INFORMED CONSENT FOR TELEHEALTH SERVICES 

I understand that Immune Co. a/k/a MoldCo (“MoldCo”, “we”, “us”, or “our”) is a technology company which provides administrative services through its online platform to facilitate connecting me (“patient”, “me”, “you” or “your”) with its network of physician practices, which includes without limitation, Immune Co Medical Group, PA, a Florida professional association, New York Opus Medical Services, P.C., a New York professional corporation, Immune Co Medical Group West PC, a California professional corporation, and any future MoldCo affiliated practices (each a “Practice”) and affiliated licensed health Providers (each a “Provider” and collectively “Providers”) to provide healthcare for mold and biotoxin related health care conditions, including assessment, diagnosis, lab testing, treatment, follow-up and/or education telehealth including consultation, treatment, transfer of  personal and health information, emails, telephone conversations and education using interactive audio, video data communications and the use of output data from medical devices, sound and video files (“Telehealth”). Telehealth involves the delivery of healthcare services using electronic communications, information technology or other means between a healthcare provider and a patient who are not in the same physical location.  I hereby consent to engage in Telehealth services with my Provider.  I understand that my Provider is an independent contractor and is not employed by MoldCo.  My Provider may require me to execute an additional informed consent and patient intake documents prior to engaging in Telehealth and may provide additional notices and disclaimers.

I understand that the expected benefits of Telehealth are improved access to health care for mold related illnesses enabling me to remain at a more convenient remote site while the Provider is at a distant site, more efficient evaluation and management and obtaining the expertise of a distant Provider who is licensed in the state where I reside.  Additional benefits include: (1) reduced wait times for diagnosis, treatment, and appropriate prescriptions; (2) avoiding unnecessary travel; (3) the ability to obtain medical care from the comfort and privacy of my home; and (4) convenient scheduling to avoid missed work/school.

I understand that I have a right to confidentiality with Telehealth under the same laws that protect the confidentiality of my personal and health information for in-person health services. Any information disclosed by me during the course of my remote Telehealth, therefore, is generally confidential to the extent provided by law.  I understand that I will have access to all medical information from the Telehealth services to the extent set forth in applicable state law.

As with any medical care, there are potential risks associated with the use of Telehealth. These risks  include, but may not be limited to: (a) information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate Provider decision making by the Provider; (b) delays in evaluation and treatment could occur due to deficiencies or failures of the equipment; (c) the inability of my Provider to conduct certain tests, examine me in person, or assess vital signs may in some cases prevent my Provider from providing a diagnosis or treatment or from identifying the need for emergency care; (d) given regulatory requirements in certain jurisdictions, my Provider’s treatment options may be limited; (e) in rare cases, a lack of access to all of my medical records may result in adverse drug interactions or allergic reactions or other errors; and (f) the possibility of disruption, distortion or unauthorized access during transmission of personal information due to internet/electronic/technical failures beyond the control of MoldCo and my Provider.   

By signing this form, I understand the following:

1.            I understand that Telehealth is the use of electronic communication technologies by a health and/or therapeutic provider to deliver services to an individual when he/she is located at a different site than the provider; and hereby consent to the Provider to provide Provider health care services to me via Telehealth.

2.          I understand that I may be required to have certain system requirements to access electronic Telehealth services via the method chosen. I understand that I am solely responsible for any cost to obtain any additional/necessary system requirements, accessories, or software to use Telehealth services.

3.          I understand that I have the right to withhold or withdraw my consent to the use of Telehealth by  the Provider at any time, without affecting my right to future care or treatment.

4.          I understand that a variety of alternative methods of health care may be available to me, and that I  may choose one or more of these at any time.   I understand that a variety of alternative methods of health care may be available to me, and that I may choose on or more of these at any time.

5.          I represent and warrant that all required information I provide to MoldCo and the Provider is truthful and accurate, and that I will maintain the accuracy of such information.

