Patient Consent For Telehealth Services

You are requesting telehealth services which may include general medical, mental health, primary care, or coordination services (“Services”). Telehealth is the practice of healthcare that involves the use of electronic communications to diagnose or treat patients who are in different locations from their healthcare providers. This includes virtual delivery of healthcare services by a medical provider or via digital or automated tools, including without limitation tools for health related diagnosis and treatment. The Telehealth Services may be used for diagnosis, treatment, care, follow-up and/or patient education, and may include, without limitation, the following: electronic transmission of patient medical records, medical images, and/or other patient data or information; synchronous (i.e., “real time”) and asynchronous (i.e., non-“real time”) interactions via audio, video, text, and/or data or other electronic communications; automated, electronic or digital tools or services for diagnosis, care, treatment and/or communication pertaining to healthcare or medical matters; and output, transmission or exchange of data from medical devices, sound and video files.

When using the Services, you will be treated by and consent to enter into a clinician-patient relationship with a provider delivering care on behalf of UCM Digital Health’s Medical Group (“UCM Provider”) who is licensed in your state.

These Telehealth Healthcare Terms of Service (“Healthcare Services Terms”) govern your use of the Telehealth Services provided by UCM Digital Health Medical Group’s professional corporations and our affiliated medical services providers (“UCM Medical Group”, “we”, “us”, or “our”).

Please read the Healthcare Services Terms carefully before using our Telehealth Services. By using the Healthcare Services you agree to be bound by these Terms. If you are accepting these Healthcare Services Terms for another person (“Family Member”) as such Family Member’s guardian, conservator, or custodian, and as parent of a minor child Family Member, you agree to the terms, conditions, and notices contained or referenced herein on behalf of such Family Member.

UCM Medical Group is affiliated with UCM Digital Health, Inc. where UCM Digital Health Inc. provides management and administrative services to UCM Medical Group. UCM Digital Health Inc. also provides membership and other non-medical services to consumers, and the (Terms of Use) govern your use of the services provided by UCM Digital Health Inc. Please read this Patient Consent for Telehealth Services carefully before using UCM Digital Health’s Services.

You give permission to UCM Digital Health and the Telehealth Services Providers to record and process your personal details and medical data. You may withdraw these permissions at any time by no longer seeking Telehealth Services from UCM.

You consent to receive emails or other electronic communications from UCM pertaining to your care and your health, which may include Protected Health Information. You understand and hereby consent to virtual encounters via phone, email, video, or automated tools for diagnosis, care, treatment or communication pertaining to healthcare matters. You also acknowledge that such virtual encounters may involve care by a variety of Providers, including Physicians, Registered Nurses, Nurse Practitioners, Physician Assistants, Nutritionists,, Mental Health Therapists, and other support or medical personnel.

Further, you understand that it may be possible that your condition cannot be treated via the Telehealth Services, or that information transmitted through the Telehealth Services may not be sufficient or of too poor of image quality, or insufficient information or data to allow for appropriate medical decision making. Accordingly, you may be required to seek additional in-person medical care, alternative healthcare or emergency services. If your health or medical problem or condition persists after use of Telehealth Services, you will immediately contact your medical services provider and seek appropriate additional in-person medical care or emergency care, as appropriate.

Please refer to our Privacy Policy to learn how UCM Digital Health, Inc. collects, uses, shares and protects your Protected Health Information (as defined under the Health Insurance Portability and Accountability Act of 1996 or “HIPAA”). (HIPAA Notice of Privacy Practices)

Please do NOT use the Healthcare Services for emergency or medical matters. For all emergency matters that you believe may immediately affect your health, you must immediately call 911 or go to the nearest emergency room or urgent care facility.

UPDATES TO THE HEALTHCARE SERVICE TERMS

We may modify these Healthcare Services Terms from time to time. We will notify you of material changes by posting the amended terms on the UCM Digital Health website and the SAM by UCM mobile application at least thirty (30) days before the effective date of the changes. If we have your email on file, we will also notify you of material changes to the Healthcare Services Terms by email at least thirty (30) days before the effective date of the changes. Please make sure we have your current email address so that you will receive notice of any material changes. If you do not agree with the proposed changes, you should discontinue your use of the Healthcare Services before the effective date of the change. If you continue using the Healthcare Services after the effective date, you will be bound by the updated Healthcare Services Terms.

