Consent to Telehealth

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) contactyour 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 Beluga Health, P.A. for your telehealth needs. This document is intendedto inform you of what you can expect of your clinician in terms of his or her credentials and in connectionwith your treatment via telehealth. After you have carefully read this document and had an opportunity tohave your questions answered, certain state laws mandate that you must sign and date it beforecommencing services.

YOUR TELEHEALTH PROVIDER’S CREDENTIALS.

Your provider’s credentials were madeavailable to you before scheduling an appointment. If you have any questions about these credentials,please direct them to your telehealth provider. For those states that require it, you can find an explanationof the levels of regulation applicable to clinicians under the STATE REGULATIONS section of thisdocument.

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

Beluga Health and its affiliatedmedical practices offer treatment by various types of healthcare providers, including physicians andequivalent licensed professionals, via telecommunications technology (also referred to as “telehealth”).Beluga’s telehealth services include care provided via asynchronous and synchronous telehealth modalities.Asynchronous telehealth is one way to deliver telehealth.

Asynchronous communication is often referred toas “store-and-forward” communication, where participants submit and collect data at different times. Anexample of asynchronous communication is a telehealth encounter with a healthcare practitioner thatinvolves sending photos, video, or other communications via email or text message.“Asynchronous” means“not occurring at the same time” and is different from “synchronous” telehealth which generally includesvisits conducted in real-time between patients and healthcare practitioners through audio or video means(e.g., live phone calls or video-conferencing). Healthcare practitioners may use asynchronous telehealth toaid in diagnoses and medical consultations when live communication or face-to-face contact is not possibleor necessary.

Beluga’s platform (“Platform”), in particular, allows for the following asynchronous telehealth services: 1)text-based healthcare practitioner-patient interactions through short message service (“SMS”) andmultimedia messaging service (“MMS”) communications; and 2) secure information collection throughasynchronous store-and-forward patient questionnaires.

The services provided may also include chart review, remote prescribing, appointment scheduling, refillreminders, health information sharing, non-clinical services, such as patient education and other electronictransmission for the purpose of rendering care to you. The electronic communication systems we use willincorporate network and software security protocols to protect the confidentiality of patient identification andimaging data and will include measures to safeguard the data and to ensure its integrity against intentional orunintentional corruption. There are various benefits associated with telehealth services, including improvedaccess to care by enabling you to remain in your home while the provider consults with you, more efficientcare evaluation and management, and obtaining expertise of a specialist as appropriate. Possible risks includedelays in evaluation and treatment could occur due to deficiencies or failures of the equipment andtechnologies, and in rare events, our provider may determine that the transmitted information is of inadequatequality, thus necessitating a rescheduled telehealth consult or a meeting with your local primary care doctor.

At times, your clinician may seek supervision or consultation with other Beluga Health or non-Beluga Healthclinicians regarding your treatment, to enhance the services being provided to you given the multipleperspectives, experiences, and treatment philosophies. All team members are ethically and legally bound tomaintain your privacy and confidentiality in this scenario and none of your personal information will beshared or disclosed with any other individual without your consent. Exceptions to confidentiality do exist incertain situations, such as: threat of serious harm to self or others; reasonable suspicion of abuse or neglect ofa child, or abuse, neglect, or exploitation of an incapacitated or dependent adult; court order and/orsubpoena; 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 collectpayments; information released as outlined in the Beluga Health’s Notice of Privacy Practices and PrivacyPolicy; and as otherwise required by law.

By consenting to the telehealth services, You confirm that You have read and agreed to the termsoutlined in the Notice of Privacy Practices and the Privacy Policy. You understand how your personaland health information will be collected, used, and protected in accordance with applicable laws.

By consenting to this Informed Consent, You acknowledge that You understand and agree with thefollowing:
1. You hereby consent to receiving Beluga Health’s services via telehealth technologies. Youunderstand that the Telehealth Provider and its providers offer telehealth-based medical services, butthat these services do not replace the relationship between your and your primary care doctor. Ourclinicians are an addition to, and not a replacement for, your local primary care provider.Responsibility for your overall medical care should remain with your local primary care provider, ifyou have one, and we strongly encourage you to locate one if you do not. You also understand it isup to the Beluga Health provider to determine whether or not your specific clinical needs areappropriate for a telehealth encounter.