6.          I understand that there are, by law, exceptions to confidentiality by a Provider including, but not limited to, reporting child, elder and dependent adult abuse; expressed threats of violence toward an ascertainable victim; my own mental or emotional state informing a clear danger to myself or others; where I make my health, mental or emotional state an issue in a legal proceeding; where otherwise required by law.

7.          I understand that I am solely responsible for the privacy and confidentiality in my surrounding environment while engaged in telehealth and will exercise appropriate privacy measures. 

8.          I agree that if it becomes clear to the Provider, in his or her sole Provider opinion, that the  Telehealth modality is unable to provide all pertinent clinical information during the Telehealth encounter, the Provider will advise me prior to the conclusion of the live Telehealth encounter and will advise me regarding the need for me to obtain an additional in-person evaluation reasonably able to meet my needs and may make a referral to a Provider in my area.

9.          I understand that I have a duty to inform my Provider of electronic interactions regarding my care that I may have with other healthcare providers.  I agree to provide accurate and truthful information about my identity, location at the time Telehealth is rendered, and regarding my health and physical conditions.

10.        I understand that Telehealth services may not be as complete as face-to-face services.

11.        I understand that there are potential risks and benefits associated with any form of treatment, and despite my efforts and the efforts of my Provider, my condition may not improve, and in some cases may even get worse.  I acknowledge that no assurances or guarantees have been made to me by the Practices or my Provider concerning the outcome and/or results of any treatment or the Telehealth services.

12.        I have been given an opportunity to select a Provider prior to the consult, including a review of the consulting provider’s credentials.

13.        I understand there is a risk of technical failures during the Telehealth encounter beyond the control of MoldCo or my Provider. I agree to hold harmless MoldCo, the Practice, and my Provider for delays in evaluation or for information lost due to such technical failures.

14.        I understand that if I am experiencing a medical emergency or a crisis, that should dial 9-1-1 immediately and that MoldCo is not able to connect me directly to any local emergency services.

15.        I understand that that a Provider will only take responsibility for my care after I have created an account on the Telehealth and provided all requested information. Notwithstanding the foregoing, any Provider has the right to refuse to provide care to me if the Provider makes a Provider judgment that I am not qualified to receive medical care through Telehealth. I EXPRESSLY ACKNOWLEDGE THAT A REQUEST FOR TREATMENT DOES NOT CREATE A PATIENT-PROVIDER RELATIONSHIP. NOTE: In order to create a physician/patient relationship THROUGH MY USE OF ANY OF THE TELEHEALTH SERVICES with a Provider, I must complete a medical history questionnaire and acknowledge/consent to any other forms as may be provided to utilize the Telehealth from time to time.

16.        I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes as well as with other health care providers including labs and pharmacies for treatment and diagnostic purposes.

17.        I understand that my Telehealth session will not be recorded without my consent. If I do consent to recording my Telehealth session, my Provider will document my consent in my clinical record.

18.        I understand that I may verify the veracity of my Provider’s Provider license by searching one of the following practitioner licensure data bases LINK (New York) LINK (Texas) LINK (Florida).

19.        CALIFORNIA PATIENTS ONLY. By entering this Consent to Telehealth I acknowledge that I have received information regarding the applicable Practice physician’s name and license number, license status, highest level of academic degree, and board certification. Each Practice physician providing services in California is licensed to practice medicine in the state of California and may be a board certified physician or a licensed physician in his/her final year of residency who is not yet board-certified. I understand that I am encouraged to contact the Medical Board of California per the below contact information should I have any questions or concerns.

NOTICE
Medical doctors are licensed and regulated
by the Medical Board of California
(800) 633-2322
webmaster@mbc.ca.gov
www.mbc.ca.gov

20.        I understand that only when I have accurately and fully completed my medical history information and have had a Telehealth consultation, in compliance with state law governing the establishment of a legal provider/patient relationship, will I be eligible to get a prescription for any medications, as determined by the Provider in such Provider’s sole discretion and subject to the Provider’s Provider and legal obligations. NOTE: No controlled substance medications are available through Providers. If my Provider issues a prescription, I have the right to select the pharmacy of my choice. I agree that any prescriptions shall be solely for my personal use.  I agree to fully and carefully read all provided product information and labels and to contact my Provider, a physician, other provider, or pharmacist if I have any questions regarding the prescription.

