Ziggy Telehealth LLC Telehealth Informed Consent

Patient-Facing Brand: MANÜ Telehealth
Practice Contact: info@manutelehealth.com · +1 (786) 460-9055
Privacy Contact: info@manutelehealth.com · +1 (786) 460-9055

Please read this consent before continuing. Contact the Practice if you need help understanding it, an interpreter, an accessible format, or answers to your questions.

1. Important Information

This consent is between you and Ziggy Telehealth LLC (the "Practice").

The Practice and its licensed healthcare professionals provide your healthcare services. Medoura is a technology platform owned and operated by CoFabri LLC. Medoura is not a healthcare provider and does not diagnose, treat, prescribe, dispense medication, or make patient-specific clinical decisions.

Completing onboarding, submitting information, or accepting this consent:

• does not guarantee that the Practice will accept you as a patient;
• does not guarantee that any treatment or medication will be recommended or prescribed;
• does not replace a provider's professional judgment; and
• does not necessarily create a provider-patient relationship before the Practice or provider completes the steps required by applicable law and Practice procedure.

2. What Telehealth Means

Telehealth is healthcare provided when you and your healthcare provider are in different physical locations and communicate through electronic technology.

Telehealth may include:

• live video visits;
• telephone or audio visits;
• secure messages or chat;
• electronic forms and questionnaires;
• photographs, documents, laboratory results, and other files;
• remote monitoring information;
• asynchronous review, where you submit information and a provider reviews it later;
• care coordination with pharmacies, laboratories, specialists, or other healthcare providers; and
• other electronic communications permitted by law and approved by the Practice.

Telehealth may be used for evaluation, diagnosis, consultation, treatment, follow-up, monitoring, education, and prescribing when the provider determines it is clinically appropriate and legally permitted.

Email or ordinary text messaging alone may not constitute a telehealth visit and should not be used for urgent medical needs unless the Practice specifically directs you to use that method.

3. Voluntary Choice and Alternatives

Using telehealth is voluntary.

Alternatives may include:

• an in-person visit with the Practice, if the Practice offers in-person care;
• care from another healthcare provider or facility;
• urgent care or an emergency department when appropriate;
• delaying non-urgent care; or
• choosing not to receive the proposed service.

The Practice may determine that telehealth is not appropriate for your condition and may require or recommend an in-person examination, laboratory testing, imaging, emergency evaluation, or care from another provider.

Choosing not to use telehealth may mean that the Practice cannot provide some or all requested services remotely.

4. Possible Benefits

Possible benefits of telehealth include:

• more convenient access to care;
• reduced travel or waiting time;
• access to providers who may not be located nearby;
• easier follow-up and care coordination;
• electronic sharing of health information; and
• the ability to receive some services from your chosen location.

These benefits are not guaranteed.

5. Risks and Limitations

Telehealth has risks and limitations. These may include:

• the provider may receive less information than during an in-person examination;
• some symptoms or conditions may be difficult or impossible to evaluate remotely;
• information you submit may be incomplete, inaccurate, outdated, delayed, or misunderstood;
• poor lighting, sound, camera quality, connectivity, or device problems may affect the evaluation;
• technology may fail, disconnect, or delay care;
• messages or asynchronous submissions may not be reviewed immediately;
• the provider may need additional records, photographs, vital signs, laboratory testing, imaging, or an in-person examination;
• a condition may be misdiagnosed or treatment may be delayed because of telehealth limitations;
• electronic communications may be intercepted, misdirected, accessed, or disclosed despite safeguards;
• people at your location may see or hear private information;
• a pharmacy, laboratory, communications provider, or other third party may experience delay or error; and
• telehealth may not be available or legally permitted while you are in a particular location.

No technology or security measure can eliminate every risk.

6. Emergencies and Urgent Conditions

Telehealth onboarding, forms, messages, refill requests, and routine visits are not emergency services and may not be reviewed immediately.

For an emergency:

• call 911; or
• go to the nearest emergency department.

For a suicide, self-harm, mental-health, or substance-use crisis in the United States, call or text 988.

If a provider believes you need urgent or emergency care, the provider may instruct you to contact emergency services or may contact emergency services when permitted or required by law.

At the beginning of a telehealth encounter, you may be asked to provide:

• your current physical location;
• a telephone number where you can be reached;
• an emergency contact; and
• information needed to direct emergency assistance to you.

