TELEHEALTH INFORMED CONSENT

INFORMED CONSENT TO TELEHEALTH SERVICES

By accepting this Informed Consent, you (“Patient,” “I,” or “you”) consent to receive medical services from the affiliated physician-owned professional medical entity licensed in your state — including Black Forest Medical, P.A. and, for patients in Florida, Black Forest MD of Florida, PLLC (each, the “Practice”) — via telehealth technologies operated on the Practice’s behalf by Black Forest Management Services LLC (“BFMS”), a HIPAA Business Associate of the Practice.

Please read this Consent carefully. Ask any questions you have before accepting.

1. WHAT IS TELEHEALTH?

Telehealth involves the use of audio, video, and other electronic communications technology to deliver medical care between a patient and a clinician who are not in the same physical location. In this Practice, telehealth includes:

• Asynchronous intake evaluation — your initial health questionnaire and any uploaded documentation are reviewed by a licensed clinician, who decides whether to approve, request more information, escalate to video, or decline treatment.
• Asynchronous messaging — secure written communications for ongoing care and follow-up.
• Synchronous video consultations — live video calls with your clinician where the clinician determines a video visit is clinically appropriate.
• Synchronous audio consultations — live phone calls where appropriate.
• Electronic transmission of medical records, prescriptions, and lab orders.

How your first visit works

Your initial encounter with the Practice will generally be conducted asynchronously: you complete a comprehensive health questionnaire and submit any required documentation, and a licensed clinician reviews your submission and either (a) approves a treatment plan, (b) requests additional information, (c) escalates you to a synchronous video visit if clinically appropriate, or (d) declines treatment if not appropriate.

Where permitted by the law of your state — including Florida under the Florida Telehealth Practice Act (Fla. Stat. § 456.47) — asynchronous evaluation is permitted provided the clinician’s evaluation meets the same standard of care as an in-person visit.

2. WHO PROVIDES YOUR CARE

Your clinician is a physician (or, where permitted, a nurse practitioner or physician assistant) licensed in the state where you are located at the time of your visit, practicing through the Practice. Your clinician retains full, independent professional judgment over your care. Neither BFMS nor any non-clinician affiliate directs, influences, or determines any clinical decision.

The technology platform used to deliver your care — the patient portal, secure messaging, video infrastructure, scheduling, identity verification, and patient support — is operated by BFMS on the Practice’s behalf as a HIPAA Business Associate, subject to a written Business Associate Agreement.

3. CLINICIAN IDENTIFICATION

At each telehealth encounter, your clinician will identify themselves by:

• Full name
• Professional designation (MD, DO, NP, or PA)
• State medical license number, on request

You may verify your clinician’s license at any time through your state medical board’s public lookup (for Florida, www.flhealthsource.gov).

4. BENEFITS OF TELEHEALTH

Telehealth may offer benefits including:

• Greater convenience and access to care
• Reduced travel time and expense
• Reduced exposure to in-office illness
• Easier follow-up communication
• Access to specialized care that may not be locally available

5. LIMITATIONS AND RISKS OF TELEHEALTH

5.1 Inability to Perform Physical Examination

Your clinician cannot perform an in-person physical examination. This may limit the clinician’s ability to fully assess your condition. The clinician may decide that telehealth is not appropriate for your particular concern and recommend in-person evaluation.

5.2 Technical Risks and What Happens If Technology Fails

• Connection issues may interrupt or delay visits
• Audio or video quality may be insufficient at times
• Equipment failure may prevent or limit communication
• Electronic data transmission carries inherent (though low) risks of interception, despite security safeguards

If a synchronous video or audio encounter is interrupted by a technology failure, your clinician will attempt to reconnect, switch to phone or secure messaging, or reschedule the visit. No prescribing decision will be made on an incomplete encounter.

5.3 Diagnostic Limitations

Some conditions cannot be safely diagnosed or treated via telehealth alone. If your clinician determines you need in-person care, you will be advised to seek it, and the Practice will assist with continuity by providing a referral to an appropriate in-person provider where required by law.

