Telehealth Appointment Consent

Effective Date: June 25, 2024

This consent is for all telehealth services provided to you by the providers of Heartbeat Medical Group, PC; Jeffery D. Wessler, MD, PC; Heartbeat Medical Group of California, PC; Heartbeat Medical Group of New Jersey, PC; and Heartbeat Medical Group of Kansas, LLC (your “Heartbeat Provider”).

Telehealth is the use of the Internet to provide remote health care for patients. Such care may come from doctors, advanced practitioners, nurses, and professional health educators.

Specifically, your Heartbeat Provider may provide treatment (referred to in this form as Telehealth Appointment) via synchronous and asynchronous telecommunications technologies, including remotely via the Internet using a web-based audio-video platform. The telehealth platform will incorporate
network and security protocols that include measures to protect your information against intentional or unintentional corruption. The telehealth platform only hosts the software and does not provide medical advice or information.

Your Telehealth Appointment and other telehealth services you receive may be for diagnosis, continuity of care, treatment, testing, or medical consultation deemed necessary by your Heartbeat Provider or you.

Your Heartbeat Provider’s credentials will be made available to you prior to or at the beginning of your Telehealth Appointment. There are various benefits associated with telehealth services, including improved access to care by enabling you to remain in your home while the provider consults with you, more efficient care evaluation and management, and obtaining expertise of a specialist as appropriate. Possible risks include delays in evaluation and treatment due to deficiencies or failures of the equipment and technology and, in rare events, your Heartbeat Provider may determine that the quality of transmitted information is inadequate and that your Telehealth Appointment must be rescheduled or that you should schedule a meeting with your local physician.

You understand that during a Telehealth Appointment:

• details of your medical history and personal health information may be discussed with you and/or other health professionals;
• audio, video, or photo recordings containing medical details may be transmitted via secure channels and those details may become part of your permanent medical record;
• all confidentiality protections granted to you by various state and federal laws also apply to your care during this appointment;
• industry-standard network and software security protocols are in place that protect the privacy of the communication and safeguard your transmitted information against eavesdropping and corruption;
• there may be security and privacy risks associated with Internet-based communications;
• there are benefits and limitations when compared to a traditional in-person visit due to the fact that you will not be in the same room as your Heartbeat Provider;
• either your Heartbeat Provider or you can discontinue the Telehealth Appointment if either of us feels that the information obtained through remote communications is not adequate for diagnostic decision-making or for providing the care you desire;
• in addition to your Heartbeat Provider named above, you will be informed of any other person(s) who may be present during the appointment and have the right to have them leave the viewing and listening area;
• to maintain your privacy, you need to ensure that your viewing and listening area is limited to yourself and any other person that has a need to participate during the virtual appointment;
• due to the limitations of telehealth that are out of your control (such as an unreliable internet connection), you will call local authorities (9-1-1) to assist you with a medical emergency;
• You have the right to omit or withhold specific details of your medical history/physical examination that are personally sensitive;
• Your Heartbeat Provider may advise you to seek immediate treatment or determine that there is a medical emergency and, as such, local authorities may be given your personal details to assist you; and
• the communication is privileged and confidential, and you will not record the audio or video without first seeking the permission of your Heartbeat Provider.

THEREFORE, BY PARTICIPATING IN THIS TELEHEALTH APPOINTMENT, YOU ARE INDICATING THAT:

1. You desire to engage in remote audio-visual communication with your Heartbeat Provider, as well as asynchronous communication when appropriate under the standard of care.

2. You understand the risks and benefits of using Internet-based communications and that no results can be guaranteed.

3. You acknowledge that if your Heartbeat Provider believes that remote communication is insufficient for treatment, consultation, or evaluation, then you will be offered alternate services or options.

4. You understand that you may be responsible for co-payments, deductibles, or other charges from your Heartbeat Provider, and additional charges may occur for services related to this appointment.

5. You understand that some parts of the exam involving physical tests may be conducted by individuals at your location or at a third-party testing facility.

6. You acknowledge that you have received a copy of your Heartbeat Provider’s Notice of Privacy Practices, which has been made available to you at https://www.heartbeathealth.com/npp/.

7. You understand you have the ability to ask direct questions to your Heartbeat Provider about this appointment, including details about your Heartbeat Provider’s Notice of Privacy Practices. If your questions are not answered to your satisfaction, you have the right to terminate the
appointment.

8. You have read, understand, and agree to Heartbeat Health’s Terms & Conditions.

9. You consent to your Heartbeat Provider (or service providers acting on its behalf) contacting you at the phone numbers (including cell phone) or email addresses you provide, including by unencrypted text messages or emails, or any automated or prerecorded messages. You understand that such unencrypted text messages, phone calls, and emails may be intercepted by unauthorized individuals, and you understand and accept the risk of using unencrypted communications. If you do not want to receive unencrypted text messages, phone calls, or emails then you can email hello@heartbeathealth.com and ask to opt out. You have read, understand, and agree to Heartbeat Health’s Communications Terms & Conditions.

10. You have read and understand the disclosures set forth next to the state in which you are located at the time of your telehealth encounter, as set forth in the State Disclosures Appendix at the end of this consent form.

11. You certify that you are at least 18 years of age or the age of consent for treatment in your state.

STATE DISCLOSURES APPENDIX

Alaska: You understand your primary care provider may obtain a copy of your records of your telehealth encounter. (Alaska Stat. § 08.64.364).

Arizona: You understand that all medical records resulting from a telemedicine consultation are part of your medical record. (A.R.S. § 12-2291.)

