Informed Consent to Telehealth

DRAFT FOR ATTORNEY REVIEW. Original starting draft. Telehealth informed-consent requirements vary by state (including Florida's telehealth statute), so counsel must conform this before it goes live in production.

What Telehealth Is

Telehealth is the delivery of health care using secure, two-way audio and video technology instead of an in-person visit. Through Biomarker Health's platform, a licensed clinician can review your information, talk with you by video, evaluate you, and — where clinically appropriate — order labs and create a treatment plan, including hormone, peptide, or GLP-1 therapy.

This consent explains telehealth so you can decide whether to receive care this way. Please read it carefully and ask us anything before you sign.

What to Expect

• Your visit takes place by secure video with a clinician licensed in the state where you are located.
• The clinician provides the same standard of care you would receive in person, with the same privacy protections under HIPAA.
• You can ask questions, pause, or stop the visit at any time.
• The clinician may decide that telehealth is not appropriate for your situation and may recommend an in-person visit or refer you elsewhere.

Benefits

Telehealth can give you greater convenience and access to care without travel, while allowing your clinician to review your intake and lab results and manage your plan over time.

Risks and Limitations

Telehealth also has limitations you should understand:

• A clinician cannot physically examine you, which in some cases can limit evaluation and may make certain diagnoses or treatments unsuitable by telehealth.
• Technology can fail — connections may drop, audio or video quality may be poor, or a visit may be delayed or interrupted.
• Despite strong safeguards, no electronic transmission is perfectly secure, and there is a small risk that information could be intercepted or accessed improperly.
• Information you provide may be incomplete or inaccurate, which can affect the clinician's recommendations.

If a problem during a visit affects your care, your clinician will discuss next steps with you.

Prescribing by Telehealth

Whether you are prescribed any medication is determined solely by your clinician's professional judgment and applicable law. Some medications, including certain hormones such as testosterone, are controlled substances and are subject to additional federal and state requirements for telehealth prescribing, which may require an in-person evaluation. Your clinician will follow the rules that apply at the time of your care. Submitting an intake or paying a fee does not guarantee any prescription.

Alternatives

You have the right to receive care in person rather than by telehealth. If you prefer an in-person visit or if telehealth is not appropriate for you, we will discuss available options, which may include scheduling at our clinic or referral to another provider.

Privacy and Confidentiality

Information shared during your telehealth visit is protected under the same laws and policies that apply to in-person care, including HIPAA. Our practices are described in our Notice of Privacy Practices. Only those involved in your care and operations will have access to your information, except as permitted or required by law.

Recording

We do not record telehealth visits except with your separate written consent or as required by law. You may not record a visit without the clinician's consent.

Not for Emergencies

Telehealth is not for medical emergencies. If you are experiencing an emergency, call 911 or go to the nearest emergency room. If you are in crisis or having thoughts of self-harm, call or text 988.

Your Rights

• You may ask questions at any time.
• You may stop the visit or decline telehealth care at any point.
• You may withdraw this consent at any time, in writing, without affecting your right to future care by other means.
• Withdrawing consent does not apply retroactively to care already provided.

Technology and Location

To use telehealth you need a device with a camera, microphone, and a stable internet connection. You must be physically located in a state where your clinician is licensed at the time of the visit. Telehealth may be unavailable in some locations due to licensing and regulatory requirements.

Financial Responsibility

You are responsible for the fees associated with your telehealth visit and any related services, as disclosed before your visit. The Services are cash-pay and are not billed to insurance.

Consent

I have read and understand this Informed Consent to Telehealth. I have had the opportunity to ask questions and have them answered. I understand the benefits, risks, and limitations of telehealth and the alternatives available to me.

I consent to receiving care by telehealth from Biomarker Health and its clinicians.

Patient name: ______________________________

Signature: ______________________________ Date: ____________

(For online enrollment, this consent may be captured electronically with a date-and-time stamp.)