5.4 Limitations of Compounded Medications

Medications prescribed through the Service are compounded medications, prepared by a licensed compounding pharmacy on a patient-specific basis, and are not FDA-approved. The risks of compounded medications are described in the separately executed Compounded Medication Acknowledgment, which you will also sign as part of your intake.

5.5 Emergency Limitations

Telehealth is not appropriate for medical emergencies. If you experience an emergency, call 911 or go to the nearest emergency room.

6. WHEN TELEHEALTH IS NOT APPROPRIATE

You should NOT use telehealth (and should seek in-person care or emergency services) for:

• Chest pain, difficulty breathing, sudden severe headache, or signs of stroke
• Severe abdominal pain
• Suspected fracture or significant trauma
• Suicidal thoughts or psychiatric emergency
• Loss of consciousness
• Severe allergic reactions
• Severe bleeding
• Any condition you believe is a medical emergency

7. YOUR DUTY TO PROVIDE ACCURATE INFORMATION AND VERIFY YOUR IDENTITY

The safety of telehealth depends substantially on the accuracy and completeness of the information you provide. You acknowledge and agree that:

• You will provide accurate, complete, and current information about your medical history, medications, allergies, symptoms, and treatment goals.
• You will update that information whenever it changes.
• You will verify your identity through the Practice’s identity-verification process at intake and again at any later point the clinician requests verification. You authorize the Practice and BFMS to collect, process, and verify your government-issued photo identification, selfie image (where required), date of birth, and address.
• You will confirm your physical location (the state you are in) at the time of each encounter. Misrepresenting your physical location is a violation of this Consent and is grounds for the clinician to decline to prescribe and to terminate your account.

The Practice and your clinician are not liable for adverse outcomes resulting from undisclosed, inaccurate, or out-of-date health or identity information that you provided.

8. PRIVACY AND CONFIDENTIALITY

Your telehealth encounters are subject to the same confidentiality protections as in-person visits, under HIPAA, applicable state law, and the Practice’s privacy policies. See:

• HIPAA Notice of Privacy Practices — describes how the Practice uses and discloses your Protected Health Information (“PHI”) and your rights under HIPAA and applicable state law.
• Privacy Policy — describes the broader information practices of the Site.

8.1 No Recording Without All-Party Consent

Many states — including Florida (Fla. Stat. § 934.03) — require the consent of all parties to record a communication. Regardless of your state, neither you nor your clinician may record (audio or video) a telehealth encounter without the other party’s express written consent. The Practice does not record visits in the ordinary course. If recording is contemplated for clinical or quality-assurance reasons, you will be informed in advance and asked for separate written consent.

8.2 Notes Are Part of Your Record

Your clinician may take written notes during the visit; those notes become part of your medical record and are stored in the Practice’s electronic health record system (Canvas Medical) under a Business Associate Agreement.

8.3 Privacy on Your End

You are responsible for taking your telehealth encounter in a private location where household members, coworkers, or others cannot overhear or view your screen. If your environment is not private and your clinician is concerned about confidentiality, the encounter may be rescheduled.

8.4 Medical Record Retention

Records are retained per the requirements of HIPAA and Fla. Stat. § 456.057 — generally a minimum of five years from the last patient encounter for adult patients, longer for minors. The full retention policy is set out in the HIPAA Notice of Privacy Practices.

9. USE OF AI AND AUTOMATED TOOLS

The Practice and BFMS may use artificial intelligence and machine-learning technologies (“AI”) to improve customer support and the efficiency of clinical workflows — for example, to help draft replies that a licensed clinician then reviews, to triage non-clinical support tickets, or to summarize information for your care team.

No AI tool makes clinical decisions. All clinical messages, prescriptions, and treatment decisions are reviewed and approved by a licensed clinician, who remains fully responsible for your care.

You will be informed when you are directly interacting with an AI-supported chatbot, agent, or similar automated communication channel.