7. Your Identity, Location, and Eligibility

You agree to provide accurate identity, contact, health, and location information.

You understand that:

• your provider generally must be licensed, registered, or otherwise legally authorized to provide care where you are physically located;
• you must disclose your actual physical location during each telehealth encounter;
• the state listed in your profile does not replace confirmation of your current location;
• the Practice may delay, decline, or stop care if your location cannot be verified or the provider is not authorized to treat you there;
• the Practice may require identity verification before providing care; and
• you must promptly update inaccurate or outdated information.

Do not misrepresent your identity, age, location, symptoms, medical history, medications, laboratory results, or other information.

8. Provider Information and Clinical Judgment

The treating provider will be identified through the Practice's workflow.

You may ask about the provider's:

• name;
• professional title;
• licensure;
• credentials;
• role in your care; and
• location.

Provider availability may vary based on scheduling, professional scope, state authorization, and clinical needs.

The provider may:

• decide that telehealth is not appropriate;
• request more information;
• require a live visit;
• require an in-person examination or testing;
• refer you to another provider or facility;
• decline to prescribe a medication; or
• discontinue telehealth care when clinically or legally appropriate.

9. Your Responsibilities During Telehealth

You agree to:

• provide complete and truthful information;
• follow reasonable instructions from the Practice and provider;
• participate from a reasonably private and safe location;
• use a device and connection suitable for the encounter;
• tell the provider if another person is present or can hear the encounter;
• tell the provider if you do not understand something;
• disclose changes in symptoms, medications, allergies, pregnancy status, medical history, or location;
• seek emergency or in-person care when instructed;
• not use telehealth while driving or operating dangerous equipment; and
• protect your account, authentication codes, device, and communications from unauthorized use.

You are responsible for privacy at your location. Use headphones or a private room when reasonably possible.

10. Other People, Interpreters, and Observers

Tell the provider if another person is present with you.

The Practice will identify interpreters, caregivers, trainees, scribes, consultants, or other participants when required and will obtain additional permission where applicable.

You may ask a person to leave unless their participation is necessary or legally required.

Do not record a telehealth encounter unless all participants have first agreed and the recording is permitted by applicable law.

The Practice will not intentionally record the audio or video of a visit without notice and any consent required by law. Ordinary medical records, audit logs, messages, and technical records may still be created and retained.

11. Privacy and Health Information

Telehealth requires electronic collection, use, transmission, and storage of health and identifying information.

This information may include:

• identity and contact information;
• medical history;
• symptoms and diagnoses;
• treatment plans;
• medications and pharmacy information;
• laboratory and imaging information;
• photographs, documents, audio, or video;
• communications with providers;
• billing and payment information; and
• technical and acceptance records.

The Practice will use and disclose your information as permitted or required by law and as described in its Notice of Privacy Practices.

Practice Notice of Privacy Practices:

The Practice uses Medoura and may use other technology vendors to support telehealth. Medoura handles information on the Practice's behalf under applicable agreements. The Practice may also share information with pharmacies, laboratories, specialists, emergency services, payment processors, and other persons or organizations involved in your care or operations as permitted by law.

Reasonable safeguards are used, but confidentiality and security cannot be guaranteed.

12. Medical Records and Care Coordination

The Practice will document telehealth services in your medical record as required by law and Practice policy.

The Practice may use or disclose relevant information for treatment, payment, healthcare operations, legal obligations, and other purposes described in its Notice of Privacy Practices.

When permitted or authorized, the Practice may send records or treatment information to:

• your primary care provider;
• another treating provider;
• a pharmacy;
• a laboratory;
• a specialist;
• an emergency department; or
• another person or organization involved in your care.

Contact the Practice for medical-record requests, corrections, restrictions, or other patient-rights requests.

Medical Records or Privacy Contact: info@manutelehealth.com · +1 (786) 460-9055

13. Medications and Prescribing

You understand that:

• a provider will prescribe only when the provider determines that prescribing is clinically appropriate and legally permitted;
• no medication or particular medication is guaranteed;
• the provider may require identity verification, vital signs, laboratory testing, records, follow-up, a live visit, or an in-person examination;
• prescribing rules may vary based on the medication, provider type, and your physical location;
• controlled substances and other regulated medications may have additional restrictions;
• the provider may decline, discontinue, change, or refuse to renew a medication when clinically or legally appropriate;
• pharmacy choice may be limited by law, product availability, service arrangements, safety, or clinical considerations; and
• pharmacies and fulfillment providers are separate entities responsible for dispensing, compounding, shipping, and related operations.