Colorado: You are informed that if you want to register a formal complaint about a provider, you should file at https://dpo.colorado.gov/FileComplaint.

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

D.C.: You have been informed of alternate forms of communication between your and a physician for urgent matters. (D.C. Mun. Regs. tit. 17, § 4618.10).

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

Iowa: You have been informed that if you want to register a formal complaint about a provider, you should visit the medical board’s website, here: https://medicalboard.iowa.gov/consumers/filing-complaint

Idaho: You have been informed that if you want to register a formal complaint about a provider, you should visit the medical board’s website, here: https://dopl.idaho.gov/filing-a-complaint/

Illinois: You have been informed that if you want to register a formal complaint about a provider, you should visit the Illinois Division of Professional Regulation at https://idfpr.illinois.gov/admin/dpr/complaint.html

Indiana: You have been informed that if you want to register a formal complaint about a provider, you should visit the medical board’s website, here: https://inoag.my.salesforce-sites.com/ConsumerComplaintForm

Kansas: You understand that if you have a primary care provider or other treating physician, the person providing telemedicine services must send within three business days a report to such primary care or other treating physician of the treatment and services rendered to you during the telemedicine
encounter. (Kan. Stat. Ann. § 40-2,212(2)(d)(2)(A). You understand that the complaint process may be found here: http://www.ksbha.org/complaints.shtml

Kentucky: You have been informed that if you want to register a formal complaint about a provider, you should visit the medical board’s website, here: https://kbml.ky.gov/grievances/Pages/default.aspx

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

Maine: You have been informed that if you want to register a formal complaint about a provider, you should visit the medical board’s website, here: https://www.maine.gov/md/complaint/file-complaint

Maryland: Telehealth services may not be provided based solely on an online questionnaire. You have been informed that if you want to register a formal complaint about a provider, you should visit the medical board’s website, here: https://www.mbp.state.md.us/forms/complaint.pdf.

Nebraska: All existing confidentiality protections shall apply to the telehealth consultation. You shall have access to all medical information resulting from the telehealth consultation as provided by law for access to your medical records. Dissemination of any patient identifiable images or information from the telehealth consultation to researchers or other entities shall not occur without your written consent. You understand that you have the right to request an in-person consult immediately after the telehealth consult and you will be informed if such consult is not available. (Neb. Rev. Stat. Ann. § 71-8505; 471 Neb. Admin. Code § 1-006.05). You have been informed that if you want to register a formal complaint about a provider, you should visit: https://dhhs.ne.gov/Pages/Complaints.aspx

New Hampshire: You understand that 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 understand you have the right to request a copy of your medical information and you understand your medical information may be forwarded directly to your primary care provider or health care provider of record, or upon your request, to other health care providers. (N.J. Rev. Stat. Ann. § 45:1-62).

Ohio: You understand that the telehealth provider may forward your medical records to your primary care or treating provider. Ohio Admin. Code 4731-11-09(C).

Oklahoma: You have been informed that if you want to register a formal complaint about a provider, you should visit the medical board’s website, here: http://www.okmedicalboard.org/complaint. Board of Osteopathic Examiners can be found at: https://www.ok.gov/osboe/faqs.html

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

South Carolina: You understand your medical records may be distributed in accordance with applicable law and regulation to other treating health care practitioners. (S.C. Code Ann. § 40-47-37).

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).

Texas: You understand that your medical records may be sent to your primary care physician. (Tex. Occ. Code Ann. § 111.005). You have been informed of the following notice:

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 at the following address: 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 by calling the following telephone number: 1-800-201-9353, For more information, please visit our website at www.tmb.state.tx.us.

AVISO SOBRE LAS QUEJAS- Las quejas sobre médicos, asi como sobre otros profesionales acreditados e inscritos del Consejo Médico de Tejas, incluyendo asistentes de médicos, practicantes de acupuntura y asistentes de cirugia, 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 nuestro sitio web en www.tmb.state.tx.us

Utah: You understand (i) any additional fees charged for telehealth services, if any, and how payment is to be made for those additional fees, if the fees are charged separately from any fees for face-to-face services provided in combination with the telehealth services; (ii) to whom your health information may be disclosed and for what purpose, and have received information on any consent governing release of your patient-identifiable information to a third-party; (iii) your rights with respect to patient health information; (iv) appropriate uses and limitations of the site, including emergency health situations. You understand that the telehealth services meets industry security and privacy standards, and comply with all laws referenced in Subsection 26-60-102(8)(b)(ii). You were warned of potential risks to privacy notwithstanding the security measures and that information may be lost due to technical failures, and you agree to hold the provider harmless for such loss. You have been provided with the location of telehealth company’s website and contact information. You were able to select your provider of choice, to the extent possible. You were able to select your pharmacy of choice. You are able to a (i) access, supplement, and amend your patient-provided personal health information; (ii) contact your provider for subsequent care; (iii) obtain upon 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. 156-1-603).

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, or utilizing other reliable authentication techniques, as well as potential risks to privacy
notwithstanding such measures; You agree to hold harmless Heartbeat Health and your Heartbeat Provider for information lost due to technical failures; and you provide your express consent to forward patient-identifiable information to a third party. (Virginia Board of Medicine Guidance Document 85-12).

Vermont: You understand that 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. You have been informed that if you want to register a formal complaint about a provider, you
should visit the medical board’s website, here: http://www.healthvermont.gov/health-professionals-systems/board-medical-practice/file-complaint; Board of Osteopathic Examiners can be found at: https://sos.vermont.gov/osteopathic-physicians/