Informed Consent Agreement

Effective: December 1, 2023 
Today you are requesting Teladoc’s telemedicine services which may include general medical, mental health, primary care, dermatology, or nutrition services (“Services”). Telemedicine is the practice of medicine that involves the use of electronic communications to diagnose or treat patients who are in different locations from their healthcare providers. Telemedicine can be used for diagnosing, treating, and prescribing medication. When using the Services, you will be treated by and will enter into a clinician-patient relationship with a provider of Teladoc Health Medical Group (“Teladoc Clinician”) who is licensed in your state. Teladoc Health, Inc. does not provide the Services; it performs administrative, payment, and other activities for Teladoc Clinicians in support of the Services they provide to you. Responsibility for your comprehensive care shall always remain with your local clinician or primary care physician. The expected benefits of using telemedicine include:

• Improved and quicker access to medical care through reduced travel and visit time
• Ability to access care from any location, and
• More efficient medical evaluation and management

The potential risks associated with using telemedicine may include:

• Delays in medical evaluation and treatment due to failures of technology, such as a disconnected phone call
• Information may be lost due to technical failures, and
• In rare cases, a lack of access to complete medical information may result in adverse drug interactions, allergic reactions, or other judgment errors

The inability to have direct, physical contact with your healthcare provider is the primary difference between telemedicine and in-person health care. The alternative to telemedicine is receiving care in a traditional in-person care setting. In receiving the Services, you understand and agree:

1. It is necessary for you to provide complete and accurate medical history and you will update your medical health records periodically, but no less than once a year.
2. You cannot use Teladoc’s Telemedicine Services to get prescriptions for DEA controlled substances, non-therapeutic drugs and certain other drugs which may be harmful because of their potential for abuse.
3. You cannot use Teladoc’s Telemedicine Services for life threatening emergencies. If you think you are experiencing a medical emergency, you need to call 911 or go immediately to the closest emergency room.
4. There is no guarantee that you will be treated by a Teladoc Clinician. The Teladoc Clinicians reserve the right to deny care for potential misuse of Services or for any other reason if, in the professional judgment of the Teladoc Clinician, the provision of the Service is not medically or ethically appropriate.
5. There is no guarantee that you will be given a prescription by the Teladoc Clinician.
6. You are required to pay all visit fees at the time you schedule a visit, unless payment arrangements have been established through your employer, benefit provider or other entity.
7. For California members: When you obtain telemedicine services through Teladoc, Teladoc will automatically fax a complete detailed record of all previous and future related consults to your primary care provider (PCP). The records will be faxed to the fax number you provided in your medical history. Please be sure you have provided the correct fax number for your PCP in your medical history. If you have not provided your PCP’s fax number in your medical history, your consult history will not be sent. You will have the ability to opt-out of Teladoc faxing your consult history to your PCP during the request a visit process.
8. For California members enrolled through Medi-Cal: You have the right to access Medi-Cal covered services through an in-person, face-to-face visit instead of through telehealth. Medi-Cal provides coverage for transportation services to in-person services when other resources have been reasonably exhausted.
9. Applicable only to Florida residents receiving care for weight loss.
   
   1. By providing consent, I acknowledge that weight loss treatments carry potential risks and benefits, which I will discuss with my provider.
   
   2. Florida Weight Loss Bill of Rights:
   Warning: Rapid weight loss may cause serious health problems. Rapid weight loss is weight loss of more than 1½ 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. Consult your personal physician before starting any weight-loss program. Only permanent lifestyle changes, such as making healthful food choices and increasing physical activity, promote long-term weight loss. Qualifications of this provider are available upon request.
   
   You have a 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.

Consent on behalf of Minors: If you are a parent or legal guardian consenting on behalf of a minor (under the age of 18), you acknowledge and agree to the following:

1. By providing consent, you confirm that you have the legal authority to consent to the use of Teladoc’s Telemedicine Services on behalf of the minor.
2. You are responsible for providing complete and accurate medical history for the minor and ensuring that their medical records are updated periodically, but no less than once a year.
3. You agree to be present during the telemedicine session if required, to assist the minor in understanding the nature of the consultation and to facilitate communication with the Teladoc Clinician.
4. You understand that the Teladoc Clinician will base their treatment decisions on the information provided and will communicate directly with you regarding the minor’s care.
5. As the legal guardian or parent, you have the right to withdraw consent for the minor at any time by ending the session. This will not affect the minor’s right to future services.

By consenting to the use of Teladoc’s Telemedicine Services for the minor, you agree to these terms and understand that the provisions of this consent apply to both you and the minor under your care.

Your use of this Service is voluntary and you have the right to withdraw your consent to the Services at any time by ending this session. If you choose to end your session, your right to future Services will not be affected. Do you understand the statements above and do you consent, on your own behalf or on behalf of your minor dependents, to receive Services by a Teladoc Clinician?