Electronic Agreement and Signature:

BY CHECKING THE “AGREE” BOX FOR THE BELOW TERMS OF USE AND ANY OTHER SUCH FORMS WHICH ARE PRESENTED TO YOU AS PART OF ANY TRANSACTION WITH HEADS UP OR AS ANY SIMILAR AGREEMENTS MAY BE PRESENTED TO YOU FROM TIME TO TIME ON THE WEBSITE, YOU UNDERSTAND AND AGREE TO THE TERMS CONTAINED THEREIN AND AGREE THAT SUCH ON-GOING ACTIONS IN USING THE SITE CONSTITUTE A LEGAL SIGNATURE AS WELL AS AN ON-GOING AGREEMENT BY YOU TO THESE TERMS OF USE OR RELATED AGREEMENTS.

Definition of Terms:

All capitalized terms used in this Consent to Telehealth but not defined herein have the meanings assigned to them in the Heads Up Terms of Use document.  For avoidance of any doubt, the terms “Heads Up”, “we”, “us”, or “our” refer to Complete Care Medical, Inc., Carepharm Pharmacy, and their affiliated entities and the terms “you” and “yours” refer to the person using the Service.

Telehealth/Telemedicine Overview:

Telehealth involves the delivery of healthcare services using electronic communications, information technology or other means between a healthcare provider and a member who are not in the same physical location.  Telemedicine, on the other hand, refers specifically to medical services delivered by a healthcare provider, such as a physician, to a patient using technology.  In many instances the terms are interchangeable, since telemedicine falls within telehealth, but telehealth includes healthcare services beyond diagnosis and treatment by a physician or other professional.  Under the law, telemedicine may be used for diagnosis, treatment, follow-up or member education, and may include, but is not limited to:

• Electronic transmission of medical records, photo images, personal health information or other data between a member and a healthcare provider;
• Interactions between a member and healthcare provider via audio, video and/or data communications; and
• Use of output data from medical devices, sound and video files

The electronic systems used in Heads Up’s Service will incorporate network and software security as well as confidentiality protocols to protect the privacy and security of protected health information and imaging data, and will include measures to safeguard the data to ensure its integrity against intentional or unintentional corruption.

Possible Benefits of Telemedicine

• Can be easier and more efficient for you to access medical care and treatment.
• You can obtain medical care and treatment at times that are convenient for you.
• You can interact with providers without the necessity of an in-office appointment.

Possible Risks of Telemedicine

• Information transmitted to your provider(s) may not be sufficient to allow for appropriate medical decision making by the provider(s).
• The inability of your provider(s) to conduct certain tests or assess your condition in-person could prevent the provider(s) from making a complete and accurate diagnosis, from identifying the need for emergency medical care, or ordering comprehensive treatment for you.
• Your provider may not able to provide medical treatment for your particular condition via telemedicine and you may be required to seek alternative testing or care.
• Delays in medical evaluation or treatment could occur due to technological failures such as lack of internet service.
• Security protocols or safeguards could fail causing a breach of privacy.
• Depending on certain regulatory mandates in specific geographic areas, your provider may have limited treatment options available, especially with regard to certain pharmaceuticals or custom medical equipment.

By accepting this Consent to Telehealth/Telemedicine, you acknowledge your understanding and agreement to the following:

• I have read this special Consent to Telehealth/Telemedicine carefully and understand the risks and benefits of using telemedicine in my medical care and treatment provided through the Heads Up platform by its Providers.
• I give my informed consent to the use of telemedicine by the Providers.
• I understand that the delivery of telehealth or telemedicine is an evolving field and that the use of telehealth or telemedicine in my medical care and treatment may include uses of technology not specifically described in this consent.
• I understand that while the use of telehealth or telemedicine may provide benefits to me, as with any medical care service, no such benefits or any specific results have been promised or can be guaranteed to me by Heads Up and its Providers.  Thus, I acknowledge that my condition may not be cured or may not improve and, in some cases, may get worse.
• I understand that my Provider(s) may determine in his or her sole discretion that my condition is not suitable for treatment using telemedicine, and that I may need to seek medical care and treatment in-person or from an alternative source of my choosing.
• I understand that the same confidentiality and privacy protections that apply to my other health care services also apply to any telehealth or telemedicine services from Heads Up.
• I understand that I have access to all of my health and wellness information pertaining to the telehealth or telemedicine services in accordance with applicable laws and regulations.
• I understand that I can withhold or withdraw this consent at any time by emailing Heads Up with such instruction. Otherwise, this consent will be considered renewed upon each new telemedicine consultation with a Provider(s).
• I agree and authorize my Provider to share information regarding the telemedicine exam with other healthcare providers or their staff for treatment, payment and health care operations purposes.
• I agree and authorize my other healthcare providers to release information regarding my protected health information (PHI) to the Provider or to Heads Up and its affiliates.