TELEHEALTH INFORMED CONSENT

EMERGENCIES AND URGENT NEEDS

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I. Introduction

By accessing or using telehealth services coordinated through Evolve Your Bod, you are agreeing to this Telehealth Informed Consent. These services are facilitated through our online platform, mobile app, or other telehealth technologies (collectively, the “Evolve Platform”). This document supplements, but does not override, the Terms of Service, Privacy Policy, Notice of Privacy Practices, or PHI / Data-Sharing Authorization associated with Evolve Your Bod and its affiliated healthcare providers (“Providers”).

By creating an account, beginning a consultation, clicking “I consent to telehealth,” checking a related box, or otherwise engaging with the Evolve Platform, you acknowledge and agree to the risks, limitations, and benefits of telehealth services as described herein.

This Telehealth Informed Consent applies to telehealth consultations delivered as part of the Telehealth (TH) care model and to the telehealth component of the Hybrid (Consult + IV) care model. If you are receiving care under the Hybrid model, you will also be asked to review and sign the Hybrid Satellite-Site Facilitation Disclosure and, if IV therapy is administered, the IV Therapy Treatment Consent.

II. What Is Telehealth?

Telehealth is a method of delivering healthcare services using electronic communication technologies to connect licensed healthcare providers with patients in remote locations. These services include consultations, diagnoses, treatment plans, follow-ups, and patient education. Telehealth can occur through various modalities, including synchronous (real-time video or audio), asynchronous (store-and-forward technology), or interactive audio with shared data.

In the Telehealth (TH) care model, you receive care entirely through the Evolve Platform from a remote provider. In the Hybrid care model, the telehealth consultation occurs while you are physically present at a satellite or partner clinic location, with an on-site nurse facilitating the encounter. In both cases, the remote provider is the treating clinician who makes clinical decisions using their independent medical judgment.

III. Provider Identity Disclosure

Before your telehealth consultation begins, you will be informed of the identity of the provider or Medical Group responsible for your care. Evolve Your Bod is a technology and care coordination platform and does not practice medicine. Your care is delivered by an independent, licensed healthcare provider affiliated with a Medical Group that coordinates with Evolve. The provider may include physicians, nurse practitioners, physician assistants, or other licensed professionals.

If you are receiving care under the Hybrid model, you will also be informed that the on-site clinical staff (such as a registered nurse) at the satellite location is a facilitator assisting with intake, vitals, and/or IV administration — not the treating physician. The remote provider conducting the telehealth consultation is the rendering clinician.

IV. Benefits of Telehealth

Telehealth offers numerous benefits, including easier and more efficient access to healthcare services. By using telehealth, you can obtain medical care at times and locations that are convenient for you. This includes follow-up care, which can often be completed without the need for an in-office visit. Telehealth reduces the need for travel and minimizes disruption to your daily schedule.

If you require further assistance or follow-up care, you can contact Evolve Your Bod at +1 866-301-3141 or via email at info@evolveyourbod.com during our business hours: Monday–Thursday, 8:00 AM–5:00 PM CST and Friday 8:00 AM–12:00 PM CST.

V. Risks and Limitations of Telehealth

While telehealth is a convenient and effective tool for many patients, it is not without its risks:

– Information transmitted electronically may not always be complete or sufficient for an accurate diagnosis or treatment plan.

– Your provider may determine that certain conditions are not suitable for telehealth and recommend in-person care.

– Technical issues such as internet disruptions, hardware malfunctions, or software failures may delay or interrupt your consultation.

– Incomplete medical records or insufficient data could lead to incorrect treatment, adverse drug interactions, or allergic reactions.

– Diagnostic testing services, including lab work ordered via the Evolve Platform, are provided by third-party laboratories. These tests may occasionally produce false-positive, false-negative, or inconclusive results.

– Telehealth consultations may not be appropriate for all medical conditions. Some conditions require a physical examination or in-person evaluation.

You have the right to decline or discontinue telehealth services at any time. However, fees may still apply if a consultation has occurred. Evolve Your Bod and its affiliated Providers are not responsible for ensuring the continuity of care if you choose to terminate telehealth services.

VI. Prescriptions and Compounded Medications

If your provider determines that medication is medically appropriate, a prescription may be issued. You acknowledge and agree to the following:

– Prescriptions are not guaranteed and are subject to the professional judgment of your provider.

– Medications may include both commercially available and compounded medications. Compounded medications are produced by licensed compounding pharmacies and are not FDA-approved. Their safety and efficacy may differ from commercially manufactured drugs.

– You are responsible for disclosing all current medications, allergies, and medical conditions to your provider to reduce the risk of adverse drug interactions.

