Telehealth Treatment Consent

1. Who We Are and Our Roles

1. Evergreen provides technology platforms, websites, mobile apps, and administrative support that enable you to receive telehealth services. Evergreen is not a medical group or healthcare provider and does not practice medicine.
2. All professional medical services, including diagnosis, treatment, and prescribing, are provided by the Medical Group and its licensed clinicians (physicians and other licensed professionals), who are independent of Evergreen.
3. For HIPAA purposes, the Medical Group is typically the "Covered Entity," and Evergreen acts as its "Business Associate" under a Business Associate Agreement. Evergreen may also act as a separate entity for certain services as permitted by law.

2. Eligibility and Location

1. Telehealth services are provided only when you are located in a state where the treating clinician is appropriately licensed or otherwise authorized to provide care.
2. You agree to:
   • Accurately disclose your current physical location at the time of each telehealth encounter, and
   • Use the services only in jurisdictions where we indicate that services are available.
3. If we determine we cannot legally provide care to you in your location, you will not receive clinical services and may be directed to in‑person care or other resources.

3. Nature of Telehealth Services

"Telehealth" (or "telemedicine") means that your healthcare services may be provided using electronic communications, information technology, or other means between you and a clinician who is not in the same physical location. This may include:

• Two‑way, real‑time audio and video visits;
• Asynchronous ("store‑and‑forward") technologies, where you submit information, images, and/or videos for later review by a clinician; and
• Secure in‑app messaging and electronic prescribing, as applicable.

Telehealth may be used for evaluation, diagnosis, consultation, treatment, follow‑up, and education as determined appropriate by your clinician.

You understand that:

• Your clinician may not have the same ability to physically examine you as during an in‑person visit.
• Certain clinical assessments may be limited by the quality of the transmitted data (e.g., images, audio, video).

4. Risks, Benefits, and Alternatives

You acknowledge the following:

1. Potential benefits of telehealth may include:
   • Convenience and improved access to care;
   • Ability to obtain care without traveling;
   • Faster follow‑up and communication with your care team.
2. Potential risks and limitations include, but are not limited to:
   • Insufficient information for diagnosis and treatment due to:
     • Poor image resolution, audio quality, or incomplete history;
     • Technical failures or interruptions of the audio/video connection;
   • Unauthorized access to data if security protocols fail, despite our efforts to protect your privacy;
3. Alternatives:
   • You may always choose in‑person care with a local healthcare provider instead of, or in addition to, telehealth services.
   • Your clinician may determine that telehealth is not appropriate for some or all of your care and may recommend in‑person evaluation or a higher level of care.
4. No Guarantee of Treatment or Prescription:
   • You understand that paying membership or consultation fees and completing an assessment does not guarantee that you will receive a particular diagnosis, treatment, or prescription.
   • Clinicians may decline to prescribe or treat if, in their professional judgment, it is not safe, effective, or appropriate.

5. Not for Emergencies

1. You understand that Evergreen and the Medical Group do not provide emergency medical services.
2. If you believe you are experiencing a medical emergency, such as (but not limited to):
   • Chest pain or pressure,
   • Difficulty breathing,
   • Sudden weakness, numbness, or trouble speaking,
   • Severe or worsening pain,
   • Uncontrolled bleeding,
   • Thoughts of harming yourself or others, or
   • Any condition you believe may be life‑threatening,

   you will call 911 immediately or go to the nearest emergency room.

3. You agree not to rely on telehealth services, in‑app messaging, or email/SMS for emergency or urgent situations.

6. Technology, Asynchronous Care, and Response Times

1. Store‑and‑Forward / Asynchronous Care

2. Response Times and Hours of Operation

• Telehealth encounters and in‑app messages are not monitored 24/7.
• We will aim to respond within a commercially reasonable timeframe, but response times may vary.
• You should not rely on the platform for time‑sensitive or emergency issues.

