Telehealth Consent

INFORMED CONSENT REGARDING USE OF TELEHEALTH

Last Updated: (February 25, 2025)

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BY CLICKING “I AGREE,” CHECKING A RELATED BOX TO SIGNIFY YOUR ACCEPTANCE, USING ANY OTHER ACCEPTANCE PROTOCOL PRESENTED THROUGH THE SERVICE 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 HEREBYGRANT AGENCY AUTHORITY TO ANY PARTY WHO CLICKS ON THE “I AGREE” BUTTON OR OTHERWISE INDICATES ACCEPTANCE TO THIS CONSENT ON YOUR BEHALF.

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IF YOU ARE EXPERIENCING A LIFE-THREATENING SITUATION SUCH AS CONTEMPLATING SUICIDE, CALL 911 OR THE 988 SUICIDE & CRISIS LIFELINE AT 988.

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For emergency situations, telehealth is not an appropriate method of care. If you require immediate or urgent care, you must seek care at an emergency room facility or other provider equipped to deliver urgent or emergent care. Providers may not respond promptly to communications submitted through the Service.

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TELEHEALTH SERVICES

Ahvina, LLC provides an online platform through which users can access virtual consultations with independent, licensed healthcare professionals (referred to as “Providers”) and mail-order pharmacy services for any prescribed medications (collectively, the "Services"). These Services constitute a form of telehealth, which enables healthcare delivery through electronic communication between healthcare providers and patients who are not physically present in the same location. Telehealth offers various advantages, including convenience, privacy, and affordability.

Telemedicine, as provided by Ahvina, LLC, may be used for a variety of purposes, including but not limited to:

Transfer of electronic medical records: This includes the secure transmission of medical records, personal health information, images, or other relevant data between the patient and the healthcare provider.

Communication through multiple channels: Patients and healthcare providers can interact via various forms of communication, such as audio, video, or data-based systems, allowing for real-time consultations and information exchange.

Integration of medical device data: The healthcare provider may analyze data collected from medical devices, as well as sound or video files, to assist in the diagnosis or treatment of the patient.

Secure data exchange: All information transmitted electronically is safeguarded to ensure patient confidentiality and data integrity during the healthcare interaction.The electronic systems employed by Ahvina, LLC follow strict network and software security protocols designed to protect the privacy and confidentiality of your health information. These systems include safeguards that maintain the integrity of your data and prevent both intentional and unintentional access or corruption by unauthorized parties.

By accepting this Telehealth Consent Form, you explicitly agree to receive disclosures, notifications, messages, reports, and other communications from Ahvina, LLC, its contracted providers, and affiliated healthcare organizations through electronic channels, such as your account or email. You are responsible for checking and reviewing these communications regularly. You understand and agree that Ahvina, LLC, its providers, or any affiliated healthcare organization will not be responsible for any loss, injury, or damage resulting from your failure to read or respond to these communications, or from not following treatment recommendations.

Additionally, while Ahvina, LLC strives to protect the security of electronic transmissions, you acknowledge that no electronic communication system can be guaranteed 100% secure. By utilizing the Services, you agree to accept any risks associated with electronic transmission of your health information. Any information shared electronically between you and Ahvina, LLC, or its Providers, is considered as legally binding as if provided in written form.

Before beginning a telehealth consultation, your Provider will obtain your explicit consent to receive telehealth services.

Ahvina, LLC does not provide medical services, either directly or through its platform. Instead, Ahvina, LLC offers a technological platform that allows you to access and communicate with independent, licensed healthcare providers ("Providers") who are either employed by or contracted with a network of physician practices. You may utilize the platform and any information or resources it offers at your discretion when planning your healthcare or wellness. However, the resources and information provided through the platform are for informational purposes only and do not constitute medical advice or serve as a substitute for direct, in-person medical services. These resources do not guarantee any specific medical outcomes or results. Decisions regarding diagnosis, treatment recommendations, or both are entirely between you and the healthcare provider.

You acknowledge and agree that by using the Services to consult or coordinate care with a healthcare provider through the platform, you are not establishing a physician-patient relationship with Ahvina, LLC, its employees, or representatives. The platform is solely a facilitator of healthcare services provided by third-party professionals.

Unless you are in direct communication with a Provider, none of the information you receive through the platform constitutes or should be considered medical advice.