FINANCIAL RESPONSIBILITY AND ASSIGNMENT OF BENEFITS

You agree to pay UCM Digital Health Medical Group all applicable charges at the prices then in effect for the Healthcare Services provided to you or another person on whose behalf you are accepting these Healthcare Services Terms and/or payment responsibility (such as your children or other family members) (“Covered Family Member”). You will be charged for the Healthcare Services provided to you or your Covered Family Member by a UCM Digital Health healthcare service provider (each, a “Provider”). You authorize UCM Digital Health Inc to charge your chosen payment method (your “Payment Method”) for the Healthcare Services provided to you or your Covered Family Member. If your Payment Method is invalid at the time payment is due, you agree to pay all amounts due upon demand. The third party services provider who manages your Payment Method may impose terms and conditions on you, which are independent of these Healthcare Services Terms, and you agree to comply with all of those terms. We may accumulate charges that you’ve incurred for the Healthcare Services and submit them as one or more aggregate charges during or at the end of each billing cycle. UCM Digital Health reserves the right to correct any billing errors or mistakes even if payment has already been requested or received.

Telehealth Services include remote visits with our providers. These visits are conducted remotely over a secure video and audio connection rather than in person. If you provide information about your health insurance or health plan, that will be deemed your authorization for us to submit claims for covered Healthcare Services to your health insurer or health plan. You hereby assign or otherwise authorize payment of medical or behavioral health benefits to us for the Healthcare Services provided to you or your Covered Family Member. You authorize the release of any medical or other information necessary to process any claims for the Healthcare Services provided. You further understand and accept your financial responsibility for any portion of the bill not covered by your Employer, health insurer or health plan. SUBMISSION OF CHARGES DOES NOT WAIVE OUR RIGHT TO SEEK PAYMENT DIRECTLY FROM YOU.

APPOINTMENTS, LATE CANCELLATIONS AND MISSED APPOINTMENTS

You understand and agree that if you do not show for your appointment or you cancel your appointment with less than 24 hours’ notice, we may charge you a fee for a missed/late canceled appointment.

PERMISSION TO TREAT

You give permission to the Providers to medically care for you and your Covered Family Member. You may withdraw this consent at any time by no longer seeking Healthcare Services from UCM.

You understand and agree that as part of providing Medical Services to you, your Protected Health Information (as defined by HIPAA), including test results, may be released to an online personal health record and via communication with the UCM healthcare team electronically (in accordance with our Notice of HIPAA Privacy Practice).

SERVICE TERMINATION

You may terminate your use of the Healthcare Services at any time by not using the Healthcare Services any more. We may terminate your use of the Healthcare Services at any time in our reasonable discretion, for causes including but not limited illegal conduct such as falsifying information to obtain controlled substances, abusive and threatening behavior, and continued refusal to pay for our services. We may terminate your use of the Healthcare Services by sending notice to you at the mail or email address you provided to us or by otherwise contacting you. If we terminate your use of the Healthcare Services, we will use reasonable effort to notify your Sponsor, if any.

CONSENT TO ELECTRONIC COMMUNICATIONS

You agree that UCM may send the following to you by email or by posting them on our website and mobile application: legal disclosures; these Healthcare Services Terms, Notice of HIPAA Privacy Practices; future changes to any of the above; and other notices, policies, communications or disclosures and information related to the Healthcare Services. You agree that UCM may contact you via secure messaging, email, phone, text, or mail regarding the Healthcare Services. You consent to receive such communications electronically. You agree to update your contact information to ensure accuracy.If you later decide that you do not want to receive certain future communications electronically, please send an email to (insert email address or insert physical address) You may also opt out of certain electronic communications through your account or by following the unsubscribe instructions in any communication you receive from UCM. Your withdrawal of consent will be effective within a reasonable time after we receive your withdrawal notice described above.

UCM will need to send you certain communications electronically regarding the Healthcare Services. You will not be able to opt out of those communications – e.g., communications regarding updates to these Healthcare Services Terms or information about billing. Your withdrawal of consent will not affect the legal validity or enforceability of the Medical Services Terms provided to and accepted by, you.

DISCLAIMERS

TO THE MAXIMUM EXTENT NOT PROHIBITED BY LAW, EXCEPT IN CASE OF NEGLIGENCE OR WILLFUL MISCONDUCT, WE AND OUR AFFILIATES, PROVIDERS, EMPLOYEES, OFFICERS, DIRECTORS OR AGENTS WILL NOT BE RESPONSIBLE FOR ANY LOSS OR DAMAGE, INCLUDING PERSONAL INJURY OR DEATH, RESULTING FROM ANYONE’S USE OF OR INABILITY TO USE THE MEDICAL SERVICES.

The Medical Services are intended for use only within the United States and its territories. We make no representation that the Medical Services are appropriate, or are available for use outside the U.S. Those who choose to access and use our Medical Services from outside the U.S. do so on their own initiative, at their own risk, and are responsible for compliance with applicable laws.

For California patients, the state of California requires that physicians in California share notice of the Open Payments database. 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.

