Informed Consent for Medical Services and AI Use

Procedure and Medication Consent

I hereby give my informed consent for medical treatment and procedures to be administered by healthcare professionals at Telemedicine Group DE, L.L.C. dba TeleMed2U (“TeleMed2U”) and Cloud Health Medical Group, P.A., Cloud Health Medical Group of California, P.C., Cloud Health Medical Group of New Jersey, P.A., and Cloud Health Medical Group of Kansas, P.C. (collectively, “Cloud Health Medical”). I understand that procedures may occasionally be recommended, ranging from routine medication injections to more detailed procedures such as thyroid ultrasound or fine needle aspiration. All procedures carry some degree of risk, including allergic reaction; vascular, nerve, tendon, or tissue damage; infection; scarring; rash; bleeding; and, in rare circumstances, disability or death. Medications administered by injection or mouth, in the clinic or at home, may cause routine complications, side effects, or severe allergic reactions. I accept responsibility for discussing concerns with my provider and pharmacist. I will not accept a medication or procedure until my questions and concerns have been addressed to my satisfaction. I will ensure that my provider is aware of my allergies, prior unacceptable reactions to medications or procedures, and any possibility of pregnancy.

Educational Consent

I understand that this organization participates in the training of student nurses and other healthcare personnel. I agree that they may participate in my care to the extent deemed appropriate by TeleMed2U staff.

Liability for Cost Share

I understand that, even if I have insurance, I am financially obligated to pay applicable copayments, coinsurance, deductibles, Medi-Cal Share of Cost, noncovered services, and other patient-responsible amounts for covered services provided by TeleMed2U and Cloud Health Medical.

Lab Work, Forms, and Medication Refills

Lab work not conducted by TeleMed2U may be sent to a reference laboratory such as LabCorp or Quest. Those fees are separate from TeleMed2U and Cloud Health Medical charges, may be billed to insurance by the laboratory, and remain my responsibility. Fees may apply for completion or signature of healthcare-related forms, paperwork, or applications. Medication Refill Policy: Prescriptions should ordinarily be refilled during scheduled visits. If that is not possible, I or my pharmacy should notify the clinic three to five business days before medication runs out; patients should contact the clinic directly. At least three business days’ notice is required. TeleMed2U does not refill medication prescribed by another physician unless a TeleMed2U practitioner first evaluates the patient. I am responsible for monitoring medication supply and scheduling an appointment before it runs out. I will not request early refills of controlled medication that is overused, lost, or stolen.

Patient Conduct and Respectful Communication

We are committed to maintaining a welcoming, respectful, and safe environment for everyone. We encourage patients, providers, and staff to communicate thoughtfully and work together to address questions or concerns. When challenges arise, we will seek a constructive and appropriate resolution while considering individual circumstances, safety, and continuity of care.

Providers and Consent to Treat

I understand that TeleMed2U uses physicians, Advanced Practice Providers (“APPs”), and other healthcare professionals, and I consent to their involvement in my care. I request that my physician, APP, other healthcare providers, or their designees perform examinations, testing, treatment, and care they deem necessary and available during an office visit or outpatient procedure, including tests, examinations, anesthetics, X-rays, medical and surgical treatment, and other prescribed procedures. I may discuss the purpose, risks, and benefits of recommended care, ask questions, and accept or refuse medical or surgical treatment. I certify that I understand these statements and voluntarily consent to treatment by TeleMed2U and Cloud Health Medical.

Telehealth Consent

I consent to telehealth delivery of healthcare using audio, video, and other electronic communications for diagnosis, treatment, follow-up, consultation, and education.

TeleMed2U and its healthcare professionals may use artificial intelligence, machine learning, automated technology, or other technology-assisted tools (“AI Tools”) to support healthcare delivery and administration.

• Clinical documentation and preparation of medical notes
• Summarization of information discussed during an encounter
• Review or organization of medical-record information
• Clinical decision support for a healthcare professional’s consideration
• Patient communications and educational materials
• Scheduling, coding, billing, quality improvement, and other administrative functions
• Other treatment, payment, and healthcare operations permitted by law

AI Tools assist healthcare professionals and do not replace the professional judgment of a licensed provider. The provider remains responsible for evaluating information and making clinical decisions. AI systems may produce incomplete, inaccurate, or incorrect information; AI-generated documentation and information therefore require appropriate professional oversight and review. Approved AI Tools may process protected health information (“PHI”) and other personal or health information only after evaluation and approval under applicable privacy, security, information-governance, and legal requirements. Information remains protected under applicable federal and state privacy and security law, including HIPAA when applicable. AI Tools approved for clinical use may not use PHI outside purposes authorized by TeleMed2U or otherwise permitted by law.

