Section 01

Consent to Telehealth

Telehealth is a mode of delivering health care services via communication technologies to facilitate diagnosis, consultation, treatment, education, care management, and self-management of a patient's healthcare. The purpose of this consent form (“Consent”) is to provide you with information about telehealth and to obtain your informed consent to the use of telehealth in the delivery of healthcare services to you by physicians, physician assistants, nurse practitioners, and other licensed clinicians (“Providers”) using the online platform owned and operated by MEANT and/or its affiliates and subsidiaries (the “Service”).

In this Consent, the terms “you” and “yours” refer to the person using the Service. You represent and warrant that you are at least 18 years of age or older.

You are reviewing and acknowledging this Telehealth Consent Form because you are seeking Services from MEANT and its affiliated healthcare entities utilizing telehealth technologies facilitated through the MEANT website, mobile app, or any partner platform or web mobile technologies (collectively, the “Platform”). This Telehealth Consent Form supplements but does not modify or supersede any Terms of Use, Privacy Policy, or Notice of Privacy Practices of MEANT or its healthcare partners.

By clicking “I consent to telehealth” you indicate that you have reviewed this Consent Form or had it explained to you, that you understand the risks and limitations of using telehealth technologies, that you have been given the opportunity to ask questions and that such questions have been answered to your satisfaction, and that you consent to receiving Services from licensed healthcare providers employed by or contracted with MEANT’s partner Medical Groups who are located at sites remote from you.

If you would like to speak to our privacy team, email us at support@meant.health.

Section 02

Treatment-Specific Consent

By clicking “I consent to telehealth”, you understand and agree to the following:

1. I understand that MEANT offers telehealth visits conducted through videoconferencing, telephonic, and asynchronous technology and my Provider will not be present in the room with me.
2. I am consenting to MEANT importing and accessing my medical records and medication list, including prescription records.
3. To protect the confidentiality of my health information, I agree to undertake my telehealth visit in a private location, and I understand that my Provider will similarly be in a private location. If any other individuals are present, I will be informed of their presence and role, and given the opportunity to consent.
4. I understand there are potential risks to the use of telehealth technology, including but not limited to interruptions, delays, unauthorized access, technical difficulties, data processing errors, AI misinterpretation, recording failures, and ambient listening inaccuracies. I understand that either my Provider or I can discontinue the telehealth appointment if technical connections are not adequate. I AGREE TO HOLD HARMLESS MEANT AND ITS HEALTHCARE PARTNERS, TOGETHER WITH THEIR EMPLOYEES, CONTRACTORS, AGENTS, DIRECTORS, MEMBERS, MANAGERS, SHAREHOLDERS, OFFICERS, REPRESENTATIVES, ASSIGNS, PREDECESSORS, AND SUCCESSORS, FOR DELAYS IN EVALUATION OR FOR INFORMATION LOST DUE TO TECHNICAL FAILURES OR FOR ANY ISSUES ARISING FROM THE USE OF AI TECHNOLOGIES, RECORDINGS, OR AMBIENT LISTENING SYSTEMS.
5. I understand that my telehealth visit may involve the use of artificial intelligence (AI) technologies for purposes including but not limited to transcription of conversations, analysis of medical information, clinical decision support, quality assurance, and improvement of telehealth services. AI systems may process, analyze, and store information from my telehealth visit, including my voice, image, and medical information. AI processing may occur in real-time and/or after my visit has concluded. Information processed by AI systems will be protected in accordance with applicable privacy laws and MEANT’s privacy policies. I have the right to request information about what AI technologies are being used during my care.
6. I understand that my Provider may use AI tools to assist with analyzing medical data or records, supporting clinical decision making, generating summaries or documentation, or recommending potential diagnoses or treatment options. AI tools are intended to support, not replace, the professional judgment of my Provider. My Provider will review any AI-assisted outputs before making clinical decisions, and I have the right to ask questions about how AI is used in my care and to request that AI not be used in certain aspects of my treatment, where feasible.
7. I understand that my telehealth visit may be recorded (audio and/or video) for purposes including quality assurance, provider training, clinical documentation, and care coordination. I will be notified at the beginning of any session that is being recorded. Recordings may be retained in accordance with applicable laws and MEANT’s retention policies. I have the right to request access to recordings of my telehealth visits, subject to applicable laws and policies.
8. I understand that ambient listening technologies may be used during my telehealth visit to capture relevant clinical information. These technologies may include third parties contracted by MEANT. I can request that ambient listening be disabled during portions of my visit by notifying my Provider. Information captured through ambient listening will be protected in accordance with applicable privacy laws and MEANT’s policies.
9. I understand that in some cases, my Provider might be a nurse practitioner or a physician assistant and not a physician.
10. I understand that I could seek an in-office visit rather than obtain care through MEANT, and I am choosing to participate in a telehealth visit. I further understand that my Provider may not have access to a complete copy of my medical records and will not be able to perform an in-person examination, which could result in negative health outcomes from the recommended treatment. I understand that while using telehealth technologies may benefit me, no such benefits or specific results are guaranteed, and my condition may not improve.
11. Certain technology, including the Services, may be used while still in a development or beta phase. Technology used to deliver care may contain bugs or errors that could limit functionality, produce erroneous results, or cause records to be corrupted or lost, which could impact the quality, accuracy, or effectiveness of the care you receive.
12. The delivery of healthcare services via telehealth is an evolving field. No potential benefits from the use of telehealth or other technology can be guaranteed. Your condition may not be cured or improved, and in some cases may get worse. There are limitations in the provision of medical care via telehealth and you may not be able to receive diagnosis or treatment through telehealth for every condition.
13. I agree that any information I provide as part of any telehealth visit is accurate, true, and complete.
14. I understand that my Provider may determine that a telehealth visit is not appropriate for me. In such a case: (i) I will receive an alert notifying me that I will be unable to use the Services for the particular issue submitted; (ii) my request will not be submitted to my Provider; (iii) my Provider will not receive any information I submitted; and (iv) I will need to seek care in another way.
15. I understand that participating in a telehealth visit is not a guarantee that I will be given a prescription, and that the decision as to whether a prescription is appropriate will be made in the professional judgment of my Provider.
16. I understand that while the Platform may provide access to certain pharmacy or diagnostic lab services, I may request to use any pharmacy or lab of my preference.
17. I understand that I am responsible for payment of any amounts due and owing resulting from my telehealth visit.
18. I understand that Providers do not address medical emergencies via the Platform. I understand that the responsibility of my Provider may be to direct me to emergency medical services, such as an emergency room.
19. I understand and agree that I give permission to Providers to use and disclose my protected health information including my entire medical record for the purpose of telehealth treatment.