LIMITATION OF LIABILITY

TO THE MAXIMUM EXTENT NOT PROHIBITED BY LAW, IN NO EVENT WILL WE AND OUR AFFILIATES, PROVIDERS, EMPLOYEES, OFFICERS, DIRECTORS OR AGENTS BE LIABLE FOR ANY CONSEQUENTIAL, EXEMPLARY, INCIDENTAL, SPECIAL OR PUNITIVE DAMAGES, INCLUDING WITHOUT LIMITATION THOSE RELATING TO LOST PROFITS OR THE COST OF SUBSTITUTE PRODUCTS OR SERVICES ARISING OUT OF OR IN CONNECTION WITH THE MEDICAL SERVICES OR FROM THE USE OF OR INABILITY TO USE THE MEDICAL SERVICES, WHETHER BASED ON CONTRACT, WARRANTY, PRODUCT LIABILITY, TORT OR OTHER LEGAL THEORY AND EVEN IF WE HAVE BEEN INFORMED OF THE POSSIBILITY OF SUCH DAMAGES. SOME JURISDICTIONS DO NOT ALLOW THE EXCLUSION OR LIMITATION OF LIABILITY FOR CONSEQUENTIAL OR INCIDENTAL DAMAGES, SO THE ABOVE EXCLUSION MAY NOT APPLY TO YOU.

GENERAL PROVISIONS

1. The expected benefits of using telemedicine include:
   • Improved and quicker access to medical care
   • Ability to access care from any location, and
   • More efficient medical evaluation and management
2. The potential risks associated with using telemedicine may include:
   • Delays in medical or behavioral health evaluation and treatment due to failures of technology, such as a disconnected phone call and technology failures, and
   • In rare cases, a lack of access to complete health information that may result in adverse drug interactions, allergic reactions, or other judgment errors
   • The inability to have direct, physical contact with your healthcare provider is the primary difference between telehealth and in-person health care.
3. These Healthcare Services Terms make up the entire agreement relating to your use of the Healthcare Services, and supersede all prior agreements relating to the subject matter hereof.
4. We may change, suspend, or discontinue any of the Healthcare Services at any time. We will try to give you prior notice of any material changes to the Healthcare Services. We will not be liable to you or to any third party for any modification, suspension or discontinuance of the Medical Services.
5. It is necessary for you to provide complete and accurate medical and healthcare history and you will update your health records periodically, but no less than once a year.
6. You cannot use UCM’s Telehealth Services to get prescriptions for DEA controlled substances, non-therapeutic drugs and certain other drugs which may be harmful because of their potential for abuse.
7. If you think you are experiencing a life threatening emergency, you need to call 911 or go immediately to the closest emergency room.
8. There is no guarantee that you will be treated by a UCM Clinician. The UCM Clinicians reserve the right to deny care for potential misuse of Services or for any other reason if, in the professional judgment of the UCM Clinician, the provision of the Service is not medically or ethically appropriate.
9. There is no guarantee that you will be given a prescription by the UCM Clinician.
10. You are required to pay all visit fees at the time you schedule a visit, unless payment arrangements have been established through your employer, benefit provider or other entity.
11. You are responsible for the costs of all recommended treatments, services, medications and referrals by a UCM Clinician and that these recommendations are not included in your telehealth visit with a UCM Clinician.
12. You acknowledge and accept that the physical examination portion of the Services, if any, will be performed via Telehealth, in reliance upon either video, images, telephone consultation, questionnaire, medical records or otherwise.
13. Your use of this Service is voluntary and you have the right to withdraw your consent to the Services at any time by ending this session. If you choose to end your session, your right to future Services will not be affected. Even after termination, certain terms including confidentiality of health information will survive such termination as applicable by federal and state law.
14. You understand that technical difficulties, such as service interruptions, may occur during a telehealth visit and that if you are unable to reconnect with a UCM Clinician within ten (10) minutes of an interruption, you may need to reschedule the Telehealth encounter.
15. The state in which you reside may also require us to provide additional notices to you or obtain additional consents from you regarding our TeleHealth Services. Please review the provisions applicable to your state, if any.

You hereby represent that you have read and fully understood and agreed to:

• 2024 Patient Consent For Telehealth Services
• 2024 Private Pay Agreement/Patient Service Agreement
• 2024 HIPAA Notice of Privacy Practices
• UCM Terms of Use and UCM Accessibility Policy (Sam App)

By electronically signing this form, you acknowledge and agree that you have read and understand the statements above and you consent, on your own behalf or on behalf of those you have legal representation to sign on behalf of to receive Services by a UCM Clinician.

If you have any questions about these Healthcare Services Terms, please contact info@ucmdigitalhealth.com.

Revised/Reviewed: June 2024