Consent to Telehealth, Artificial Intelligence Usage and Remote Monitoring

1. For the purposes of this document, telehealth is defined as the electronic communications technologies used by Convenient Care Solutions and its providers and staff (collectively, the Practice), to enable them to obtain information and communicate remotely while providing me, the patient, with patient care through the Practice’s telehealth framework which utilizes artificial intelligence (AI) with respect to certain aspects of the intake, documentation and otherwise within the platform, which is then reviewed by a provider at a later point in time. I understand, accept and consent to the telehealth platform, the use of AI and further consent to the remote monitoring on this platform. I understand that the same standard of care applies to medical treatment obtained through telehealth communications as applies to an in-person visit. The information obtained through telehealth communications may be used for diagnosis, treatment, follow-up and/or education and may include any of the following:

• Patient medical records
• Medical images
• Live two-way audio and/or video and data communications
• Output data from medical devices and sound and video files
• Questionnaires, email, and text messaging

2. The electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption. The security of these platforms and outside third parties cannot be guaranteed. You are assuming the risks associated with these systems, platforms and networks by electing to use these electronic platforms.

3. I, the patient, understand, acknowledge and consent to the following:

(a) Telehealth involves the communication of my health information in an electronic or technology-assisted format;

(b) All electronic medical communications carry some level of risk;

(c) Despite reasonable security efforts, it is possible for electronic communication to be forwarded, intercepted, and/or changed without my knowledge;

(d) Electronic systems that are accessed by employers, friends, and/or others are not secure and should be avoided;

(e) It is important for me to use a secure network and to communicate through the platform’s secure communication methods, and I acknowledge and agree that my use of texting, email and/or other communications outside of the secure platform of the Practice are not secure communication methods and have increased risk of hacking and intercepting of my personal health and other information;

(f) Despite reasonable efforts on the part of the Practice, the transmission of medical information could be disrupted or distorted by technical failures;

(g) I may opt-out of the telehealth visit at any time;

(h) The Practice will maintain information exchanged during my telehealth visit as part of my medical record;

(i) The Practice is not responsible for breaches of confidentiality caused by an independent third party, hacking or by myself;

(j) I must verify my identity and current location to my provider and failure to do so may terminate the telehealth visit;

(k) I must not and agree not to use electronic communication, email or text messages or any telehealth or remote platform or any electronic communication with the Practice or its providers in any emergencies or time-sensitive matters, in which case I will always call 911;

(l) Electronic communication may be used to communicate highly sensitive medical information, such as treatment for or information related to HIV/AIDS, sexually transmitted diseases, or addiction treatment (alcohol, drug dependence, etc.);

(m) A medical evaluation via telehealth may limit the Practice’s and my provider’s ability to fully diagnose a condition or disease, and as the patient, I agree to accept responsibility for following my provider’s recommendations - including further diagnostic testing, such as lab testing, a biopsy, or an in-office visit;

(n) There is never a warranty or guarantee as to a particular result or outcome related to a condition or diagnosis when medical care is provided.

4. Risks of Telehealth, AI and Remote Monitoring

As with any technology used in medical care, there are potential risks associated with the use of telehealth, remote monitoring and with AI assisted telehealth delivery and documentation. These risks include, but may not be limited to:

(a) Information transmitted may not be sufficient to allow for appropriate medical decision making by the provider;

(b) We may not be able to provide medical treatment for your particular condition remotely; regulatory and other requirements may limit our ability to provide certain treatment options, including certain prescriptions;

(c) Delays in medical evaluation and treatment could occur due to deficiencies or failures in technology equipment and accompany remote intake of patient data;

(d) Security protocols could fail, resulting in privacy breaches of personal medical information and/or other personal and/or financial information.

(e) Use of AI assisted technology to assist with clinical documentation during a telehealth visit and the generation of SOAP notes (which is an automatically generated Subjective Objective Assessment Plan summary of a patient encounter and is used for AI assisted medical documentation where the AI records the encounter via microphone, telehealth stream or ambient device and converts the conversation or interaction to text to include certain data in a medical note, which integrates into the Practice’s electronic health record, or EHR) includes many risks, including but not limited to that any documentation will be reviewed and edited (if needed) at a later time and require review by a licensed provider before it can be relied upon and I understand, consent to and accept the risks of this type of AI-assisted documentation and care on the Practice’s platform, including but not limited to any inaccuracies, omissions, misinterpretations, biases, hallucinations, fabrications, missing or misplaced data, overgeneralizations, misaligned assessments, incomplete data, inconsistencies, missed contexts, training data biases, lack of human review in real time, non-standardized notes without validation, repetitive errors, potential privacy, regulatory and security risks associated with the transmission and storage of health information, technical failures (such as internet connectivity, software errors, etc.) that could delay or disrupt documentation, inaccuracies and deficiencies in communications and images, and failure of AI assisted documentation to capture nuances of my condition, history and/or preferences, and I fully understand that clinical judgment and decision-making must come from the provider after review and certification of such AI assisted notes.

(f) The Practice and Provider is providing telehealth services through the use of remote monitoring devices for the purpose of data acquisition, patient communication, confirmation of expected therapeutic results, confirmation of stability, and assessing changes in previously diagnosed chronic conditions, provided that, you, the patient, or, if applicable, your legal representative, gives consent to this use and accept the risks associated with this use, and you understand and consent to the various risks described herein to such remote monitoring.