2. You understand that if you need to receive non-emergent follow-up care related to your treatment,please contact your clinician by sending a message via the modality in which the conversation wasinitiated (e.g., in the app chat or via SMS).You understand that federal and state law requires health care providers to protect the privacy andthe security of health information. You understand that Beluga Health will take steps to make sure

3. that your health information is not seen by anyone who should not see it. You understand thattelehealth may involve electronic communication of your personal medical information to otherhealth practitioners who may be located in other areas, including out of state.

4. You expressly consent to allow Beluga or its healthcare practitioners to call, email, or text you (viaSMS and/or MMS) with or regarding Personal Data (as defined in the Beluga Privacy Policy),appointments, or similar matters related to your telehealth encounter using the contact informationyou have provided. Any calls or texts to you may be placed using an auto-dialer or a pre-recorded orartificial voice, even if your number is on a do-not-call list. Your phone carrier’s normal rates mayapply. This is consent, not a condition of purchase. You may revoke this consent at any time byemailing us at admin@belugahealth.com.

5. You understand there is a risk of technical failures during the telehealth encounter beyond thecontrol of Beluga Health. You agree to hold harmless the Beluga Health for delays in evaluation orfor information lost due to such technical failures.

6. You understand that you may be asked to provide identification and confirm your physical locationprior to or during the telehealth visit.

7. You understand that you have the right to withhold or withdraw your consent to the use of telehealthin the course of your care at any time, without affecting your right to future care or treatment. Youunderstand that you may suspend or terminate use of the telehealth services at any time for anyreason or for no reason. You understand that if you are experiencing a medical emergency, that youwill be directed to dial 9-1-1 immediately and that the Beluga Health providers are not able toconnect you directly to any local emergency services. You may request to delete your patient profileat any time by emailing admin@belugahealth.com.

8. You understand that alternatives to telehealth consultation, such as in-person services are availableto you, and in choosing to participate in a telehealth consultation, you understand that some parts ofthe services involving tests may be conducted by individuals at your location, or at a testing facility,at the direction of the Beluga Health provider (e.g., labs or bloodwork). You understand that BelugaHealth does not have any in-person clinic locations.

9. 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.

10. Because Beluga Health does not have access to your complete medical records, if you do notdisclose to your telehealthcare practitioner a full list of your medical history including diagnoses,treatments, medications/supplements, and allergies, adverse treatment, drug interactions or allergicreactions, or other negative outcomes may occur.

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

12. You understand that you will not be prescribed any narcotics.

13. You understand that there is no guarantee that You will be issued a prescription and that the decisionof whether a prescription is appropriate will be made in the professional judgement of the BelugaHealth Provider.

14. You understand that there is no guarantee that You will be treated by the Beluga Health Provider.Beluga Health's Provider reserves the right to deny care for potential misuse of the Services or forany other reason if, in the professional judgment of the Provider, the provision of the Services is notmedically or ethically appropriate.

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

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

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STATE REGULATIONS:

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

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

Colorado: You are informed that if you want to register a formal complaint about a provider, you should file at https://dpo.colorado.gov/FileComplaint.

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(D.C. Mun. Regs. tit. 17, § 4618.10).

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)).

Iowa: To file a complaint, fill in the form below or fill out the complaint form and email it to the medical board at ibmcomplaints@iowa.gov.

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. Code653-13.11(147,148,272C)(13.11(11))

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: File a Complaint | Division of Occupational and Professional Licensesmatters.

Illinois: You have been informed that if you want to register a formal complaint about a provider, you should visit the Illinois Division of Professional Regulation at Division of Professional Regulation File a Complaint

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 practitionerh as 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.If you are a Medicaid patient, you have the right to choose between an in-person visit or telehealth visit.Indiana Medicaid Manual: Telehealth and Virtual Services.

Kansas: You understand that if you have a primary care provider or other treating physician, the personproviding telemedicine services must send within three business days a report to such primary care or othertreating 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, youshould visit the medical board’s website, here: https://kbml.ky.gov/board/Pages/default.aspx.Information related to filing grievances may be found herehttps://kbml.ky.gov/grievances/Documents/Consumer%20Guide%20and%20Grievance%20Form.pdfIf requested by you, your physician must share the medical record with your primary care physician andother relevant members of your existing care team. Kentucky Board Opinion on the Use of TelemedicineTechnologies (2014), as amended September 15, 2022.