10. RIGHT TO REFUSE OR WITHDRAW

You have the right to:

• Refuse telehealth services without affecting your right to seek care elsewhere
• Withdraw consent to telehealth at any time, by notifying the Practice at [email protected] (withdrawal does not affect treatment already provided)
• Terminate any encounter at any time, with no further obligation to continue
• Request an in-person provider — the Practice does not offer in-person care, but will provide a referral to an in-person provider where clinically appropriate

11. ALTERNATIVE OPTIONS

You may also receive care through:

• In-person consultation with your primary care physician
• Hospital emergency departments (for emergencies)
• Urgent care centers
• Other telehealth providers

12. PRESCRIPTION POLICY

• Your clinician will only prescribe medications they believe are medically appropriate based on your individualized evaluation
• Not all conditions or requests result in a prescription; the clinician’s professional judgment is final
• Compounded medications prescribed will be filled by a licensed compounding pharmacy designated by the Practice that holds the permits required for your state, or by another pharmacy of your choice where clinically appropriate
• The Practice does not prescribe controlled substances through the Service. Specific state-law restrictions on telehealth controlled-substance prescribing (including Fla. Stat. § 456.44) are not addressed in this Consent because they do not apply to the care you will receive.

13. STATE-SPECIFIC PROVISIONS

The provisions in this Section 13 apply to patients located in the listed state at the time of the encounter. States not individually listed do not require consent language beyond the General Provision below; where your state imposes additional telehealth requirements, your clinician will comply with them.

General Provision — All States

Regardless of the state in which you are located:

• Your consent to telehealth is obtained and documented in accordance with the law of the state where you are located at the time of the encounter
• Your clinician holds an active license (or authorization under an applicable licensure compact or telehealth registration) in that state, and care is delivered at the same standard of care that applies to in-person medical care in that state
• You may withdraw consent to telehealth at any time and seek in-person care instead, without affecting your right to future care
• Where your state requires a synchronous (live video or audio) visit before a prescription may be issued, your evaluation will include one
• Where your state requires additional state-specific disclosures or consents, they will be presented to you during intake or before treatment
• You have the right to access your medical records in accordance with your state’s law and HIPAA

California

Care provided to patients located in California is delivered in accordance with California’s telehealth law (Cal. Bus. & Prof. Code § 2290.5). Your consent to the use of telehealth is obtained before services are provided and documented in your medical record. NOTICE TO CONSUMERS: Medical doctors are licensed and regulated by the Medical Board of California (www.mbc.ca.gov).

Texas

Care provided to patients located in Texas is delivered as telemedicine in accordance with Texas Occupations Code Chapter 111 and the rules of the Texas Medical Board. As required by Texas law, you are notified that complaints about physicians may be directed to the Texas Medical Board, www.tmb.state.tx.us, 1-800-201-9353. Your clinician will follow Texas requirements for establishing a practitioner-patient relationship via telemedicine before prescribing.

Arizona

For patients located in Arizona, your oral or written consent to telehealth is obtained and documented before services are provided, as required by Arizona law (A.R.S. § 36-3602).

Nebraska

For patients located in Nebraska, this document serves as the written consent statement required by the Nebraska Telehealth Act. You acknowledge receiving it before receiving telehealth services.

New Jersey

Care provided to patients located in New Jersey is delivered in accordance with New Jersey’s telemedicine and telehealth law (N.J.S.A. 45:1-61 et seq.), by a clinician authorized to practice in New Jersey, at the same standard of care applicable to in-person services.

Vermont

For patients located in Vermont, your informed consent to telehealth is obtained and documented in accordance with 18 V.S.A. § 9361 before services are delivered.

Florida (Fla. Stat. § 456.47)

13.1 Compliance with the Florida Telehealth Practice Act

Your care is provided pursuant to the Florida Telehealth Practice Act (Fla. Stat. § 456.47). The Practice and your clinician affirm that:

• Your clinician will conduct a patient evaluation sufficient to diagnose and treat you, at the same standard of care as would apply in an in-person encounter
• Your clinician will document the evaluation, your medical history, and the basis for any treatment decision in your medical record
• Your clinician will verify your identity and physical location at the time of the encounter
• Your clinician will maintain professional responsibility for your care, including any prescribed compounded medication
• Your clinician will have the ability to refer you for in-person care when clinically necessary

13.2 Provider Identification

Your treating clinician is licensed by the Florida Board of Medicine or the Florida Board of Osteopathic Medicine (as applicable). License verification is available at www.flhealthsource.gov.