3. Technology or Equipment Failure

• If a telehealth session is interrupted due to technical issues, we may attempt to reconnect or reschedule.
• For technical support or to reschedule due to technology issues, you may contact us at connect@evergreentelehealth.com.
• If you experience a medical concern during a technology failure and cannot reach us, you should seek in‑person care or call 911 for emergencies.

7. Access to and Use of Medical Records

1. After your evaluation is completed and a clinician has rendered a treatment decision, your visit notes, orders, and other records will be made available to you.
2. You can access your records by:
   • Logging into your Evergreen account and clicking on the medical records section; then
   • Downloading or printing your records for your own use or to share with your primary care provider or other clinicians.
3. Submission of an intake form alone does not complete the evaluation; the evaluation is complete when a treating clinician has reviewed your information and rendered a clinical decision.

8. How to Contact Your Provider After the Visit

1. For follow‑up questions or non‑urgent issues after your visit, you may use the secure message icon in your Evergreen app or account to contact your care team.
2. You understand that:
   • In‑app messaging is intended for non‑emergency communication;
   • Response times may vary; and
   • We may request that you schedule a follow‑up telehealth visit or seek in‑person care for certain questions or concerns.
3. You acknowledge that ongoing treatment typically requires regular follow‑up and agree to follow up with:
   • Your Evergreen clinician and/or
   • Your primary care physician within a time frame recommended by your clinician (often within about one month or as clinically indicated).

9. Communication Preferences: In‑App, Email, and Text (SMS)

9.1 In‑App Messaging

• All clinical communications should occur through the in‑app secure messaging system or through scheduled telehealth visits.
• We do not accept or respond to clinical questions by standard email.

9.2 Email

By providing your email address, you authorize Evergreen to send you non‑clinical emails limited to:

1. Status updates on your assessment or appointment;
2. Links or instructions to:
   • Start or join a telehealth visit,
   • Upload documentation, or
   • Request or confirm a follow‑up appointment;
3. Other transactional or account‑related communications.

You understand that:

• Email may not be fully secure or encrypted end‑to‑end;
• We will not include detailed medical diagnoses or treatment instructions in standard email;
• You may opt out of non‑essential email communications by following the unsubscribe instructions in those messages or adjusting your account settings, while still receiving necessary transactional messages.

9.3 Text Messages (SMS)

By providing your mobile number and electing to receive SMS, you consent to receive text messages from Evergreen that may include:

1. Status of your assessment or order;
2. Reminders and links to start a video visit;
3. Prompts to upload documentation; and
4. Follow‑up or appointment request links.

You understand that:

• Message and data rates may apply, depending on your mobile carrier and plan;
• Message frequency may vary based on your use of the services;
• Text messages may not be fully secure, and you should not send sensitive health information by SMS;
• You can opt out of SMS at any time by replying STOP to any text message we send, or by updating your communication preferences in your account.

10. Financial Terms and Responsibility

1. Consultation Fees and Membership
   • Telehealth consultation fees are included in your Evergreen membership or subscription, as described in your membership plan.
   • Your membership fee covers access to the platform and certain telehealth services but does not guarantee that any particular treatment or prescription will be provided.
2. Self‑Pay / Insurance
   • Currently, we do not bill, submit claims to, or otherwise access your health insurance on your behalf.
   • You are solely responsible for all fees associated with your care and membership.
   • If you choose to seek reimbursement from your insurance plan independently, you are responsible for submitting any required documentation and understanding your plan's rules.
3. No Refund Guarantee
   • Fees may be non‑refundable even if a clinician determines that no prescription or specific treatment is appropriate after reviewing your information.
   • Any refund, credit, or adjustment policies will be as described in Evergreen's Terms & Conditions.

11. Privacy, Confidentiality, and Use/Disclosure of Information

HIPAA and Confidentiality

• Your health information will be handled in accordance with applicable privacy and security laws, including HIPAA where applicable.
• All existing confidentiality protections apply to telehealth encounters to the same extent as in‑person care.