Louisiana: You understand the role of other health care providers that may be present during the consultationother 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 shouldvisit the medical board’s website, here: File a Complaint | Maine Board of Licensure in Medicine

Nebraska: If you are a Medicaid recipient, you retain the option to refuse the telehealth consultation at anytime without affecting your right to future care or treatment and without risking the loss or withdrawal ofany program benefits to which the patient would otherwise be entitled. All existing confidentialityprotections shall apply to the telehealth consultation. You shall have access to all medical informationresulting from the telehealth consultation as provided by law for access to your medical records.Dissemination of any patient identifiable images or information from the telehealth consultation toresearchers or other entities shall not occur without your written consent. You understand that you have theright to request an in-person consult immediately after the telehealth consult and you will be informed ifsuch consult is not available. (Neb. Rev. Stat. Ann. § 71-8505; 471 Neb. Admin. Code § 1-006.05). You have been informed that if you want to register a formal complaint about a provider, you should visit:https://dhhs.ne.gov/Pages/Complaints.aspx

New Hampshire: You understand that the telehealth provider may forward your medical records to yourprimary 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 youunderstand your medical information may be forwarded directly to your primary care provider or health careprovider of record, or upon your request, to other health care providers. If you do not have a primary careprovider or other health care provider of record, the health care provider engaging in telemedicine ortelehealth may advise you to contact a primary care provider, and, upon request by you, may assist you withlocating a primary care provider or other in-person medical assistance that, to the extent possible, locatedwithin reasonable proximity to you. N.J. Rev. Stat. Ann. § 45:1-62.

Ohio: You understand that the telehealth provider may forward your medical records to your primary care ortreating 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 aboard agency to assist you. You understand that the provider may ask if you need more detail. ORS17-52-677.07. See also Or. Medical Board, Statement of Philosophy: Telemedicine (Oct 2, 2020)
Complaints may be filed with:Oregon Medical Board1500 SW 1st Ave., Suite 620Portland, OR 97201-5847Complaint 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 youunderstand the types of transmissions that will be permitted and the circumstances when alternate forms ofcommunication or office visits should be utilized. You have also discussed security measures, such asencryption of data, password protected screen savers and data files, or utilization of other reliableauthentication techniques, as well as potential risks to privacy. You acknowledge that your failure to complywith this agreement may result in the telehealth provider terminating the relationship. (Rhode IslandMedical Board Guidelines).

South Carolina: You understand your medical records may be distributed in accordance with applicable lawand regulation to other treating health care practitioners. You understand the value of having a primary caremedical home and, if requested, we can provide assistance in identifying available options for a primary caremedical home. S.C. Code Ann. § 40-47-37.You also understand that if you are a Medicaid beneficiary, you can withdraw your consent at any time.
South Carolina Health and Human Svcs. Dept. Physicians Provider Manual, p. 35 (Feb. 2024).

South Dakota: You have received disclosures regarding the delivery models and treatment methods orlimitations. You have discussed with the telehealth provider the diagnosis and its evidentiary basis, and therisks and benefits of various treatment options. (S.D. Codified Laws § 34-52-3).

Tennessee: You understand that you may request an in-person assessment before receiving a telehealthassessment if you are a Medicaid recipient. TN Dept. of Mental Health and Substance Abuse Services.Office of Crisis Services Telecommunications Guidelines, p. 8, (2012) (Accessed Jan. 2024).

Texas: You understand that your medical records may be sent to your primary care physician. (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 andregistrants of the Texas Medical Board, including physician assistants, acupuncturists, and surgical assistantsmay 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 infiling a complaint is available by calling the following telephone number: 1-800-201-9353, For moreinformation, please visit our website at www.tmb.state.tx.us.

A VISO SOBRE LAS QUEJAS- Las quejas sobre médicos, asi como sobre otros profesionales acreditados einscritos 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 MedicalBoard, 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 másinformación, 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 healthinformation; (ii) contact your provider for subsequent care; (iii) obtain upon request an electronic or hardcopy of your medical record documenting the telemedicine services, including the informed consentprovided; and (iv) request a transfer to another provider of your medical record documenting thetelemedicine services. Utah Admin. Code r. 156-1-602.