Financial Policies and Card Authorization

Patients missing an appointment without at least 24 business hours’ notice, excluding weekends and holidays, may be charged a $50 fee. I voluntarily authorize TeleMed2U and its payment processor to securely store the payment-card credential I provide and charge patient-responsible amounts, including copayments, coinsurance, deductibles, noncovered services, self-pay services, missed-appointment fees, and outstanding balances. Charges will not exceed $500 per transaction unless I separately authorize a higher amount. Insurance estimates are not guarantees, and my final responsibility may change after claim processing. TeleMed2U will provide or make available information identifying the amount and reason for a charge consistent with its policies and applicable requirements. This authorization remains effective until I revoke it through TeleMed2U’s designated billing or payment contact method. Revocation applies prospectively and does not affect prior charges or amounts owed. If the stored card expires, is declined, or is replaced, I remain responsible and will provide another payment method. I retain the right to question or dispute a charge, will keep billing and card information current, and understand that the card security code will not be stored except as permitted by applicable payment-card requirements.

Other Acknowledgements

• For in-person services, if a healthcare worker is exposed to my blood or body fluid in a manner posing a risk of blood-borne infection, I consent to HIV testing at no cost to me so the worker can be treated promptly, and I authorize release of the result to the exposed worker and the worker’s healthcare provider.
• TeleMed2U may support wellness through traditional medicine and nontraditional lifestyle-improvement approaches. A nontraditional approach supplements and does not replace conventional medical treatment. A patient choosing an exclusively nontraditional approach does so at the patient’s own risk; TeleMed2U may support the decision but is not liable for resulting outcomes.
• I acknowledge receipt of the Notice of Privacy Practices and Bill of Rights and Responsibilities from TeleMed2U and Cloud Health Medical. I understand that the Notice explains how PHI may be used and disclosed, may change, and can be reviewed at www.telemed2u.com or obtained from staff. I authorize collection, use, and disclosure of my health information for treatment, payment, and healthcare operations.
• I authorize release of information necessary to process claims and coordinate care.
• If I am self-pay because valid active insurance is not presented at service, I agree to pay in full at the visit; TeleMed2U will not bill an insurer for that day’s services, and procedures or laboratory tests may involve separate fees.
• If valid active insurance is presented, I assign benefits to the provider, remain responsible for copayments, deductibles, noncovered services, and separate procedure or laboratory fees, and will provide accurate current insurance information and report changes.
• I authorize release of medical, demographic, and other information needed to process claims and for payment, treatment, healthcare operations, quality assurance, utilization review, transfers, and referrals, including disclosures required or permitted to government agencies or other organizations.
• I will follow post-treatment instructions and attend recommended follow-up appointments.
• If I cannot make medical decisions, I authorize TeleMed2U, Cloud Health Medical, and their healthcare providers to make necessary decisions on my behalf using professional judgment and applicable law.
• I may choose the pharmacy that fulfills prescriptions resulting from the services, and I authorize disclosure of information to my chosen pharmacy as necessary to provide pharmacy services.
• I am responsible for all charges incurred and understand insurance estimates are not final until claims are processed. My signature may be used on billing claim forms.
• I authorize insurers to pay TeleMed2U directly; I will pay for noncovered services and actual collection costs, including attorney fees and interest. I authorize application of account credits to unpaid services on my or my guarantor’s accounts.
• I authorize TeleMed2U to obtain medication history prescribed by other providers for inclusion in my medical record.
• I consent to sharing data through Surescripts’ National Record Locator and Exchange and other health information exchanges to locate and exchange relevant records, including medication history, among EHRs, repositories, public-health agencies, and HIEs.
• I may refuse or withdraw consent for treatment, subject to consequences that should be discussed with my provider.
• I agree to provide accurate medical, medication, allergy, insurance, and demographic information.
• In an emergency, I will call 911; a telehealth provider cannot connect me directly to local emergency services.
• My electronic signature is binding as if signed on paper.

Agreement and Nature of Consent

I have read and understood this Medical Consent Form and voluntarily consent to medical treatment and procedures from TeleMed2U and Cloud Health Medical. By signing, I authorize TeleMed2U, Cloud Health Medical, and their healthcare providers to provide treatment, conduct diagnostic testing, and perform necessary procedures to diagnose and treat my condition. My electronic signature is binding and enforceable as if signed on paper.