Telehealth Informed Consent & Communication Authorization

1. Who We Are

1. All professional medical services, including diagnosis, treatment, and prescribing, are provided by NVP Medical Group, P.A. and its affiliates (collectively, the "Medical Group”) and its licensed clinicians (physicians and other licensed professionals) using the technology platforms, websites, and mobile apps (“Site”) owned and operated by ConsultRX LLC dba Evergreen Telehealth (“Evergreen”). Evergreen is not a medical group or healthcare provider and does not practice medicine.

2. Evergreen has a financial relationship with the Medical Group which employs or contracts with clinicians. You are free to obtain your medical examination and care from another healthcare provider that is not associated with the Site.

3. Evergreen uses an artificial intelligence agent ('Evie') to guide your intake, collect health information, send reminders, and support your care experience. Evie is not a licensed clinician and does not provide medical advice, diagnosis, or treatment. All clinical decisions — including whether to prescribe — are made solely by licensed Medical Group clinicians. You will be informed when you are communicating with an AI assistant rather than a human, and you may request to speak with a human at any time. Information you share with Evie may become part of your medical record and be reviewed by your clinician.

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.

Important: Telehealth services are not available everywhere and may be limited by state and federal law.

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, conduct certain tests, and assess vital signs compared to an in‑person visit.
• Certain clinical assessments may be limited by the quality of the transmitted data (e.g., images, audio, video).
• Your clinician may not be able to provide medical treatment for your particular condition via telehealth and you may be required to seek alternative healthcare or emergency care services.

You will be provided the name and professional credentials of the clinician responsible for your care. You may verify any clinician's license through the medical board of your state; contact information for each state board is available through the Federation of State Medical Boards (fsmb.org).

Special Notice to California Clients. Physicians and midwives are licensed and regulated by the Medical Board of California. To confirm a license or file a complaint, go to www.mbc.ca.gov or call (800) 633-2322.

Special Notice to Texas Clients. Complaints about physicians, as well as other licensees and registrants of the Texas Medical Board, including physician assistants, acupuncturists, and surgical assistants may be reported for investigation at the following address: 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 the following telephone number: 1-800-201-9353, For more information, please visit the Texas Medical Board website at www.tmb.state.tx.us.

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 and at times that are convenient for you;
• 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;
• Delays in evaluation or treatment due to equipment or connection issues;
• In rare cases, information transmitted may be incomplete or inaccurate, which could contribute to a misdiagnosis or treatment error.

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 telehealth is not appropriate for 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,

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

4. 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

• You may be asked to complete forms, answer adaptive questions, or upload photos/videos.
• A clinician will review this information and render a clinical decision, which may include prescriptions, recommendations, or a request for more information, or a referral for in‑person care.
• You may request a live video visit instead of asynchronous care when available by scheduling through the Site’s member dashboard or mobile app.
• The telehealth modality used for your initial evaluation will comply with the laws of the state where you are located. In some states, a real-time audio-video visit (or other specified encounter) is required before a clinician may treat or prescribe; where applicable, we will require that telehealth modality before your evaluation is completed.

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.

4. Pharmacy Choice

• You have the right to have any prescription filled at the pharmacy of your choice. For convenience, we may offer to route prescriptions to partner pharmacies, but you are never required to use them.

• Some medications available through our platform may be prepared by a compounding pharmacy. Compounded medications are not FDA-approved and are prepared based on a clinician's prescription for an individual patient. While compounding pharmacies are regulated by state boards of pharmacy and (where applicable) the FDA under Section 503A or 503B of the Federal Food, Drug, and Cosmetic Act, compounded drugs do not undergo the same FDA approval process as commercially manufactured drugs. Your clinician will inform you if a compounded medication is being prescribed, and you may always elect to receive a commercially manufactured alternative if one is available and clinically appropriate.

7. Access to and Use of Medical Records

1. Records of your telehealth encounter, including clinical notes and orders, are created and securely maintained within the Site.

2. Your records become available once your evaluation is complete. Submission of an intake form alone does not complete your evaluation; the evaluation is complete when a treating clinician has reviewed your information and rendered a clinical decision.

3. You may access, obtain copies of, and share your records with your primary care provider or any other clinician you choose, either through your account or by contacting our AI agent, Evie. Records requests are fulfilled, and records retained, in accordance with the requirements of your state of residence.

8. How to Contact Your Provider After the Visit

1. For follow‑up questions or non‑urgent issues after your visit, you may contact your care team using the secure message icon in the Site’s app or account.