Ahvina, LLC makes no representations or warranties regarding the competence, qualifications, or skills of any Provider. You are solely responsible for determining whether to seek treatment from a Provider through the platform. While Ahvina, LLC takes limited steps to verify that Providers possess the required licenses, certifications, or legal registrations mandated by law, Ahvina, LLC expressly reserves the right to exclude or remove any Provider from its network, at its sole discretion, if it believes the Provider has engaged in inappropriate conduct, violated the platform’s terms of service, or for any other reason deemed necessary by Ahvina, LLC.

By accessing and using the Services, you certify and warrant that you are physically located in the state you have entered as your current location. You further acknowledge and agree that your ability to access and use the Services is contingent upon the truthfulness of this certification and that Ahvina, LLC, its Providers, and its Pharmacy Network rely on the accuracy of this certification to provide you with services. If it is discovered that this certification is inaccurate or false, you agree to indemnify, defend, and hold harmless Ahvina, LLC, its Providers, and its Pharmacy Network from and against any and all damages, losses, claims, liabilities, costs, or expenses arising as a result of such inaccuracy, including reasonable attorneys' fees and costs of litigation.

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Summary of Services Provided

The Services provided by Ahvina, LLC may include, but are not limited to, the following:

• Offering individuals information on healthcare and wellness topics.
• Providing individuals access to a network of licensed physicians and healthcare providers who are licensed in the state where the individual resides.
• Facilitating access to mail-order pharmacy services for the delivery of prescribed medications.
• Offering technology-driven tools designed to address specific health concerns.
• Assisting in the development and collection of healthcare records and health information for use in appointments with healthcare providers, ongoing communications, and pharmacy services, all of which are conducted by third-party providers unaffiliated with Ahvina, LLC.
• Providing administrative support for scheduling healthcare provider appointments and processing payments for healthcare and pharmacy services.
• Enabling telecommunications support to facilitate direct communication between users and healthcare providers for consultations, assessments, and treatments via the Services.
• Assisting individuals with the coordination of care between healthcare providers and ensuring the continuity of care throughout treatment.
• Offering individuals access to educational resources and tools to promote preventive care and lifestyle changes.
• Providing assistance with navigating the healthcare system, including referrals to specialists or additional healthcare services as needed.
• Maintaining a secure platform for storing and transmitting personal health information to ensure privacy and compliance with healthcare regulations.

It is important to note that the Services provided by Ahvina, LLC do not constitute medical treatment. You should always consult with a qualified healthcare professional for any final diagnosis, treatment decisions, and guidance on which medications or treatments may be appropriate for you. None of the information provided through the Services guarantees that any specific medication or treatment is safe, effective, or appropriate for your individual circumstances. Ahvina, LLC does not endorse or recommend any specific tests, physicians, medications, products, or procedures.

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Availability and Eligibility

Ahvina, LLC is based in the United States, and the Services are intended solely for individuals located within the United States. Ahvina, LLC makes no representations or warranties that the Services, or any content provided through them, are accessible, appropriate, or available outside the United States. If you access the Services from outside the United States, you do so at your own risk and are solely responsible for compliance with applicable local laws, including export laws.

Our Services are available for use only by individuals who meet the following criteria. By accessing or using the Services, you represent and warrant that:

• Age Requirement: You must be at least 18 years old to access or use the Services. In certain cases, specific Services may only be available to individuals who are 21 years or older; you will be notified of such age restrictions where applicable. If you are under 18 years of age, you may only access the Services with the express consent of a parent or legal guardian.
• Geographical Requirement: You confirm that you are physically located in a state where Ahvina, LLC operates. The Services are intended to be used only by individuals located within states where Ahvina, LLC is authorized to provide services.
• Compliance: By using the Services, you agree to comply with all applicable laws, regulations, and these Terms of Service. You further agree to provide accurate and truthful information when required, and to adhere to any additional requirements specific to certain Services as outlined by Ahvina, LLC.
• Eligibility Acknowledgment: You understand that satisfying the above criteria does not guarantee access to all Services offered by Ahvina, LLC. Ahvina, LLC reserves the right to update or modify eligibility requirements at any time, at its sole discretion, and without prior notice.
• Technology Requirements: In order to access or use the Services, you must have a compatible device, reliable internet access, and any necessary software. Additional fees or charges may apply for mobile data usage and internet services.

Meeting the above criteria does not guarantee that you will be provided access to all Services. Ahvina, LLC and its affiliated professional entities reserve the right to modify eligibility criteria or add new requirements at any time, at their sole discretion, without prior notice.