21.        I understand and agree that the Practices and Providers do not treat or provide medical advice on matters unrelated to mold or biotoxin related healthcare conditions including lab results that may identify conditions or indications unrelated to mold.  As a result, I agree that all ancillary Lab test results are for my informational purposes only and do not constitute a diagnosis or treatment of any disease or any other illness or health condition.  I understand that it is my responsibility alone to have a follow-up examination performed by my personal physician to assess the results of any such lab results and to obtain any advice or treatment, if applicable.  I acknowledge that none of MoldCo, the Lab, Practices or Practitioners have any obligation to provide follow up care, diagnosis, treatment or Healthcare Services arising from such ancillary lab results.

22.        I acknowledge that none of Practice or any Provider will actively participate in any litigation on my behalf other than responding to record requests and fulfilling any other obligation required under applicable laws.

23.        I acknowledge and understand that the Practices are not enrolled in Medicare or Medicaid and, as such, the Telehealth services are not covered by Medicare or Medicaid. You are responsible for paying for the Telehealth Services and our services are not eligible for subsequent reimbursement by Medicare, Medicaid or any other government-funded program.

THIRD PARTY LABS 

I understand that, depending on the type of service I request through MoldCo, I may request to certain lab tests with a MoldCo or Practice contracted “Third Party Lab” and in such case, I understand that I will be required to consent to such Third Party Labs’ respective consent to telehealth and notice of privacy practices, and any other terms and conditions governing the Telehealth and any related services with such Third Party Lab.  In the event, I engage with Junction f/k/a Vital Labs (“Junction”) for such Third Party Lab services, I understand that I will receive Telehealth through affiliated practices of Junction which includes, as applicable, Openloop Healthcare Partners, PC, Openloop Healthcare Partners California, PC, Openloop Healthcare Partners Colorado, PC, Openloop Healthcare Partners New Jersey, PC, Openloop Healthcare Partners Wisconsin SC, Reliant.MD Medical Associates, PLLC, Reliant.MD Medical Associates California, PC, Reliant.MD Medical Associates Colorado, PC, Reliant.MD Medical Associates New Jersey, PC, Reliant.MD Medical Associates Wisconsin, SC, MECNB Physician Services, PC, MECNB Physician Services California, PC, MECNB Physician Services Colorado, PC, MECNB Physician Services New Jersey, PC, and MECNB Physician Services, SC.  I understand that Junction will administer and coordinate the ordering and scheduling of my lab test, and I understand that I will be required to consent to Junction’s separate consent to telehealth and notice of privacy practices, and any other terms and conditions applicable to the Telehealth services provided by Junction.