– You may choose your preferred pharmacy, regardless of Evolve Platform recommendations.

– Prescription fulfillment is handled by third-party licensed pharmacies. Evolve Your Bod does not dispense medications.

VII. Patient Acknowledgments

By signing below, electronically accepting this Consent through the Evolve Your Bod platform, clicking ‘I consent to telehealth,’ checking the associated consent box, or proceeding with a telehealth consultation after being presented with this Consent, you affirm the following:

– I have reviewed this Telehealth Informed Consent and understand the risks, benefits, and limitations associated with telehealth.

– I acknowledge the potential for privacy risks due to the electronic nature of telehealth services.

– I understand that my provider may include nurse practitioners, physician assistants, or other licensed professionals affiliated with an independent Medical Group.

– I understand that Evolve Your Bod is a technology and care coordination platform and does not practice medicine or deliver clinical care.

– I understand that others (e.g., tech support, translators, on-site clinical staff in Hybrid encounters) may be present during my session when necessary, and I will be informed of their roles.

– I agree that the information I provide during my telehealth sessions is accurate, truthful, and complete.

– My provider may utilize asynchronous methods (e.g., store-and-forward technology) when appropriate, and I consent to this form of communication.

– I hold harmless Evolve Your Bod and its affiliates for any delays, errors, or information lost due to technical failures.

– Evolve Your Bod may not fulfill all healthcare needs, and I may need to seek additional resources or providers.

– My messages and inquiries on the Evolve Platform may not be reviewed in real time, and I am responsible for regularly checking the platform for updates.

– I may withdraw my consent to telehealth services at any time, but understand this may limit my access to care through Evolve Your Bod.

– I have access to my medical records as required by applicable law.

– I acknowledge that Evolve Your Bod is a third-party beneficiary of this consent and reserves the right to enforce its terms.

– If I am receiving care under the Hybrid model, I understand that the on-site nurse is a facilitator and that the remote provider is the treating clinician. I will also sign the Hybrid Satellite-Site Facilitation Disclosure and, if applicable, the IV Therapy Treatment Consent.

VIII. Telehealth Payment

Telehealth (TH) services coordinated through the Evolve Platform are provided on a cash-pay basis. Insurance is not accepted for telehealth-only consultations. You are solely responsible for all fees associated with telehealth services.

If telehealth is part of a Hybrid encounter, insurance may apply to the overall clinical encounter through the rendering provider or partner clinic. See your Hybrid Satellite-Site Facilitation Disclosure for details.

IX. State-Specific Disclosures

Certain states require additional disclosures regarding telehealth services. If you are accessing the Evolve Platform for healthcare services, please note the following information specific to your state:

Iowa

If you wish to express concerns about a provider’s service, visit the Iowa Medical Board: https://dial.iowa.gov/about-dial/boards-0/medicine

Kentucky

Guidance for submitting concerns is available at the Kentucky Board of Medical Licensure: https://kbml.ky.gov/grievances/Pages/default.aspx

Maine

The Maine Board of Licensure in Medicine offers resources for formal concerns: https://www.maine.gov/md/complaint/file-complaint

New York

Information about professional standards and patient rights: https://www.health.ny.gov/professionals/doctors/conduct/

Oregon

Oregon Medical Board complaint process: https://www.oregon.gov/omb/investigations/pages/how-to-file-a-complaint.aspx

Rhode Island

Rhode Island Department of Health complaint resources: https://health.ri.gov/complaints/

Texas

Notice Regarding Complaints

I acknowledge that I have been informed of the following: If you wish to file a complaint against a physician or any other licensed or registered healthcare professional regulated by the Texas Medical Board, including physician assistants, acupuncturists, and surgical assistants, you may submit your complaint 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. For assistance in filing a complaint, please call 1-800-201-9353. Additional information: www.tmb.state.tx.us

Aviso Sobre Quejas

Reconozco que se me ha informado de lo siguiente: Si desea presentar una queja contra un médico u otro profesional de la salud con licencia o registrado ante el Consejo Médico de Texas, incluyendo asistentes médicos, acupuntores y asistentes quirúrgicos, puede enviar su queja para su investigación a la siguiente dirección:

Consejo Médico de Texas, Atención: Investigaciones, 333 Guadalupe, Torre 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018. Para recibir asistencia: 1-800-201-9353. Sitio web: www.tmb.state.tx.us

Vermont

Vermont Board of Medical Practice: https://www.healthvermont.gov/systems/board-medical-practice/file-complaint

Wyoming

Wyoming Board of Medicine: https://wyomedboard.wyo.gov/consumers/file-a-complaint

X. 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