders or health information via text or email, please notify us in writing or email us at privacy@openloophealth.com

7. Additional State-Specific Disclosures

The following consents apply to patients accessing the Services for the purposes of participating in a telehealth visit within the states listed below, as required by state law:

Treatment Records

I understand that if I live in one of the following states, my primary care provider or other treating physician may obtain a copy of my telehealth treatment records with my consent, and Practice may securely send a copy of my telehealth treatment records to my primary care provider or other treating physician. If I need help sending my telehealth treatment records to my primary care provider I can contact call 1-855-597-1248.

States: Alaska, Connecticut, Kansas, New Hampshire, New Jersey, Ohio, South Carolina, Texas

California Patients

The Open Payments database is a federal tool used to search payments made by drug and device companies to physician and teaching hospitals. It can be found at https://openpaymentsdata.cms.gov.

Billing

Patients residing in New Jersey, New York, and Rhode Island have the right under each states respective billing laws to request an itemized price list for laboratory results.

Formal Complaints

If you want to register a formal complaint about a provider, please visit your state medical board's website. Contact information for specific states is available in the full consent document.

8. Emergency Situations

When to Seek Emergency Care

Examples of emergency situations include:

• Chest pain or difficulty breathing
• Severe allergic reactions
• Loss of consciousness
• Severe bleeding or injuries
• Suicidal thoughts or intent to harm yourself or others

If you are having suicidal thoughts or making plans to harm yourself, you can call the National Suicide Prevention Lifeline at 1.800.273.TALK (8255) for free 24 hour hotline support.

9. Consent and Agreement

By clicking "I consent to telehealth", you indicate that:

• I have read and understand the information provided in this consent form
• I have had the opportunity to ask questions about telehealth services
• I understand the benefits and risks of telehealth
• I understand the limitations of telehealth services
• I consent to receive healthcare services via telehealth
• I understand that my healthcare provider may determine that an in-person visit is necessary
• I agree that OpenLoop Health, Inc. is a third party beneficiary of the Telehealth Consent Form and has the right to enforce it against me
• I understand and agree that I give permission to Providers to use and disclose my protected health information including my entire medical record for the purpose of telehealth treatment

10. Withdrawal of Consent

I have the right to withhold or withdraw consent for my treatment at any time without affecting my right to future care or treatment.

I may revoke this authorization in writing at any time by sending a written notification to Privacy Officer at 317 6th Ave. Ste. 400, Des Moines, IA 50309 or emailing us at privacy@openloophealth.com. Your notice of revocation will not apply to actions taken by Providers prior to the date of receipt of the notice.

11. Contact Information

If you have questions about our telehealth services or this consent form, please contact us:

Phone: 1(844) 819-7956

Email: privacy@openloophealth.com

Address: 317 6th Ave. Ste. 400, Des Moines, IA 50309