Medical Consent

INFORMED CONSENT FOR TELEHEALTH SERVICES

DO NOT USE THIS SERVICE IF YOU MAY BE EXPERIENCING A MEDICAL EMERGENCY.
In an emergent situation, you can: (i) call 911; (ii) go to the nearest emergency room; (iii) contact your local crisis center; (iv) if applicable, call the National Suicide Prevention Lifeline (1-800-273- 8255); or (v) if applicable, contact the Crisis Text Line (text "GO" to 741-741).

We are pleased you have chosen FSA Store Inc. (“FSA Store”, “we”, “our”, “us”) for your telehealth needs. This document is intended to inform you of what you can expect of your clinician in terms of his or her credentials and in connection with your treatment via telehealth.

IMPORTANT INFORMATION REGARDING YOUR TREATMENT BY TELEHEALTH HEALTH PROVIDERS, INCLUDING POTENTIAL RISKS AND BENEFITS. FSA Store Inc. (“FSA Store”, “we”, “our”, “us”) offers treatment by various types of healthcare providers via telecommunications technology (also referred to as "telehealth"). Our partner provider network includes physicians, nurses, and equivalent licensed professionals. The services provided may also include chart review, remote prescribing, appointment scheduling, refill reminders, health information sharing, and non-clinical services, such as patient education. The electronic communication systems the provider network uses will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption. 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 could occur due to deficiencies or failures of the equipment and technologies, and in rare events, a provider may determine that the transmitted information is of inadequate quality, thus necessitating a rescheduled telehealth consult or a meeting with your local primary care doctor.

All team members are ethically and legally bound to maintain your privacy and confidentiality in this scenario and none of your personal information will be shared or disclosed with any other individual without your consent. Exceptions to confidentiality do exist in certain situations, such as: threat of serious harm to self or others; reasonable suspicion of abuse or neglect of a child, or abuse, neglect, or exploitation of an incapacitated or dependent adult; court order and/or subpoena; permission from the client or guardian (i.e. voluntary release signed by the client or guardian); during supervisory consultations; diagnosis and dates of service shared with an insurance company to collect payments; information released as outlined in our partner provider network Privacy Practices and Privacy Policy; and as otherwise required by law.

By checking the box associated with "Informed Consent", you acknowledge that you understand and agree with the following:

1. You hereby consent to receiving provider network services via telehealth technologies. You understand that our partner provider network and its providers offer telehealth-based medical services, but that these services do not replace the relationship between you and your primary care doctor. You also understand it is up to the assigned provider to determine whether or not your specific clinical needs are appropriate for a telehealth encounter.

2. You have the opportunity to review the assigned provider's credentials.

3. You understand that federal and state law requires health care providers to protect the privacy and the security of health information. You understand that our partner provider network will take steps to make sure that your health information is not seen by anyone who should not see it. You understand that telehealth may involve electronic communication of your personal medical information to other health practitioners who may be located in other areas, including out of state.

4. You understand there is a risk of technical failures during the telehealth encounter beyond the control of the provider network. You agree to hold harmless the provider network for delays in evaluation or for information lost due to such technical failures.

5. You understand that You have the right to withhold or withdraw your consent to the use of telehealth in the course of your care at any time, without affecting your right to future care or treatment. You understand that You may suspend or terminate use of the telehealth services at any time for any reason or for no reason. You understand that if you are experiencing a medical emergency, that you will be directed to dial 9-1-1 immediately and that Your assigned providers are not able to connect you directly to any local emergency services.

6. You understand that alternatives to telehealth consultation, such as in-person services are available to you, and in choosing to participate in a telehealth consultation, you understand that some parts of the services involving tests may be conducted by individuals at your location, or at a testing facility, at the direction of Your assigned provider (e.g., labs or bloodwork).

7. You understand that you may expect the anticipated benefits from the use of telehealth in your care, but that no results can be guaranteed or assured.

8. You understand that your healthcare information may be shared with other individuals for scheduling and billing purposes. Persons may be present during the consultation other than the assigned provider in order to operate the telehealth technologies. You further understand that you will be informed of their presence in the consultation and thus will have the right to request the following: (a) omit specific details of your medical history/examination that are personally sensitive to you; (b) ask non-medical personnel to leave the telehealth examination; and/or (c) terminate the consultation at any time.

9. You understand that you will not be prescribed any narcotics, nor is there any guarantee that you will be given a prescription at all.

10. You understand that if you participate in a consultation, that you have the right to request a copy of your medical records which will be provided to you at reasonable cost of preparation, shipping and delivery.

11. You have read and you understand the disclosures set forth next to the state in which you are located at the time of the telehealth encounter, as set forth below:

STATE REGULATIONS:

Alaska: You understand your primary care provider may obtain a copy of your records of your telehealth encounter. (Alaska Stat. § 08.63.210(C)(2).

Arizona: You understand that all medical records resulting from a telemedicine consultation are part of your medical record. (Ariz. Rev. Stat. Ann. § 36-3602(D)).

Physicians: All physicians licensed to practice in the State of California are licensed and regulated by the Medical Board of California. To check on a physician's license or to file a complaint, go to www.mbc.ca.gov, email licensecheck@mbc.ca.gov, call (800) 633-2322 or use this QR code:

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 you and a physician for urgent matters. (D.C. Mun. Regs. tit. 17, § 4618.10). Relevant communications with the physician, including those done via electronic methods shall be documented and filed in your medical record. (D.C. Mun. Regs. tit. 17, § 4618.9).