CONSENT FOR GENETIC TESTING

• If genetic testing is being ordered by a Provider, I acknowledge that I have requested the performance of the genetic test (“Genetic Test”) at the Third Party Lab designated and ordered by the Provider. I acknowledge that my submission of a DNA specimen to be tested is voluntary.
• I understand that the purpose of the Genetic Test is to look for mutations or genetic characteristics known to be associated with certain genetic diseases, conditions, or pharmaceutical therapies related to mold or biotoxin exposure. I acknowledge that I have reviewed information specific to the Genetic Test and understand the Genetic Test’s risks, benefits, and limitations.
• I acknowledge that I have been provided with information about obtaining genetic counseling prior to giving my consent, and I understand that I may seek consultation with a geneticist, genetic counselor, and/or physician after testing.
• I understand that I will be asked to provide a blood, cheek swab, or saliva specimen in accordance with specified collection procedures.
• I understand that my specimen, along with my other personal and health information, will be sent for analysis to the Third Party Lab. DNA will be extracted from the specimen, and certain markers within regions of my genome relevant to the Genetic Test will be sequenced and analyzed. Upon successful completion of the Genetic Test, the results will be sent to me or my authorized representative. No other tests will be performed using the specimen except as authorized herein or permitted by applicable law.
• I hereby acknowledge that the Genetic Test results may become part of my permanent medical record and understand that some test results may impact my ability to obtain certain insurance benefits or insurance pricing. Laws against genetic discrimination may not apply to the military. I hereby acknowledge that genetic test results may have implications for my biological family members and unexpected family relationships may be identified through genomic testing.
• I acknowledge that the Genetic Test analyzes specific gene regions based on currently available information in the medical literature and scientific databases, as well as lab informatics and algorithms that may be subject to change. I further acknowledge that, as such, new information may replace or add to the information that was used to analyze my results that may impact the interpretation of results. I hereby acknowledge that, as with any lab test, there is a possibility of error including a false positive or a false negative result. Other sources of error, while rare, include specimen mix-up, poor specimen quality or contamination, inherent DNA sequence properties, and technical errors in the Third Party Lab.
• A positive Genetic Test result is indication that I may be predisposed to or have the specific disease or condition tested for.  I may wish to consider further independent testing and/or to consult a physician or genetic counselor.  I understand that a negative result does not guaranty that I will not develop the disease or condition tested.
• I acknowledge that if I have certain rare biological conditions or have had certain bone marrow, kidney, liver or heart transplants, transfusions, or hematologic malignancies, these conditions may limit the accuracy or relevance of the results or prevent the Genetic Test from being completed.
• I hereby acknowledge that MoldCo and Third Party Lab each disclaim any liability for the inaccuracy of the genetic test results due to such conditions or the failure to provide accurate, correct or complete information.
• I acknowledge that the Third Party Lab will obtain, retain, and use my personal, genetic and health information, specimen, and test information in compliance with applicable law and maintain the confidentiality thereof and protect from unauthorized disclosure or misuse in accordance applicable legal requirements. To the extent permitted by law, Provider and Third Party Lab may de-identify my discarded specimen and information for regulatory compliance purposes, internal quality control, validation studies, or research and development. I understand that any use or disclosure of the specimen and any data will be done in an anonymized manner by either encrypting or removing personally identifiable information in accordance with applicable law. 
• I give my DNA sample to the applicable Third Party Lab and it may be discarded or retained by the Third Party Lab as they deem appropriate and in accordance with applicable state and federal law. I understand that some samples may be stored indefinitely for test validation or education purposes after personal identifiers are removed. I agree that I am giving up any property or other interest in the DNA sample. As applicable, I understand that in certain states I have the option of giving Third Party Lab permission to store any specimen that remains after testing has been completed. All New York samples are discarded 60 days following test completion. I understand that I may request disposal of my sample by contacting Provider or Third Party Lab.
• The Third Party Lab results will be maintained in my records for as long as the applicable Practice and/or Third Party Labs elects to retain them.
• None of MoldCo, the Practices, my Provider, nor the Third Party Labs will use my information to grant or deny any insurance, employment, mortgage, loan, credit, public accommodation, educational opportunity or any other use prohibited by applicable law. The following are some of the examples of how my DNA analysis, genetic test results and other information and samples may be used and shared with others, as allowed by law: (i) with other healthcare providers and entities for treatment; (ii) with health plans and other payers as needed for payment for my testing and treatment; and (iii) for the Practices’ and Third Party Labs’ health care operations, including quality assurance and other lawful purposes.
• I agree that I have received a clear and prominent disclosure regarding the manner of collection, use, retention, maintenance and disclosure of my DNA specimen or the results of my Genetic Test for a specific purpose.

I have read and understand the information provided above regarding Telehealth and all of my questions  have been answered to my satisfaction. By clicking the “I AGREE” button and typing my name and date of birth at the  bottom of this page, I am authorizing the Practice and Provider to whom MoldCo facilitates a connection to assess my health via Telehealth and  confirming my agreement and understanding of the statements above. I hereby give my informed consent and authorization for my Provider to use Telehealth in my healthcare.