Privacy Policies and Notices

• You acknowledge that you have had the opportunity to review:
  • Evergreen's Terms & Conditions; and
  • Evergreen's Privacy Policy.
• You understand that the Medical Group maintains a Notice of Privacy Practices describing how your health information may be used and disclosed and your rights under HIPAA, which will be provided separately and is available upon request.

Use and Disclosure for Treatment, Payment, and Operations

• You authorize Evergreen and the Medical Group to use and disclose your information as reasonably necessary to:
  • Provide, coordinate, and manage your medical care;
  • Communicate with pharmacies, labs, or other providers involved in your treatment;
  • Operate, maintain, and improve the telehealth platform and services; and
  • Comply with applicable laws and regulations.

Authorization for Release of Information (Self‑Pay Context)

• Because we currently do not bill insurance, we will not routinely disclose your information to health plans, employers, or workers' compensation carriers unless:
  • You ask us to and sign a specific authorization, or
  • We are required by law to do so (for example, for public health reporting, mandatory disclosures, or as ordered by a court).

Third Parties and Research/Education

• De‑identified or aggregated information that does not reasonably identify you may be used for quality improvement, analytics, research, and educational purposes.
• Any use of identifiable information for research or other non‑treatment purposes will only occur as permitted by law and, when required, with your separate written consent.

Security Measures

• Medical records are stored in systems designed to comply with applicable security standards.
• Telehealth video sessions are protected using encryption and other security protocols.

12. Consent to Telehealth Treatment

By accepting this Consent, you:

1. Voluntary Participation
   • Voluntarily consent to receive telehealth services from the Medical Group and its clinicians using Evergreen's platform.
   • Understand that you may withdraw this consent at any time by notifying us in writing or through your account settings, which will stop telehealth services on a going‑forward basis but will not affect actions taken before your withdrawal.
2. Understanding of Limitations
   • Understand that:
3. Accuracy of Information
   • Agree to provide accurate, complete, and current information about your health, medications, allergies, and medical history.
   • Understand that the Medical Group and its clinicians rely on the information you provide; they cannot be responsible for treatment decisions based on incomplete or inaccurate information provided by you or others.
4. Duration of Consent
   • This Consent will remain in effect for as long as you maintain an account with Evergreen and seek telehealth services, unless and until you withdraw it in writing or as otherwise required by law.

13. Minors, Parents, and Legal Guardians

1. If you are a minor under the laws of your state, telehealth services may only be provided:

   As otherwise permitted under applicable state laws for minor consent to certain types of services (e.g., sexual health, mental health), as determined by the clinician.

2. If you are signing this Consent as a parent, legal guardian, or other legally authorized representative of a minor or another individual:
   • You confirm that you have the legal authority to act on the patient's behalf regarding healthcare decisions;
   • You consent to the provision of telehealth services to the identified patient under the terms of this Consent; and
   • All references to "you" and "your" in this document shall apply to the patient, where appropriate.

14. Incorporation of Terms & Conditions; Dispute Resolution

1. By agreeing to this Consent, you also acknowledge and agree to Evergreen's Terms & Conditions and Privacy Policy, which are incorporated by reference.
2. The Terms & Conditions may include additional provisions related to:
   • Dispute resolution (including, where applicable, arbitration and class action waivers);
   • Limitations of liability; and
   • Other important rights and obligations concerning your use of the platform.

You should review the Terms & Conditions carefully. If there is any conflict between this Consent and the Terms & Conditions, the Terms & Conditions will generally control for non‑clinical matters, and this Consent will control for clinical consent and telehealth‑specific issues, subject to applicable law.

15. Acknowledgment

By clicking "I Agree," checking a box, or otherwise providing an electronic signature, you acknowledge that:

1. You have read this Consent (or had it read to you) and fully understand it.
2. You have had the opportunity to ask questions about telehealth, the services offered, and this Consent, and your questions have been answered to your satisfaction.
3. You voluntarily consent to receive telehealth services and to the uses and disclosures of your information as described above, subject to applicable law.