Informed Consent

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 (1-800-272-8255); or (v) if applicable, contact the Crisis Text Line (text “GO” to 741-741).

We are pleased you have chosen Mora Medical for your telehealth needs. This document is intended to inform you of what youcan expect of your clinician in terms of his or her credentials and in connection with your treatment via telehealth. After you havecarefully read this document and had an opportunity to have your questions answered, certain state laws mandate that you mustsign and date it before commencing services.

YOUR TELEHEALTH PROVIDER’S CREDENTIALS.

Your provider’s credentials were made available to you before scheduling an appointment. If you have any questions about thesecredentials, please direct them to your telehealth provider. For those states that require it, you can find an explanation of thelevels of regulation applicable to clinicians under the STATE REGULATIONS section of this document.

IMPORTANT INFORMATION REGARDING YOUR TREATMENT BY TELEHEALTH HEALTH PROVIDERS, INCLUDING POTENTIAL RISKS AND BENEFITS.

Mora Medical offers treatment by various types of healthcare providers via telecommunications technology (also referred to as“telehealth”). Our providers include physicians, nurses, and equivalent licensed professionals. The services provided may alsoinclude chart review, remote prescribing, appointment scheduling, refill reminders, health information sharing, and non-clinicalservices, such as patient education. The electronic communication systems we use will incorporate network and software securityprotocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the dataand to ensure its integrity against intentional or unintentional corruption. There are various benefits associated with telehealthservices, including improved access to care by enabling you to remain in your home while the provider consults with you, moreefficient care evaluation and management, and obtaining expertise of a specialist as appropriate. Possible risks include delays inevaluation and treatment could occur due to deficiencies or failures of the equipment and technologies, and in rare events, ourprovider may determine that the transmitted information is of inadequate quality, thus necessitating a rescheduled telehealthconsult or a meeting with your local primary care doctor. Please be aware that by participating in a group telehealth session, yourhealthcare provider may release medical and psychosocial information about you or your family members that will be heard byother members of the group. In some cases, this may be confidential or sensitive information. By signing this form, you consent tothe release of medical and psychosocial information about you or your family members during a shared medical appointment.You understand that all information exchanged in a group session is confidential, and agree to keep anything said during asession confidential. Specifics from or related to your group sessions may only be discussed with members of the immediatesession or your provider. By participating in group sessions and signing below, you further agree to keep confidential the namesof other members of the group and you agree not to disclose to anyone outside of the group any information that may identifyanother group member, including but not limited to names, physical descriptions, biological information, and specifics relating tothe content of interactions with other group members. You may also share your experience with your healthcare providers or asotherwise required by law.

Your provider’s credentials were made available to you before scheduling an appointment. If you have any questions about thesecredentials, please direct them to your telehealth provider. For those states that require it, you can find an explanation of thelevels of regulation applicable to mental health clinicians under the STATE REGULATIONS section of this document.

By signing this form, you are representing that you have read this document and understand the information found in it.

At times, your clinician may seek supervision or consultation with other Mora Medical or non-Mora Medical clinicians regardingyour treatment, to enhance the services being provided to you given the multiple perspectives, experiences, and treatmentphilosophies. All team members are ethically and legally bound to maintain your privacy and confidentiality in this scenario andnone of your personal information will be shared or disclosed with any other individual without your consent. Exceptions toconfidentiality do exist in certain situations, such as: threat of serious harm to self or others; reasonable suspicion of abuse orneglect 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 MoraMedical’s Notice of Privacy Practices and Privacy Policy; and as otherwise required by law.

In accordance with state laws, consent for treatment of a minor can only be authorized by a current legal guardian for the minor. Ifthe parents of a minor are separated, treatment is provided to the minor only with the written consent of both parents. If the parentsof the minor are divorced, consent for treatment of the minor may be given by the parent authorized to make medical decisions forthe minor. If a court of law has ordered that medical decisions for the minor are to be made jointly by the minor’s parents, thenconsent of both parents is required for treatment of the minor. In the case of minors, as defined by state law, parents may requestinformation about their child’s diagnosis or treatment. While release of this information will be provided, it is best that the processbe a collaborative one involving the minor, parent, and clinician in order to maintain the rapport established between the minorand clinician since rapport is vital to treatment success. Therefore, unless there is a safety concern, the minor would be consultedabout the disclosure and encouraged to share the information with the parent first in order to establish better communicationswithin the family structure.

FEES AND BILLING ARRANGEMENTS.

The fees for Mora Medical’s services are as follows: [insert]. Prices are subject to change. You are expected to pay all fees foryour telehealth services upfront at the time of service; however, you are not obligated to pay any fees for which another party (e.g.,your employer or health plan) has contractually agreed with Mora Medical to pay on your behalf. If you believe any of the fees youhave been charged are incorrect, you must immediately contact us in writing regarding the amount in question to be eligible toreceive a refund. You irrevocably waive your right to challenge the accuracy of any charge, or otherwise receive a refund, if youfail to notify Mora Medical in writing within fifteen (15) calendar days after the charge, that you believe the charge is inaccurate(setting forth an explanation of why).