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BENEFITS OF TELEHEALTH

Telehealth can offer several significant advantages, particularly in terms of accessibility and convenience. Some of the anticipated benefits of using telehealth may include:

1. Increased Access to Care: Telehealth removes the barriers of distance, enabling you to connect with Providers who may not be easily accessible through traditional in-office visits. This is particularly beneficial for those living in rural or remote areas or for individuals with mobility challenges.
2. Convenience and Flexibility: With telehealth, you can receive care from the comfort of your own home, at work, or while traveling. It allows you to schedule appointments at times that fit into your busy schedule, without the need to travel to a physical location.
3. Continuity of Care: Telehealth facilitates continuous interaction with your Provider, allowing for more frequent follow-ups or timely adjustments to your treatment plan, which can improve outcomes for both physical and mental health conditions.
4. Improved Relationship Building: Telehealth encourages ongoing communication between you and your Provider, which can lead to stronger relationships and better trust, ultimately improving your healthcare outcomes.

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POSSIBLE VULNERABILITIES

While telehealth can be a valuable tool in delivering care, it also comes with certain limitations and risks. These potential risks include, but are not limited to, the following:

1. Limitations in Quality and Accuracy: The quality of the healthcare services you receive through telehealth may be limited by the lack of direct, in-person examination. Certain conditions or symptoms may be difficult to accurately diagnose or treat remotely without physical tests, observations, or hands-on evaluations.
2. Technological Issues: The effectiveness of telehealth relies on the proper functioning of electronic communication systems. Any failure of internet connectivity, software glitches, or hardware malfunctions could lead to delays, incomplete assessments, or miscommunications between you and your Provider. Additionally, telehealth platforms may contain bugs or errors that may cause incorrect data to be transmitted or prevent certain functions from operating as intended.
3. Privacy and Security Concerns: Although the Service incorporates network and software security measures to protect your personal information and PHI, there is always a risk that unauthorized third parties could intercept or access electronic communications. Data breaches or other security vulnerabilities could result in the unintended disclosure of sensitive information.
4. Inability to Perform Certain Tests: Telehealth limits your Provider's ability to conduct physical examinations, measure vital signs, or perform diagnostic tests that would typically be conducted in a clinical setting. This could potentially delay the detection of serious health conditions or require you to seek alternative methods of care.
5. Delayed Care in Emergency Situations: Telehealth is not a substitute for emergency care. If you are experiencing a life-threatening or urgent situation, telehealth may not provide timely medical intervention. Delays in treatment or evaluation could occur if your Provider is unavailable or technical failures disrupt communication.
6. Data Integrity and Diagnostic Accuracy: The use of technology to transmit medical data (such as lab results or diagnostic images) may be subject to inaccuracies or errors in interpretation. These could affect the reliability of the diagnosis or treatment decisions made by your Provider.
7. Potential Regulatory Restrictions: Depending on your location, local laws or regulations may restrict or limit certain telehealth services, such as prescribing certain medications. These legal constraints may affect your Provider’s ability to offer comprehensive care.

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YOUR DATA

Ahvina, LLC is committed to ensuring the security and confidentiality of your personal information and protected health data. The electronic systems and services provided by Ahvina, LLC are designed with comprehensive network and software security protocols that help to protect your data against unauthorized access, alteration, or accidental loss. These safeguards include advanced encryption technologies, firewall protections, and regular system monitoring to prevent data breaches or corruption, whether intentional or unintentional.

Ahvina, LLC will not disclose any personal information that can identify you, or any protected health information, to third parties without your explicit consent, unless required by law. Such legal requirements may include, but are not limited to, the following scenarios: facilitating consultations with healthcare providers, processing payments and billing, completing administrative procedures, or complying with mandatory reporting laws.

It’s important to understand that while Ahvina, LLC takes robust measures to protect your personal and health information, the use of electronic communication tools—such as email, messaging systems, or third-party platforms—does not come without risks. Despite our best efforts to maintain the privacy and security of your information, no system is entirely immune to potential vulnerabilities. For instance, if you use unsecure communication methods, such as standard email providers, we cannot guarantee absolute confidentiality of those services. Therefore, we encourage you to take additional precautions when using non-secure communication channels and to be aware of how your personal information may be handled by external service providers.