13.3 Asynchronous Evaluation Acceptable in Florida

Florida law permits a telehealth encounter to be conducted via asynchronous (non-real-time) means, including via a comprehensive health questionnaire reviewed by a licensed clinician, provided that the clinician’s evaluation meets the standard of care described above. Your initial encounter with the Practice will generally be conducted asynchronously. The clinician may escalate to a synchronous video visit if the clinician determines, in clinical judgment, that a synchronous evaluation is necessary.

13.4 Florida Medical Records Access

Pursuant to Fla. Stat. § 456.057, you have the right to obtain a copy of your medical records upon written request. The Practice will provide records within a reasonable time and may charge a reasonable cost-based fee for copying.

13.5 Florida Pharmacy

Your prescription will be filled by a Florida-licensed compounding pharmacy that holds the appropriate state and (where applicable) federal registrations under Fla. Stat. Ch. 465.

14. NO GUARANTEE OF OUTCOME

No specific medical outcome or result can be guaranteed. Your clinician will provide care to the applicable standard of medical practice. Individual results vary.

15. CONTINUITY OF CARE AND TRANSFER BETWEEN AFFILIATES

If your state of residence or physical location changes, and the Practice does not serve your new state, your care through the Service may need to be transferred or terminated. You consent to the transfer of your medical record between the Practice and any state-affiliated medical entity associated with Black Forest MD, as necessary to continue your care.

If the Service is terminated by the Practice (for any reason other than your own request), the Practice will provide a reasonable transition period and appropriate referrals consistent with Florida’s standards on patient abandonment under the Board of Medicine rules.

16. LANGUAGES AND ACCESSIBILITY

This Consent is available in English. Upon request, the Practice will provide a Spanish-language version and, where reasonably available, other languages. Patients with limited English proficiency or with disabilities affecting reading, vision, or comprehension may request language assistance services or reasonable accommodation at no cost by emailing [email protected].

17. RELATIONSHIP TO OTHER DOCUMENTS

This Consent is intended to be read together with, and is supplemented by:

• Terms of Service — the contractual terms governing your use of the platform
• Privacy Policy — the information practices of the Site
• HIPAA Notice of Privacy Practices — your HIPAA rights and how the Practice uses your PHI
• Compounded Medication Acknowledgment — risks and acknowledgments specific to compounded medications

If a conflict arises between this Consent and any of those documents on a matter of clinical consent specifically, this Consent governs.

18. ACKNOWLEDGMENT AND CONSENT

By accepting this Consent (by electronic signature, or click-through acceptance), you acknowledge that:

• You have read and understood this Informed Consent
• You have had the opportunity to ask questions
• You understand the benefits, limitations, and risks of telehealth
• You understand that telehealth is not appropriate for emergencies
• You consent to receive medical care via telehealth from a Florida-licensed clinician of the Practice
• You consent to the use of the BFMS-operated technology platform to deliver that care, including secure messaging, video, scheduling, and electronic record-keeping under a HIPAA Business Associate Agreement
• You consent to identity verification by the Practice and its vendors, including review of government-issued photo identification and a selfie image where required
• You represent and warrant that you are physically located in Florida at the time of each encounter, and you will update your physical location promptly if it changes
• You consent to the electronic transmission, storage, and use of your medical information as described in the Privacy Policy and HIPAA Notice of Privacy Practices
• You consent to the use of AI-supported tools in non-clinical support workflows and clinician-reviewed drafting, as described in Section 9
• You acknowledge that neither you nor your clinician may record any encounter without the other party’s express written consent (Section 8.1)
• You are at least 18 years of age
• You will provide accurate and complete health information and update it as it changes