By checking the box associated with “Informed Consent”, you acknowledge that you understand and agree with thefollowing:

1. I hereby consent to receiving Mora Medical’sservices via telehealth technologies.

2. I understandthat Mora Medical and its providers offer telehealth-based medical services, but that these services donot replace the relationship between me and myprimary care doctor.

3. I also understand it is up tothe Mora Medical provider to determine whether ornot my specific clinical needs are appropriate for atelehealth encounter.

4. I have been given anopportunity to select a provider from Mora Medicalprior to the consult, including a review of theprovider’s credentials.

5. I am at least eighteen (18)years of age and possess the legal right and abilityto voluntarily and unequivocally provide this consentand agreement.

6. I understand that federal andstate law requires health care providers to protect the privacy and the security of health information.

7.I understand that Mora Medical will take steps tomake sure that my health information is not seen byanyone who should not see it.

8. I understand thattelehealth may involve electronic communication ofmy personal medical information to other healthpractitioners who may be located in other areas,including out of state.

9. I understand there is a riskof technical failures during the telehealth encounterbeyond the control of Mora Medical.

10. I agree tohold harmless Mora Medical. for delays in evaluationor for information lost due to such technical failures.

11. I understand that I have the right to withhold orwithdraw my consent to the use of telehealth in thecourse of my care at any time, without affecting myright to future care or treatment.

12. I understandthat I may suspend or terminate use of the telehealthservices at any time for any reason or for no reason.

13. I understand that if I am experiencing a medicalemergency, I will be directed to dial 9-1-1immediately and that the Mora Medical providers arenot able to connect me directly to any localemergency services.

14. I understand thatalternatives to telehealth consultation, such as in-person services are available to me, and in choosingto participate in a telehealth consultation, Iunderstand that some parts of the services involvingtests may be conducted by individuals at mylocation, or at a testing facility, at the direction of theMora Medical provider (e.g., labs or bloodwork).

15. Iunderstand that I may expect the anticipatedbenefits from the use of telehealth in my care, butthat no results can be guaranteed or assured.

16. I understand that my healthcare information may beshared with other individuals for scheduling andbilling purposes. Persons may be present during theconsultation other than the Mora Medical provider inorder to operate the telehealth technologies.

17. I further understand that I will be informed of theirpresence in the consultation and thus will have theright to request the following: (a) omit specific detailsof my medical history/examination that arepersonally sensitive to me; (b) ask non-medicalpersonnel to leave the telehealth examination; and/or(c) terminate the consultation at any time. 18. Iunderstand that I will not be prescribed anynarcotics, nor is there any guarantee that I will begiven a prescription at all. I understand that if Iparticipate in a consultation, that I have the right torequest a copy of my medical records which will beprovided to me at reasonable cost of preparation,shipping and delivery. 19. I have read and Iunderstand the disclosures set forth next to the statein which I am located at the time of the telehealthencounter, as set forth below: *

STATE REGULATIONS:

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

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

Colorado: I am informed that if I want to register a formal complaint about a provider, I should file athttps://dpo.colorado.gov/FileComplaint.

Connecticut: I understand that my primary care provider may obtain a copy of my records of my telehealth encounter, and that Ican revoke my consent at any time. (Conn. Gen. Stat. Ann. § 19a-906).
D.C.: I have been informed of alternate forms of communication between me and a physician for urgent matters. (D.C. Mun. Regs.tit. 17, § 4618.10).

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

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

Idaho: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’swebsite, here: https://elitepublic.bom.idaho.gov/IBOMPortal/AgencyAdditional.aspx?Agency=425&AgencyLinkID=650

Illinois: Ihave been informed that if I want to register a formal complaint about a provider, I should visit the Illinois Division of ProfessionalRegulation at https://www.idfpr.com/admin/DPR/DPRcomplaint.asp
Indiana: As a Medicaid patient, I have the right to choose between an in-person visit or telehealth visit. I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here: https://www.in.gov/attorneygeneral/2434.htm.

