Telehealth Consent

VelaMD

Informed Consent to Receive Telehealth Services

Last revision: January 1st, 2023

Before you give your consent to request telehealth services, please be aware of how care (the “Services”) is received from Sosha, Inc. or other to-be-determined professional medical entities contracted with VelaMd, LLC and each of their affiliates and providers (“VelaMD”), of which Services are provided through the VelaMD website, mobile application and/or other messaging portal applications (the “Platform”) which is operated and/or supported by VelaMD (either directly or through one of its vendors). If you have any questions, please send us an electronic message at admin@velamd.com.

You understand that you should never use the Platform in a medical emergency. You understand that in a medical emergency you should dial 911 or visit an emergency room.

In this consent, the terms “you” and “yours” refer to the person using the Services, or in the case of a use of the Services by or on behalf of an individual minor between the ages of thirteen (13) and eighteen (18) or higher age of majority under applicable state law, “you” and “yours” refer to and include (i) the parent or legal guardian who provides consent to the use of the Services by such minor or uses the Services on behalf of such minor, and (ii) the minor for whom consent is being provided or on whose behalf the Services is being utilized.

The Services available through the Platform, either directly through us or through one of our vendors, may include (i) providing individuals with dermatological services; (ii) information on health care matters relating to the assessment and treatment of individuals’ dermatological needs and related medical conditions, including, but not limited to, store and forward modalities; (iii) facilitating individual assessments; and (iii) an online communication platform, including through doximity, facetime, skype, telephone, and other live two way interactive communication modalities, as a means of direct access to health care providers provided by contracted medical practices and providers (the “Providers”) and similar affiliated professional entities for communication, consultations, assessments, and treatment by such health care organizations and their providers.

In using the Platform, you understand that you will be provided with the name, credentials, licensure/certification, and qualifications of the medical professional who will be providing your care. You further understand that certain Services may be provided through the Platform by non-physician practitioners such as Nurse Practitioners or Physician Assistants; provided, however, to the greatest extent possible, you will be informed in advance if you are going to be evaluated by a Nurse Practitioner or Physician Assistant before you complete your consultation questionnaire.

You understand that by using the Platform, you may not have an in-person physical exam that might identify a potentially serious medical condition. You further understand that you have the option of seeking the same care in-person with the provider of your choice. You also understand and agree that the health information you provide through the Platform may be the only source of health information used by the medical professionals during the course of your evaluation and treatment through the Platform, and that such professionals may not have access to medical records or information held with your primary provider. You certify that all of the information you provide VelaMD must be true, accurate, and complete. You understand that if you knowingly provide false, misleading, or incomplete information to a medical professional, you may not be able to receive Services through the Platform.

You agree that it is your choice whether or not to use the Platform and the Services it offers. You understand that at any time, you can change your mind about receiving Services through the Platform. You may obtain copies of your medical records for Services received through the Platform by sending us a message through the Platform.

While the use of telehealth in the delivery of care can provide potential benefits for you, there are also potential risks associated with the use of telehealth and other technology. These risks include, but may not be limited to the following: the quality, accuracy or effectiveness of the Services you receive from your Provider(s) could be limited; technology, including the Services, may contain bugs or other errors, including ones which may limit functionality, produce erroneous results, render part or all of such technology, including the Services, unavailable or inoperable, produce incorrect records, transmissions, data or content, or cause records, transmissions, data or content to be corrupted or lost; failures of technology may also impact your Provider(s) ability to correctly diagnose or treat your condition; the inability of your Provider(s) to conduct certain tests or assess vital signs in-person may in some cases prevent the Provider(s) from providing a diagnosis or treatment or from identifying the need for emergency medical care or treatment for you; your Provider(s) may not able to provide treatment for your particular condition and you may be required to seek alternative healthcare or emergency care services; delays in medical evaluation/treatment could occur due to unavailability of your Provider(s) or deficiencies or failures of the technology or electronic equipment used; the electronic systems or other security protocols or safeguards used could fail, causing a breach of privacy of your medical or other information; data stored and communicated electronically, for example, through email communications, may be more susceptible to unintended disclosure of protected health information to third parties; given regulatory requirements in certain jurisdictions, your Provider(s) diagnosis and/or treatment options, especially pertaining to certain prescriptions, may be limited; a lack of access to all of your medical records may result in adverse drug interactions or allergic reactions or other judgment errors. Certain technology, including the Services, may be used while still in a beta testing and development phase, and before such technology is a final and finished product.

Through this Platform and the Services it offers, you understand that you will be given information about the test(s), treatments(s), and procedures(s) to be provided, including the benefits, risks, possible problems or complications, and alternate choices. You understand that you are not guaranteed treatment through the Platform and that it may be determined, that through information you provide that you are not appropriate for treatment through the Platform.