If the person or entity receiving this information is not a health care provider or health plan covered by HIPAA, the information described above may be redisclosed and therefore no longer protected by HIPAA.

I may refuse to agree to this authorization. My refusal will not affect my payment, ability to obtain treatment, or eligibility for health plan benefits.

I may inspect or copy the protected health information to be used or disclosed under this authorization.

I may revoke this authorization in writing at any time by contacting: MEANT at support@meant.health. Revocation will not apply to actions taken prior to receipt of the notice.

Section 03

Additional Treatment-Specific Consent — Compounded Medications

The following consent applies to patients who receive a prescription for compounded medications:

1. I understand that the FDA does not approve nor review compounded products for safety, effectiveness, or quality.
2. I understand that compounding pharmacies must adhere to strict quality control standards. Compounding pharmacies are licensed and subject to state and federal regulations.
3. Clinical information about prescribed medications is available upon request from my Provider or MEANT’s support team.

Section 04

Additional Treatment-Specific Consent — Teletherapy

The following consent applies to patients accessing mental or behavioral health services:

I acknowledge that I may be offered a telehealth consultation related to my mental or behavioral health. Teletherapy has the same purpose as therapy sessions conducted in person, but may be experienced differently due to the nature of the technology used.

I understand that I have the following rights with respect to Teletherapy:

1. I have the right to withhold or withdraw consent for my treatment at any time without affecting my right to future care or treatment.
2. The laws that protect the confidentiality of my medical information also apply to Teletherapy. Information disclosed during a Teletherapy session is generally confidential unless an exception applies (e.g., mandatory reporting of abuse; if my Provider believes I may be a danger to myself or others; or if I raise mental health as an issue in a legal proceeding).
3. I understand that Teletherapy services may not be as complete as face-to-face services. If my Provider believes I would be better served by another form of therapeutic services, I will be referred to an appropriate professional.
4. I understand that I may benefit from Teletherapy, but that results cannot be guaranteed. My condition may not improve, and in some cases may get worse.
5. I accept that Teletherapy is not meant to cover emergency situations. If I am having suicidal thoughts or making plans to harm myself, I can call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255) for free 24-hour hotline support.
6. I understand that dissemination of any personally identifiable images or information from Teletherapy interactions to researchers or other entities shall not occur without my written consent.
7. I understand that my Provider may need to contact my emergency contact and/or appropriate authorities in case of an emergency. I agree to inform my Provider of my location at the beginning of each session and to provide an emergency contact name.

Section 05

Additional Treatment-Specific Consent — HIV Testing

The following consent applies to patients receiving telehealth consultation related to HIV testing:

HIV is the virus that causes AIDS and can be detected via an HIV antibody test. A positive result means you have been exposed to the virus and are infected with HIV. It does not mean that you have AIDS. A negative test means you are unlikely to be infected, though if you have been recently exposed you may need to be retested. Taking an HIV test is entirely voluntary.

This test is not provided on an anonymous basis. Please seek an anonymous test site if you prefer your HIV test information and results to remain anonymous. You can find the nearest anonymous test site by contacting your local health department.