Virginia: You acknowledge that you have received details on security measures taken with the use oftelemedicine services, such as encrypting date of service, password protected screen savers, encrypting datafiles, or utilizing other reliable authentication techniques, as well as potential risks to privacynotwithstanding such measures; You agree to hold harmless the Beluga Health for information lost due totechnical failures; and you provide your express consent to forward patient-identifiable information to a thirdparty. (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 willreceive one upon request immediately or within a reasonable time after the results of the initial consult.You have been informed that if you want to register a formal complaint about a provider, you should visit themedical board’s website, here:http://www.healthvermont.gov/health-professionals-systems/board-medical-practice/file-complaint;

IMPORTANT DISCLAIMER - IF YOU ARE ENROLLED IN GOVERNMENT HEALTH PLANS OR PRIV ATE INSURANCE

By choosing to receive our Asynchronous telehealth professional medical and related services (our “ServicesBy choosing to receive our Asynchronous telehealth professional medical and related services (our”), you acknowledge and agree to the following:

1. Out-of-Pocket Service. You have selected services for purchase from us on a self-pay basis.In other words, you have directed us to treat your purchase of these services as if you are an uninsuredpatient and you agree to be 100% responsible for full payment of the listed price of the services. TheServices are not covered by, and will not be billed to, any federal or state government health insuranceprogram, including but not limited to Medicare, Medicare Advantage, Medicaid, TRICARE, or any similarplan (collectively referred to as “Government Health Plans”).

2. No Reimbursement. Your insurance policy is a contract between you and your insurancecompany. It is your responsibility to know your benefits, and how they will apply to your benefit payments,and we take no responsibility to understand or be bound by the terms and conditions of such insurance. Youunderstand and agree that the Services are not covered by Government Health Plans. You further agree thatyou will not seek reimbursement for the Service from any Government Health Plan, nor will you submit anyclaim for such reimbursement to any Government Health Plan, directly or indirectly. There is no guaranteeyour insurance company will make any payment on the cost of the services you have purchased.

3. Voluntary Agreement. You are voluntarily electing to receive and pay for the Services withfull knowledge that you will be obligated to pay these charges in full as a self-pay patient, electing not to usean insurance policy benefit are not covered benefits under your Government Health Plan, if applicable. You“Servicesare not required or obligated to purchase the Services. You understand that your participation in thistransaction is not a condition of enrollment in or eligibility for any Government Health Plan. You have beengiven a choice of different services, along with their costs. You have selected the services and are willing toaccept full financial responsibility for payment.

4. Confirmation of Understanding. By proceeding with payment for the Services, you confirm that you understand this disclaimer, and that you knowingly and voluntarily agree to these terms.You further acknowledge that: 1) you do not have any health insurance through a PPO, HMO, Medicaid orMedicare or any other insurance plan; or 2) you have health insurance but you do not want to use any insurance benefit for these services, acknowledging that Beluga Health does not accept any health insurance for these services.
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5. If you are a Medicaid Beneficiary - you are not eligible to use our Synchronous visitBy continuing and receiving this service you are acknowledging that you are NOT aservices. Medicaid beneficiary.

6. If you are a Medicare Beneficiary - you are not eligible to use our Synchronous visitservices, unless you sign an ABN and consent that Synchronous telehealth visits are covered byMedicare but are not billed by Beluga Health and you consent to pay for the service out of pocket.For signing an ABN please reach out to our Customer Support at admin@belugahealth.com. Bycontinuing and receiving this service without signing an ABN you are acknowledging that you areNOT a Medicare beneficiary.

If you do not agree to these terms, you should not proceed with the Services or purchase.

You have read this document carefully, and understand the risks and benefits of the telehealthservices and have had your questions regarding the services explained and you hereby give yourinformed consent to participate in a telehealth consultation under the terms described herein.

By using Beluga Health’s Telehealth provider services You hereby state that You have read,understood, and agree to the terms of this Informed Consent

If you have questions regarding this Privacy Policy or our privacy practices, please contact us:

• Email: support@amalfiduo.com

• Address: 8911 N Capital of Texas Hwy suite 4200/1013, Austin, TX 78759