Kansas: I understand that if I 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 me during the telemedicine encounter. (Kan. Stat. Ann. § 40-2,212(2)(d)(2)(A). I understand that the complaint process may be found here: http://www.ksbha.org/complaints.shtml

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

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

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

Maryland: Regarding audiologists, speech language pathologists, and hearing aid dispensers, I recognize the inability to have direct, physical contact with the patient is a primary difference between tele health and direct in-person service delivery. Theknowledge, experiences, and qualifications of the consultant providing data and information to the provider of the tele health services need not be completely known to and understood by the provider. The quality of transmitted data may affect the quality of services provided by the provider. Changes in the environment and test conditions could be impossible to make during delivery of telehealth services. Telehealth services may not be provided by correspondence only. (Md. Code Regs. 10.41.06.04). I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here:https://www.mbp.state.md.us/forms/complaint.pdf.
Nebraska: If I am a Medicaid recipient, I retain the option to refuse the telehealth consultation at any time without affecting my rightto future care or treatment and without risking the loss or withdrawal of any program benefits to which the patient would otherwise be entitled. All existing confidentiality protections shall apply to the tele health consultation. I shall have access to all medical information resulting from the tele health consultation as provided by law for access to my medical records. Dissemination of any patient identifiable images or information from the telehealth consultation to researchers or other entities shall not occur without my written consent. I understand that I have the right to request an in-person consult immediately after the telehealth consult and I will be informed if such consult is not available. (Neb. Rev. Stat. Ann. § 71-8505; 471 Neb. Admin. Code § 1-006.05). I have been informed that if I want to register a formal complaint about a provider, I should visit: https://dhhs.ne.gov/Pages/Complaints.aspxNew Hampshire: I understand that the tele health provider may forward my medical records to my primary care or treating provider. (N.H. Rev. Stat. § 329:1-d).

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

Ohio: I understand that the tele health provider may forward my medical records to my primary care or treating provider. OhioAdmin. Code 4731-11-09(C).

Oklahoma: I have been informed that if I want to register a formal complaint about a provider, I 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 I use e-mail or text-based technology to communicate with my provider, then I understand the types of transmissions that will be permitted and the circumstances when alternate forms of communication or office visits should be utilized. I 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. I acknowledge that my failure to comply with this agreement may result in the tele health provider terminating the e-mail relationship. (Rhode Island Medical Board Guidelines).

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

South Dakota: I have received disclosures regarding the delivery models and treatment methods or limitations. I have discussed with the tele health provider the diagnosis and its evidentiary basis, and the risks and benefits of various treatment options. (S.D.Codified Laws § 34-52-3).

Tennessee: I understand that I may request an in-person assessment before receiving a telehealth assessment if I am a Medicaid recipient.

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

NOTICE CONCERNING COMPLAINTS -Complaints about physicians, as well as other licensees and registrants of the TexasMedical Board, including physician assistants, acupuncturists, and surgical assistants may be reported for investigation at thefollowing 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 ConsejoMédico de Tejas, incluyendo asistentes de médicos, practicantes de acupuntura y asistentes de cirugia, se pueden presentar enla 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, Paraobtener más información, visite nuestro sitio web en www.tmb.state.tx.us

Utah: I understand (i) any additional fees charged for tele health 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 tele health services; (ii) to whom my health information may be disclosed and for what purpose, and have received information on any consent governing release of my patient-identifiable information to a third-party; (iii) my rights with respect to patient health information; (iv) appropriate uses and limitations of the site, including emergency health situations. I 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). I was warned of: potential risks to privacy notwithstanding the security measures and that information may be lost due to technical failures, and agree to hold the provider harmless for such loss. I have been provided with the location of telehealth company’s website and contact information. I was able to select my provider of choice, to the extent possible. I was able to select my pharmacy of choice. I am able to a (i) access, supplement, and amend my patient-provided personal health information; (ii) contact my provider for subsequent care; (iii) obtain upon request an electronic or hard copy of my medical record documenting the telemedicine services, including the informed consent provided; and (iv) request a transfer to another provider of my medical record documenting the telemedicine services. (Utah Admin. Code r. 156-1-603).

Virginia: I acknowledge that I have received details on security measures taken with the use of telemedicine services, such asencrypting date of service, password protected screen savers, encrypting data files, or utilizing other reliable authenticationtechniques, as well as potential risks to privacy notwithstanding such measures; I agree to hold harmless Mora Medical forinformation lost due to technical failures; and I provide my express consent to forward patient-identifiable information to a thirdparty. (Virginia Board of Medicine Guidance Document 85-12).

Vermont: I understand that I 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.
I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here:

http://www.healthvermont.gov/health-professionals-systems/board-medical-practice/file-complaint; Board of OsteopathicExaminers can be found at: https://www.sec.state.vt.us/professional-regulation/file-a-complaint-employer-mandatory-reporting.aspx

The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians andteaching hospitals. It can be found at https://openpaymentsdata.cms.gov.

I have read this document carefully, and understand the risks and benefits of the tele health services and have had my questions regarding the services explained and I hereby give my informed consent to participate in a tele health consultation under the terms described herein. *

ACCEPT.

By checking the Box for this "INFORMED CONSENT FOR TELEHEALTH SERVICES" I hereby state that I have read, understood, and agree to the terms of this document. *

PATIENT SIGNATURE: *DATE: *