You understand that you may need to pay for certain Services received through the Platform yourself and that any insurance you have may not reimburse you for it. You understand that, unless you engaged in the Platform and Services through a practice with whom we contract with, by using this Platform, you are freely electing to pay out of pocket for all Services and prescriptions provided through the Platform and that you may be foregoing discounts or insurance coverage that might otherwise be available to you if you sought care in another health care setting. You understand that it is your responsibility to arrange and pay for any follow-up care that VelaMD recommends you receive. To the extent you engaged in the Platform and Services through a practice that we contract with, then the other practice will bill your insurance and/or collect any cash payments. If, on the other hand, you did not engage the Platform and Services by another practice with whom we have contracted with, and, instead, you engaged the Platform and Services through other means, you will be solely responsible for all payment obligations hereunder and we will not bill any insurance for the Services rendered through the Platform by the Providers. You understand that you will be told how to get care in the case of an emergency. you understand that by using the Platform, you may receive medications more slowly than if you received care in a different setting.

You understand that if you are using the Platform, you are responsible for having the latest version of the Platform on your mobile telephone or device and for having sufficient network or wireless connection to be able to use the Platform.

You understand that you should ask questions about anything you do not understand by sending an electronic message through the Platform. You understand that a medical professional is available to answer any questions you may have. VelaMD aims to respond to any message sent through the Platform within one business day, and to respond to any telephone messages within one business day. However, VelaMD may be delayed in responding to any message, and does not guarantee a response within one business day. Business days are Monday through Friday. You understand that you must check the Platform for messages because this is the way that VelaMD will communicate with you. You understand that if you do not check the Platform regularly, your care and any drug treatment may be delayed. You understand that you may receive email communications through the Platform.

You further understand that the electronic nature of the Services means that there is a greater risk to the privacy of your electronic health information. By agreeing to use the Platform, you are consenting to VelaMD’s sharing of your protected health information with certain third parties as more fully described in our Privacy Policy. In addition to the information you share with us through the Platform, the Platform may also collect your device identifier and your geolocation. This information may be necessary to be able to assign you to a medical professional licensed in your state. You understand, agree, and expressly consent to VelaMD obtaining, using, storing, and disseminating to necessary third parties, information about you and your image, as necessary to provide Services through the Platform. You further understand that records of Services provided to you through the Platform may be lost through technical failures. You understand that if you are experiencing technical difficulties through the Platform, you may send a message through the Platform. You hereby release and hold harmless VelaMD from any loss of data or information due to technical failures associated with the Platform.

If you would like to have the records relating to the telehealth services received through the Platform sent to your primary care provider, you understand that you will need to send an electronic message through the Platform requesting such transfer of records.

Further Acknowledgements

You understand that under applicable state laws, VelaMD is required to report suspicions of child abuse, neglect, statutory rape, domestic violence, and sexual assault.

You hereby consent to the use of telehealth to examine, consult, diagnose, or treat you and you understand that you may seek in-person care or follow up care should you so choose. You may also request a video consultation through the Platform.

You consent to VelaMD (i) providing copies of your medical records to your primary care physician for Services rendered through the Platform; (ii) you give access to your provider to retrieve and view prior medication history that may be available in the Platform; and (iii) consent to receive automated and/or live text and voice reminders and messages from the Platform at your listed phone number as consistent with applicable law (to which you have the right to opt-out of going forward). If you would like to have your records sent to your primary care physician, please provide your primary care physician’s information to your doctor at the time of the visit

You understand that this informed consent will become a part of your medical record.

You have the right to withdraw your consent to the use of telehealth in the course of your care, without prejudice to any future care or treatment and without risking the loss or withdrawal of any health benefits to which your entitled. Any withdrawal of your consent will be effective upon receipt of written notice to your Providers, except that such withdrawal will not have any effect on any action taken by VelaMD or your Provider(s) in reliance on this consent before it received your written notice of withdrawal. Any withdrawal of your consent will not affect any other provision of this consent, and you will continue to be bound by this consent. You understand that each of your Provider(s) may determine in their sole discretion that your condition is not suitable for diagnosis and/or treatment using telehealth technology, including the Services, and that you may need to seek care and treatment from a specialist or other healthcare provider, outside of such telehealth technology.

VelaMD has a commercial relationship with Hope Specialty Pharmacy and HRx Pharmacy. VelaMD, will use its pharmacy partner to fulfill your order directly to your door. You are free to obtain your prescription from any pharmacy of your choice by contacting our support team. You must pay the full amount of the costs associated with use of the Services, including any prescription you may receive, and you will not attempt to submit a claim to Medicare, any other federal payor, or any state or private insurer.

BY CLICKING “I AGREE,” CHECKING A RELATED BOX TO SIGNIFY YOUR ACCEPTANCE, USING ANY OTHER ACCEPTANCE PROTOCOL PRESENTED THROUGH THE PLATFORM, SERVICES OR OTHERWISE AFFIRMATIVELY ACCEPTING THIS CONSENT, YOU ACKNOWLEDGE THAT YOU HAVE READ, ACCEPTED, AND AGREED TO BE BOUND BY THIS CONSENT. IF YOU DO NOT AGREE TO THIS CONSENT, DO NOT CREATE AN ACCOUNT OR USE THE SERVICE. YOU HEREBY GRANT AGENCY AUTHORITY TO ANY PARTY WHO CLICKS ON THE “I AGREE” BUTTON OR OTHERWISE INDICATES ACCEPTANCE TO THIS CONSENT ON YOUR BEHALF.