This telehealth consent does not replace any medication-specific, treatment-specific, or compounded-medication consent or disclosure required by the Practice.

14. Fees, Insurance, and Financial Responsibility

Telehealth services may result in charges.

Your financial responsibility is governed by the Practice's current payment, subscription, cancellation, refund, and insurance terms.

Practice Payment and Refund Terms:

You understand that:

• insurance coverage and reimbursement are not guaranteed;
• the Practice may be self-pay, insurance-based, or use another payment model;
• you are responsible for confirming benefits, coverage, and out-of-pocket costs when applicable;
• laboratories, pharmacies, specialists, and other third parties may charge separately; and
• accepting this telehealth consent does not by itself authorize a particular charge, subscription, recurring payment, or waiver of payment rights.

15. Technical Problems

If technology fails during a telehealth encounter, the Practice or provider may:

• try to reconnect;
• contact you by an approved alternate method;
• reschedule;
• continue through another legally permitted method;
• direct you to in-person care; or
• stop the encounter if safe and appropriate care cannot continue.

Technical Support: info@manutelehealth.com · +1 (786) 460-9055

Do not use technical support for medical advice or emergencies.

16. Right to Ask Questions

You may contact the Practice with questions before accepting this consent.

You may also ask the treating provider questions before or during the telehealth encounter. The provider may review or reconfirm this consent with you before providing care.

Accepting this form does not prevent you from asking questions later.

Clinical Questions: info@manutelehealth.com · +1 (786) 460-9055

17. Right to Refuse or Withdraw

You may refuse telehealth or withdraw this consent prospectively by notifying the Practice.

Withdrawal:

• does not undo telehealth services already provided;
• does not require deletion of records the Practice must or may retain;
• does not remove financial responsibility for services already provided;
• does not affect lawful uses or disclosures that occurred before withdrawal; and
• may mean the Practice cannot continue providing remote services.

The Practice may explain available alternatives or refer you elsewhere but is not required to offer in-person care unless applicable law or an existing duty requires it.

How to Withdraw Consent: info@manutelehealth.com · +1 (786) 460-9055

18. Minors and Authorized Representatives

By accepting this consent, you affirm that:

• you are the patient and have legal capacity to consent; or
• you are legally authorized to consent on the patient's behalf.

If you are accepting for another person, the Practice may require:

• your name and relationship to the patient;
• proof of identity;
• proof of legal authority;
• the patient's participation or assent where applicable; and
• additional consent required by law.

The Practice may decline to proceed until authority to consent is verified.

19. Electronic Consent and Copy

You may review, download, print, or request a copy of this consent.

By checking the acceptance box:

• you choose to use an electronic record and electronic signature for this consent;
• you intend your checkbox acceptance to be your signature;
• you confirm that you can access and read this electronic document;
• you understand that the Practice and Medoura may record evidence of your acceptance; and
• you agree that an electronic copy may be retained and reproduced.

You may request a paper or electronic copy from:

Consent Copy Contact: info@manutelehealth.com · +1 (786) 460-9055

Withdrawing consent to future telehealth does not invalidate consent or records created before the withdrawal became effective.

20. Patient Acknowledgment

By accepting below, I confirm that:

• I have read this Telehealth Informed Consent or had it read or explained to me;
• I understand what telehealth is and the types of technology that may be used;
• I understand the possible benefits, risks, limitations, and alternatives;
• I understand that telehealth is not for emergencies;
• I understand that I must provide my true identity and current physical location;
• I understand that telehealth may not be appropriate for every condition;
• I understand that treatment and prescribing are not guaranteed;
• I understand how my information may be used and disclosed;
• I understand that this form does not replace service-, treatment-, or medication-specific consent;
• I know how to contact the Practice with questions;
• I understand that I may refuse or withdraw consent prospectively;
• I am accepting voluntarily and have legal authority to do so; and
• I understand that Medoura provides technology only and is not my healthcare provider.

Acceptance Checkbox

I have read and understand this Telehealth Informed Consent. I voluntarily consent to receive healthcare services from Ziggy Telehealth LLC through telehealth, including the electronic and asynchronous methods described above. I understand that I may ask questions and may withdraw this consent prospectively. By checking this box, I intend to sign this consent electronically.