By using the services provided by Ahvina, LLC, you acknowledge and accept the risks associated with electronic communications, and you agree to share information via these platforms as part of your healthcare or mental health services. However, we assure you that Ahvina, LLC will continue to prioritize the privacy and protection of your personal data to the greatest extent possible, using industry-standard security practices.

If a technical failure prevents you from communicating with your Providers through the Service, you should call the following number: 740-737-8727

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OPEN PAYMENTS NOTICE

For informational purposes only, a link to the federal Centers for Medicare and Medicaid Services Open Payments web page is provided here. The federal Physician Payments Sunshine Act requires that detailed information about payment and other payments of value worth over ten dollars ($10) from manufacturers of drugs, medical devices, and biologics to physicians and teaching hospitals be made available to the public. The Open Payments database can be found at https://openpaymentsdata.cms.gov.

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YOU EXPRESSLY ACKNOWLEDGE AND AGREE THAT:

• Use at Your Own Risk: Your access to and use of the Services, including reliance on any content or information provided by Ahvina, LLC, is done entirely at your own risk. You assume full responsibility for any risks or damages arising from your use of the Services, including any harm to your computer system, data, or devices, or loss of data resulting from downloading, accessing, or using the Services.
• No Medical or Professional Advice: The Services and any information made available through them are not intended to provide professional, financial, legal, or medical advice. You should consult with appropriate professionals, including licensed healthcare providers, for any decisions regarding medical or professional matters. Ahvina, LLC is not responsible for your reliance on any content provided through the Services, which may be inaccurate or incomplete.
• User-Generated Content: Ahvina, LLC does not endorse, warrant, or assume any responsibility for any user-generated content or communications available through the Services. Any such content is the responsibility of the individuals providing it, and Ahvina, LLC is not liable for any claims, damages, or losses arising from such content.

No Warranties of Any Kind: Ahvina, LLC makes no guarantees or representations regarding the availability, quality, reliability, or effectiveness of the Services or any products or services provided by third parties through the Services. You agree that your use of the Services is entirely voluntary and that you assume all risk and liability associated with such use.

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Limitation of Warranties in Certain Jurisdictions: Some jurisdictions do not allow the exclusion of implied warranties or limitations on how long an implied warranty lasts, so certain exclusions or limitations in this Disclaimer of Warranties may not apply to you. However, in such jurisdictions, the exclusions and limitations will apply to the maximum extent permitted by law.

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General Disclaimer: No advice, information, or statement made by Ahvina, LLC, its employees, contractors, or representatives, whether written, oral, or via the Services, shall create any warranty not expressly stated in this Disclaimer. You are solely responsible for verifying the accuracy, completeness, and suitability of all content and information obtained through the Services before relying on it. In certain instances, your provider may determine that telehealth is not appropriate for your specific condition and may refer you to seek in-person care or specialized treatment from other healthcare providers. This decision is at the sole discretion of your provider, based on their assessment of your condition.

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Limitation of Liabilities

To the fullest extent permitted by applicable law, Ahvina, LLC, its affiliates, and their respective officers, directors, employees, agents, licensors, contractors, and service providers shall not be liable for any direct, indirect, incidental, consequential, special, exemplary, punitive, or other damages whatsoever, including but not limited to:

1. Loss of profits, revenue, data, or business opportunities;
2. Business interruption, goodwill, or reputation damage;
3. Personal injury or property damage;
4. Errors, inaccuracies, or omissions in the Services;
5. Unauthorized access to or use of your accounts, personal information, or data;
6. Viruses, malware, or other harmful components that may be transmitted through the Services;
7. Any decisions or actions taken in reliance on the information or services provided through the Services;
8. Any third-party products or services used or accessed through the Services.

Ahvina, LLC shall not be liable for any damages arising out of or in connection with your use or inability to use the Services, whether based on contract, tort (including negligence), strict liability, or any other legal theory, even if Ahvina, LLC has been advised of the possibility of such damages.

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Exclusions and Limitations:
Some jurisdictions do not allow the exclusion or limitation of certain liabilities, including the exclusion of incidental or consequential damages. In such jurisdictions, the limitations and exclusions of liability set forth in these Terms of Service shall apply to the fullest extent permitted by applicable law.

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No Liability for Third Parties:
Ahvina, LLC shall not be liable for any acts, errors, omissions, or damages caused by third parties, including but not limited to affiliated healthcare providers, pharmacy services, contractors, service providers, or any third-party content accessible through the Services. Any claims or disputes you have with third parties arising from your use of the Services must be pursued directly with the third party.

