IN-PERSON TREATMENT CONSENT

I. Purpose

This In-Person Treatment Consent (“Consent”) applies to patients receiving healthcare services at a partner clinic location through the Evolve Your Bod In-Person Visit (IPV) care model. By signing this Consent, you acknowledge that you understand and agree to the terms described below.

This Consent supplements, but does not override, the Evolve Your Bod Terms of Service, Privacy Policy, Notice of Privacy Practices, and PHI / Data-Sharing Authorization.

II. Your Care Arrangement

Your in-person visit is being coordinated by Evolve Your Bod and will take place at a partner clinic. Please understand the following:

– Evolve Your Bod is a technology and care coordination platform. Evolve does not practice medicine, does not prescribe medications, and does not directly provide clinical care.

– Your clinical care will be rendered by the partner clinic and its affiliated licensed healthcare providers. The partner clinic is the rendering provider for your in-person encounter.

– The name and location of the partner clinic where your visit will take place will be disclosed to you before your appointment.

– You may be required to sign additional clinic-specific consent forms at or before your visit, as required by the partner clinic.

– The partner clinic maintains its own clinical documentation and medical records for your encounter.

III. Services

In-person services may include, but are not limited to: physical examinations, diagnostic evaluations, laboratory specimen collection, medication management, treatment planning, referrals, and follow-up consultations. The scope of services available at each partner clinic may vary.

IV. Risks of In-Person Treatment

All medical care carries inherent risks. Risks associated with in-person treatment may include, but are not limited to:

– Adverse reactions to medications, treatments, or procedures.

– Incomplete or inaccurate diagnosis based on the information available at the time of your visit.

– Exposure to communicable illnesses at the clinic location.

– Risks associated with any recommended diagnostic testing, including false-positive or false-negative results.

– Risks specific to any procedure or treatment performed, which will be discussed with you by your provider before the procedure.

V. Insurance and Payment

In-person services rendered by the partner clinic may be eligible for insurance coverage. The partner clinic or the rendering Medical Group, or Evolve Your Bod acting as a billing agent on their behalf, is responsible for insurance verification, billing, and claims submission.

You are responsible for any copays, deductibles, coinsurance, or balances not covered by your insurance plan. If your insurance does not cover a service, or if you do not have insurance, you are responsible for payment in full. You will be informed of your estimated financial responsibility before services are rendered whenever possible.

VI. Patient Acknowledgments

By signing below, electronically accepting this Consent through the Evolve Your Bod platform, clicking ‘I Agree,’ checking the associated consent box, or proceeding with your in-person visit after being presented with this Consent, you affirm:

– I understand that my in-person care is rendered by the partner clinic and its affiliated providers, not by Evolve Your Bod.

– I have been informed of the name and location of the partner clinic where my visit will take place.

– I understand the risks associated with in-person treatment as described above.

– I have had the opportunity to ask questions about my care and have received satisfactory answers.

– I understand that I may be required to sign additional clinic-specific consent forms.

– I consent to the partner clinic sharing my clinical information with Evolve Your Bod for care coordination purposes, as described in the PHI / Data-Sharing Authorization.

– I have the right to refuse treatment at any time.

– I understand that the partner clinic may bill my insurance for services rendered, and that Evolve may act as a billing agent on the clinic’s behalf.

VII. Contact Information

Evolve Your Bod (AA Health Solutions, LLC)

5521 Bellaire Drive South, Suite 200, Fort Worth, TX 76109

Email: info@evolveyourbod.com | Phone: 866-301-3141