There are federal and state laws that protect the confidentiality of your HIV test results. MEANT may disclose your results as required by law for reporting to appropriate public health authorities.

Section 06

Additional Treatment-Specific Consent — Genetic Testing

The following consent applies to patients receiving telehealth consultation related to genetic testing:

I acknowledge that I may be offered genetic testing as part of the Services. Testing for genetic conditions can be complex and specifics of the test will vary depending on the condition tested for. If offered genetic testing, my Provider will explain the specifics of my particular test, and I will have the opportunity to obtain professional genetic counseling prior to completing the test to fully understand the risks and benefits.

Section 07

Laboratory Products and Services

Certain healthcare services provided via MEANT may require that you complete an at-home diagnostic test. These diagnostic tests are provided by third-party laboratories, and MEANT cannot guarantee the accuracy or reliability of these tests. Laboratory tests can produce false negative, false positive, or inconclusive results that could impact your Provider’s ability to correctly diagnose or treat your medical condition.

Section 08

Authorization to Bill Insurance and Assignment of Benefits

By clicking “I accept”, I confirm that the above information is true, correct, and complete to the best of my knowledge. I authorize MEANT and its affiliated healthcare partners to bill my insurance company directly and further authorize any third-party payer through which I have benefits to make payment directly to the treating Medical Group or Provider. I understand that I am financially responsible for any balance. Services provided by outside companies (i.e., lab, pharmacy) are billed separately by those companies.

Section 09

Consent to Text or Email Usage for Appointment and Healthcare Reminders

By clicking “I accept”, I authorize MEANT to contact me via phone call, SMS/text message, or email at the contact information I have provided, for the purposes of:

• Appointment reminders
• Patient feedback requests
• General health and wellness information
• Care plan and prescription updates

I understand and agree to the following:

• These communications may be generated in part by automated systems or artificial intelligence (AI)
• Standard messaging and data rates may apply
• This authorization will remain in effect for future communications unless I revoke it in writing
• I may opt out of receiving such communications at any time by replying STOP to any SMS, following the opt-out instructions in each message, or by contacting MEANT directly
• Using these communication methods presents a potential security risk of unauthorized access to protected health information (PHI)
• I accept this risk and consent to receiving communications through these methods

If you prefer not to receive appointment reminders or health information via text or email, please notify us in writing or email us at support@meant.health.

Section 10

Additional State-Specific Disclosures

The following disclosures apply to patients accessing Services within the states listed below:

• Alaska: I understand that my primary care provider may obtain a copy of my records of my telehealth encounter.
• California: The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. It can be found at https://openpaymentsdata.cms.gov.
• Connecticut: I understand that my primary care provider may obtain a copy of my records of my telehealth encounter.
• Kansas: I understand that if I have a primary care provider or other treating physician, the person providing telemedicine services must send a report to such provider of the treatment and services rendered within three days of me providing consent.
• New Hampshire: I understand that my primary care provider or treating provider may obtain a copy of my records of my telehealth encounter.
• New Jersey: I understand I have the right to request a copy of my medical information, and I understand my medical information may be forwarded directly to my primary care provider or health care provider of record, or upon my request, to other health care providers.
• Ohio: I understand that my primary care provider may obtain a copy of my records of my telehealth encounter.
• South Carolina: I understand that my medical records may be distributed only with my consent and in accordance with applicable laws and regulations to other treating health care practitioners.
• Texas: I understand that with my consent my medical records may be sent to my primary care physician within 72 hours after receiving Services.

Section 11

Billing Rights

Patients residing in New Jersey, New York, and Rhode Island have the right under each state’s respective billing laws to request an itemized price list for laboratory results.

Section 12

Formal Complaints

If you wish to register a formal complaint about a Provider, please contact the medical board in your state. Below are resources for select states:

• California: Visit the Medical Board of California website
• Georgia: Visit the Georgia Composite Medical Board website
• Idaho: Visit the Idaho State Board of Medicine website
• Indiana: Visit the Indiana Medical Licensing Board website
• Iowa: Visit the Iowa Board of Medicine website
• Kentucky: Visit the Kentucky Board of Medical Licensure website
• Maine: Visit the Maine Board of Licensure in Medicine website
• New York: Visit the NY Office of Professional Medical Conduct website
• Oklahoma: Visit the Oklahoma State Board of Medical Licensure website
• Oregon: Visit the Oregon Medical Board website
• Rhode Island: Visit the Rhode Island Board of Medical Licensure website
• Vermont: Visit the Vermont Board of Medical Practice website
• Wyoming: Visit the Wyoming Board of Medicine website

Texas:

NOTICE CONCERNING COMPLAINTS — Complaints about physicians and other licensees may be reported to: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018. Assistance in filing a complaint is available by calling 1-800-201-9353. For more information, visit www.tmb.state.tx.us.

Section 13

Contact Us

support@meant.health