Medical Consent

Telehealth is the type of care that allows patients to access health services using audio-video interfaces such as videoconferencing. Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data, with measures to safeguard data integrity against intentional or unintentional corruption. Expected Benefits: • Improved access to healthcare by enabling you to receive services across distances • More efficient healthcare including medical evaluation and management • Obtaining the expertise of a specialist without travel • Maintaining connections with established providers Possible Risks: As with any medical procedure, there are potential risks associated with the use of telehealth. These risks include, but are not limited to: • In rare cases, information transmitted may not be sufficient (e.g., poor resolution) to allow for appropriate medical decision making • Delays in evaluation and treatment could occur due to equipment failures • In very rare instances, security protocols could fail, causing a breach of privacy • In rare cases, a lack of access to complete medical records may result in adverse drug interactions or other judgmental errors

• The laws that protect privacy and confidentiality of medical information also apply to telehealth, and no information obtained which identifies you will be disclosed without your consent. • You have the right to withhold or withdraw consent to telehealth at any time, without affecting your right to future care or treatment. • You have the right to inspect all information obtained in the course of a telehealth interaction and may receive copies for a reasonable fee. • A variety of alternative methods of healthcare may be available to you at any time. • It is in your best interest to inform your physician or clinical staff of any other healthcare providers involved in your care. • You may expect anticipated benefits from telehealth, but no results can be guaranteed or assured. My continued use of iScript.care services constitutes my understanding and acceptance of these terms, and I hereby authorize the use of telehealth in the course of my diagnosis and treatment.

The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. Specifically, there are rules and restrictions on who may see or be notified of your Protected Health Information (PHI). These restrictions do not include the normal interchange of information necessary to provide you with services. Our Adopted Policies: • Patient information will be kept confidential except as necessary to provide services or ensure appropriate administrative handling of your care. • This specifically includes sharing information with healthcare providers, laboratories, and health insurance payers as necessary for your care. • Patient files may be accessed by authorized office staff and third-party providers only. • We may remind patients of appointments via telephone, email, U.S. mail, or other means. • The practice utilizes vendors who may have access to PHI and must agree to abide by HIPAA confidentiality rules. • Your confidential information will not be used for the purposes of marketing or advertising without your explicit authorization. • We agree to provide patients with access to their records in accordance with state and federal laws. My continued use of iScript.care services constitutes my understanding and acceptance of these HIPAA terms and any subsequent changes in office policy.

I understand and accept that to render services, a credit card may be kept on file and any remaining balances for services rendered shall be paid in full. I authorize iScript.care (Cantobiz, Inc.) to submit on my behalf and release any medical records or other information necessary to process my consultation order. I authorize iScript.care to make invoice charges and debit my account for orders placed, goods received, and/or services rendered. All programs are auto-renewing. I consent to being automatically charged for any program I am enrolled in unless I explicitly request cancellation before my payment is processed. Please refer to our Refund Policy for cancellation and refund eligibility. I certify that I am an authorized user of the payment method provided.