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Acknowledgment of Risk:
By using the Services, you acknowledge and agree that your use is entirely at your own risk and that you are solely responsible for any damage to your property (including your computer system, mobile devices, or data) or any other loss or harm resulting from such use.

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Concerns About Providers

If you have concerns about the services provided by any healthcare professional, you may contact the relevant medical board or regulatory body in your state.

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ADDITIONAL STATE-SPECIFIC DISCLOSURES

The following consents apply to patients accessing the Services for the purposes of participating in a telehealth visit within the states listed below, as required by state law:

Alaska: You understand that your primary care provider may obtain a copy of your records from your telehealth encounter.

California Patients: 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. For informational purposes only, a link to the federal Centers for Medicare and Medicaid Services (CMS) Open Payments web page is provided above. The federal Physician Payments Sunshine Act requires that detailed information about payment and other payments of value worth over ten dollars ($10) from manufacturers of drugs, medical devices, and biologics to physicians and teaching hospitals be made available to the public.

Treatment Records: If you live in one of the following states, your primary care provider or other treating physician may obtain a copy of your telehealth treatment records with your consent. If you need help sending your telehealth treatment records to your primary care provider, you can call 740-737-8727.

Connecticut: You understand that your primary care provider may obtain a copy of your records from your telehealth encounter.

Kansas: If you have a primary care provider or other treating physician, the person providing telemedicine services must send a report to your primary care or other treating physician of the treatment and services rendered to you during the telemedicine encounter within three days of you providing consent to the person providing telemedicine services to send such a report.

New Hampshire: You understand that your primary care provider or treating provider may obtain a copy of your records from your telehealth encounter.

New Jersey: You understand that you have the right to request a copy of your medical information, and that your medical information may be forwarded directly to your primary care provider or health care provider of record, or, upon your request, to other health care providers.

Ohio: You understand that your primary care provider may obtain a copy of your records from your telehealth encounter.

South Carolina: You understand that your medical records may be distributed only with your consent and in accordance with applicable laws and regulations to other treating health care practitioners.

Texas: You understand that with your consent, your medical records may be sent to your primary care physician within 72 hours after receiving services.

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Billing:

Patients residing in New Jersey, New York, and Rhode Island have the right under each states respective billing laws to request an itemized price list for laboratory results.

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Formal Complaints:

California: You have been informed that if you want to register a formal complaint about a provider, you should visit the medical board’s website here, or the physician assistant board’s website here.

Georgia: You have been informed that if you want to register a formal complaint about a provider, you should visit the medical board’s website, here.

Idaho: You have been informed that if you want to register a formal complaint about a provider, you should visit the medical board’s website, here.

Indiana: You have been informed that if you want to register a formal complaint about a provider, you should visit the medical board’s website, here.

Iowa: You have been informed that if you want to register a formal complaint about a provider, you should visit the medical board’s website, here.

Kentucky: You have been informed that if you want to register a formal complaint about a provider, you should visit the medical board’s website, here.

Maine: You have been informed that if you want to register a formal complaint about a provider, you should visit the medical board’s website, here.

New York: You have been informed that to get information regarding your rights and how to report professional misconduct, you should visit here.

Oklahoma: You have been informed that if you want to register a formal complaint about a provider, you should visit the medical board’s website, here; or, the Oklahoma Board of Osteopathic Examiners’ website, here.

Oregon: You have been informed that if you want to register a formal complaint about a provider, you should visit the medical board’s website, here.

Rhode Island: You have been informed that if you want to register a formal complaint about a provider, you should visit the medical board’s website, here.

Texas:

NOTICE CONCERNING COMPLAINTS - 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 our website at www.tmb.state.tx.us.

AVISO SOBRE LAS QUEJAS - Las quejas sobre médicos, asi como sobre otros profesionales acreditados e inscritos del Consejo Médico de Tejas, incluyendo asistentes de médicos, practicantes de acupuntura y asistentes de cirugia, se pueden presentar en la siguiente

dirección para ser investigadas: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018, Si

necesita ayuda para presentar una queja, llame al: 1-800-201-9353, Para obtener más información, visite nuestro sitio web en www.tmb.state.tx.us.

Vermont: You have been informed that if you want to register a formal complaint about a provider, you should visit the medical board’s website, here; or, the Vermont Board of Osteopathic Examiners’ website, here.

Wyoming: You have been informed that if you want to register a formal complaint about a provider, you should visit the medical board’s website, here.