Florida: Patients that are prescribed GLP-1 medications, such as Semaglutide, for weight-loss - You have been provided with the Weight-Loss Consumer Bill of Rights.

Weight-Loss Consumer Bill of Rights:
A. Warning: Rapid weight loss may cause serious health problems. Rapid weight loss is weight loss of more than 1 ½ pounds to 2 pounds per week or weight loss of more than 1 percent of body weight per week after the second week of participation in a weight-loss program.
B. Consult your personal physician before starting any weight-loss program.
A. Only permanent lifestyle changes, such as making healthful food choices and increasing physical activity, promote long-term weight loss.
B. Qualifications of this provider are available upon request.
C. You have the right to:
   1. Ask questions about the potential health risks of this program and its nutritional content, psychological support and educational components.
   2. Receive an itemized statement of the actual or estimated price of the weight-loss program, including extra products, services, supplements, examinations, and laboratory tests.
   3. Know the actual or estimated duration of the program.
   4. Know the name, address, and qualifications of the dietitian or nutritionist who has reviewed and approved the weight-loss program according to s.468.505(1)(j), Florida Statutes.

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)).

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/ (Idaho Guidelines for Appropriate Regulation of Telemedicine). You further understand that your informed consent for the use of telehealth services shall be obtained by applicable law. Idaho Statutes 54-5708.

Indiana: If a prescription is issued to you, and subject to your consent the prescriber shall notify your primary care provider of any prescriptions the prescriber has issued for you if the primary care provider's contact information is provided by you. This requirement does not apply if: (A) The practitioner is using an electronic health record system that your primary care provider is authorized to access. (B) The practitioner has established an ongoing provider-patient relationship with the patient by providing care to the patient at least 2 consecutive times through the use of telehealth services. If the conditions of this clause are met, the practitioner shall maintain a medical record for you and shall notify your primary care provider of any issued prescriptions. Ind. Code Ann. 25-1-9.5-7.

Iowa: To file a complaint, fill out the complaint form and email it to the medical board at ibmcomplaints@iowa.gov. Iowa Admin. Code 653-13.11(147,148,272C)(13.11(18)).

As appropriate your provider will identify the medical home or treating physician(s) for you, when available, where in-person services can be delivered in coordination with the telemedicine services. Your provider shall provide a copy of the medical record to your medical home or treating physician(s). Iowa Admin. Code 653-13.11(147,148,272C)(13.11(11))

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).

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/board/Pages/default.aspx.

If requested by you, your physician must share the medical record with your primary care physician and other relevant members of your existing care team. Kentucky Board Opinion on the Use of Telemedicine Technologies (2014), as amended September 15, 2022.

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. (Code Me. R. tit. 02-373 Ch. 11, § 3.).

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 that 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. If you do not have a primary care provider or other health care provider of record, the health care provider engaging in telemedicine or telehealth may advise you to contact a primary care provider, and, upon request by you, may assist you with locating a primary care provider or other in-person medical assistance that, to the extent possible, located within reasonable proximity to you. N.J. Rev. Stat. Ann. § 45:1-62.

New York: Patients that are prescribed GLP-1 medications, such as Semaglutide, for weight-loss - You have been provided with the Weight-Loss Consumer Bill of Rights.

WEIGHT LOSS AND DIETING INFORMATION
A. WARNING! Rapid weight loss may cause serious health problems. Rapid weight loss is weight loss of more than 1 1/2 to 2 pounds per week or weight loss of more than 1 percent of body weight per week after the second week of participation in a weight loss program.
B. Consult your physician before starting any weight loss program or using any diet medications or formulas.
C. Long term weight control is the safest and most important goal of any diet program. Permanent lifestyle changes such as eating nutritious foods, calorie control and increasing physical activity help promote long term weight loss according to medical experts.
D. Ask the person providing or selling you weight loss advice or diet products, medications or formulas about their qualifications and training in nutrition and health.
E. You have the right to:
   a. Ask questions about the potential health risks of this program or product, its nutritional content, and its psychological-support and educational components;
   b. Know the price of treatment, including the price of any extra products, services, supplements and laboratory tests; and
   c. Know the program duration of the program recommended to you. N.Y. Gen. Bus. Law § 642.

Ohio: You understand that the telehealth provider may forward your medical records to your primary care or treating provider. Ohio Admin. Code 4731-37-01(C)(4).

Oregon: If you have a concern or complaint about the providers providing care to you, you may contact a board agency to assist you. You understand that the provider may ask if you need more detail. ORS 17-52- 677.07. See also Or. Medical Board, Statement of Philosophy: Telemedicine (Oct 2, 2020)

Complaints may be filed with:
Oregon Medical Board
1500 SW 1st Ave., Suite 620
Portland, OR 97201-5847
Complaint Resource Staff: 971-673-2702 | complaintresource@omb.oregon.gov

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. You understand the value having of having a primary care medical home and, if requested, we can provide assistance in identifying available options for a primary care medical home. 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 within 72 hours. 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 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. 156-1-602.

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 the provider network 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 understand that receiving telehealth services via store-and-forward technologies by the provider network does not preclude you from receiving real-time telemedicine or face-to-face services with the distant provider at a future date. (Vt. Stat. Ann. § 9361).

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/opr/complaints-conduct-discipline/#emr (Vt. Board of Medical Practice, Policy on the Appropriate Use of Telemedicine Technologies in the Practice of Medicine (March 1, 2023).

You have read this section carefully, understand the risks and benefits of the telehealth services, and have had your questions regarding the services explained. By proceeding with scheduling a consultation, you hereby give your informed consent to participate in a telehealth consultation under the terms described herein.