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 Medical Group clinician and/or
• Your primary care physician- within a time frame recommended by your clinician

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

9.1 General. It is your sole responsibility to respond to in-app messages, emails, and texts via the Site regarding your diagnosis, care, and/or treatment. It is your sole responsibility to monitor and respond to these messages, reports, and emails, and neither the Site, the Medical Group, nor any Medical Group clinician will be responsible in any way and you will not hold the Site, Medical Group, or clinician liable for any loss, injury or claims of any kind resulting from your failure to read or respond to these messages or for your failure to comply with any treatment recommendations or instructions from the Medical Group or your clinician.

9.1 In‑App Messaging

• All clinical communications should occur through the Site’s 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 the Site 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; and

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 clinical information 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 the Site that may include, among others:

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 Site membership or subscription, as described in your membership plan.
• Your membership fee covers access to the Site and certain telehealth and other 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 federal or private payor health insurance on your behalf.
• You are solely responsible for all fees associated with your care and membership.
• [We may accept health savings account (HSA) or flexible spending account (FSA) cards as a payment method where our payment processor supports them. However, we do not make any representation that our services qualify as eligible medical expenses under your HSA, FSA, or other health reimbursement arrangement and we are not obligated to provide letters of medical necessity, itemized superbills, or other documentation to support reimbursement or substantiation requests. You are solely responsible for determining whether any payment qualifies under your HSA/FSA rules and for any tax consequences of using tax-advantaged accounts.]

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. Data Privacy and Protection

1. General. The electronic systems used in the Site incorporate network and software security protocols to protect the privacy and security of your information, and will include measures to safeguard data against loss and intentional or unintentional corruption.

2. Terms & Conditions, Privacy Policies, and Notices

• You acknowledge that you have had the opportunity to review:
  • Evergreen’s Terms & Conditions;
  • Evergreen’s Privacy Policy;
  • Medical Group’s Privacy Policy; and
  • Medical Group’s Notice of Privacy Practices.
• You understand that these documents describing how your health information may be used and disclosed including for the purposes of consultation, treatment, payment/billing, and certain administrative purposes.

3. Session Recording and Observers

• Telehealth video sessions are not recorded without your prior consent.
• Written summaries of your interactions with Evie and your care team may be retained as part of your medical record; this is distinct from audio or video recording of live sessions, which does not occur without your prior consent.

4. 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.
• Despite these measures, no system can be guaranteed 100% secure; you acknowledge this residual risk.

12. Consent to Telehealth Treatment

By accepting this Consent, you:

1. Voluntary Participation

• Voluntarily consent to examination, diagnosis, and treatment by Medical Group clinicians delivered via telehealth, including the issuance of prescriptions where the clinician determines such treatment is appropriate.
• Understand that you are authorizing the Medical Group's clinicians to evaluate your submitted information and, where clinically appropriate, to provide treatment via telehealth. A provider–patient relationship is established when a licensed Medical Group clinician reviews your information and renders a clinical decision (such as a treatment plan, prescription, or determination that further information or in-person evaluation is needed). Acceptance of this consent alone, payment of fees, or submission of intake forms does not establish a provider–patient relationship. Understand that you may withhold or withdraw this consent at any time without affecting your right to future care or treatment and without risking the loss or withdrawal of any benefit to which you would otherwise be entitled. Withdrawal will stop telehealth services on a going-forward basis but will not affect actions taken in reliance on this Consent before withdrawal.

2. Understanding of Limitations

• Understand that:
  • Telehealth is not the same as an in‑person visit;
  • There may be limitations in physical examination and diagnostic accuracy;
  • Technical issues may occur; and
  • Your clinician may decide telehealth is not appropriate for some or all of your care.
  • No potential benefits from the use of telehealth or other technology or specific results can be guaranteed. Your condition may not be cured or improved, and in some cases, may get worse. There are potential risks to the use of telehealth and other technology, including but not limited to the risks described in this Consent.

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.
• Acknowledge that following an appropriate medical evaluation and if you are prescribed controlled or non-controlled medication for the treatment of your injury, illness, or disease, prior to such prescription you will inform your Medical Group clinician of all other medications you are taking, including your alcohol and drug use history, take the medication exactly as prescribed, store medication securely to prevent theft or diversion, not share, sell, or trade the medication, refrain from altering the dosage or discontinuing the medication abruptly without clinician supervision, and inform your primary care physician that you are taking a prescribed medication.

4. Duration of Consent

• 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 you are entitled, but you understand that the Medical Group clinicians who utilize the Site do not offer in- person treatment. This Consent will remain in effect for as long as you maintain an account with the Site and seek telehealth services, unless and until you withdraw it in writing or as otherwise required by law.

13. 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.

14. 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.