Telehealth Informed Consent

1. Important Emergency Notice

Telehealth services do not address medical emergencies. If I believe I am having a medical emergency, a mental-health crisis, suicidal thoughts, or a condition requiring immediate in-person evaluation, I will call 911, go to the nearest emergency department, or contact an appropriate crisis or emergency service. I understand that a provider available through this platform may not be able to respond immediately or provide emergency intervention.

2. Parties and Purpose of This Consent

This Telehealth Informed Consent and Communication Preferences document (this "Consent") applies to telehealth services provided by the independent professional entity made available to you through RubyMD (the "Practice") and the independent licensed healthcare professionals who provide clinical services through or in connection with the Practice (each, a "Provider"). The Practice is the entity responsible for the clinical care and for the patient's clinical records.

RubyMD provides non-clinical technology, administrative, scheduling, customer-support, education, payment-administration, marketing, and operational services. RubyMD is not a healthcare provider, pharmacy, or prescriber. No clinician-patient relationship is created with RubyMD. This Consent does not replace the Practice's Notice of Privacy Practices, the patient's treatment-specific consent forms, pharmacy documents, medication guides, or any additional disclosures required by applicable law.

The purpose of this Consent is to explain telehealth, describe its material benefits, risks, and alternatives, and obtain my voluntary informed consent to receive telehealth services from the Practice and a Provider when clinically appropriate.

3. Voluntary Consent and Acknowledgment

By checking the acceptance box, clicking "I Consent," signing electronically, or otherwise affirmatively accepting this Consent, I acknowledge and agree that:

• I have read this Consent or had an opportunity to have it explained to me.
• I have had the opportunity to ask questions about telehealth and receive answers.
• I am at least eighteen (18) years old and am able to consent to my own healthcare, unless a different legally valid consent process is provided by the Practice.
• I am physically located in the state I report at the time of each telehealth encounter.
• I understand that I may decline telehealth or withdraw this Consent for future telehealth services at any time by notifying the Practice, subject to any legal, clinical, financial, or recordkeeping obligations that have already arisen.
• I understand that withdrawal of consent will not affect services already provided or disclosures already made in reliance on this Consent, or my right to seek other care. The Practice or Provider may require an in-person evaluation or discontinue telehealth if withdrawal makes remote care inappropriate.

4. What Telehealth Means

Telehealth means the delivery of healthcare services using secure communications technology when the patient and Provider are in different locations. Depending on the clinical circumstances and applicable law, telehealth may include live audio-video visits, telephone visits, secure messaging, asynchronous review of information, remote monitoring, electronic questionnaires, and other permitted communication methods.

Telehealth may be used for evaluation, consultation, diagnosis, treatment planning, education, follow-up, care management, prescription-related discussions, and other healthcare services that a Provider determines may be appropriately delivered remotely. I understand that the Provider will decide whether telehealth is clinically appropriate for my particular needs.

5. Benefits, Risks, Limitations, and Alternatives

I understand that telehealth may offer convenience, timely access to a Provider, reduced travel, improved continuity of care, and access to clinicians with relevant experience. I also understand that telehealth has important risks and limitations, including:

• technical failures, interrupted connections, delayed transmissions, poor audio or video quality, device or internet problems, or inability to complete a visit;
• privacy or security risks if I use an unsecured network, public location, shared device, or communication channel that others can access;
• a Provider's inability to conduct a full in-person examination, obtain vital signs, perform certain tests, assess all physical findings, or access a complete medical record;
• the possibility that incomplete information, inaccurate information, delayed communication, or limitations of remote examination could affect assessment or treatment;
• the possibility that I will need in-person care, urgent care, emergency care, referral, testing, or a different form of treatment;
• the possibility that telehealth will not be effective or appropriate for my condition, that my condition will not improve, or that it may worsen; and
• the possibility that a prescription, medication, treatment plan, referral, or other requested outcome will not be offered because a Provider determines it is not clinically appropriate or legally permitted.

I understand that alternatives to telehealth may include an in-person visit with the Practice, another clinician, urgent care, emergency care, or no treatment. I may discuss alternatives with my Provider. I understand that I may stop a telehealth encounter if the connection, privacy, or other circumstances are inadequate, and the Provider may also stop or reschedule it.

6. Provider Identity, Licensure, and Clinical Judgment

Before or at the time I receive care, the Practice will make available the identity and professional credentials of the Provider involved in my care as required by law. The Provider may be a physician, nurse practitioner, physician assistant, mental-health professional, registered dietitian, or other appropriately licensed professional acting within the Provider's permitted scope of practice.

I understand that the Provider's professional judgment is independent. The Provider, not RubyMD, determines whether to accept me as a patient, whether telehealth is appropriate, what information or follow-up is needed, whether a prescription is appropriate, and whether to refer or direct me to other care. No part of this Consent guarantees a particular diagnosis, prescription, medication, treatment, or result.

7. My Responsibilities as a Patient

I agree to:

• provide accurate, complete, current, and truthful information about my identity, age, location, medical history, symptoms, medications, allergies, conditions, and other information relevant to my care;
• tell the Provider about material changes in my condition, medications, allergies, contact information, or location;
• be physically located in the state I identify at the start of each encounter and promptly notify the Provider if my location changes;
• participate from a private and safe location, use reasonable safeguards to protect my devices and passwords, and tell the Provider if another person is present;
• disclose the name and role of any person assisting me during a visit, including an interpreter or caregiver;
• follow reasonable instructions for follow-up, in-person assessment, medication use, and emergency care;
• immediately seek emergency care rather than waiting for a response through the platform when I have an emergency; and
• keep the Practice informed of a reliable method of contact and, where requested, an emergency contact.

8. Privacy, Security, and Health Information

The Practice will maintain my medical record and use reasonable safeguards designed to protect the privacy and security of my health information. I will receive the Practice's Notice of Privacy Practices, which describes my rights concerning protected health information and the Practice's legal duties. I may request a copy at any time using the Practice's privacy contact information below.

I understand that no technology or method of transmission is entirely free from risk. I accept the ordinary and inherent risks of using communications technology, including unauthorized access caused by my own use of unsecured devices, shared accounts, public networks, or private locations that are not secure. This does not waive any right I may have under applicable law or excuse the Practice from its legal duties to protect health information.

The RubyMD-enabled patient portal, intake, scheduling, clinical-visit, and medical-record environments are intended to be operated without advertising pixels, behavioral-advertising tags, session-replay tools, or other marketing trackers. I should not send medical or urgent information through ordinary email, social media, a public-site contact form, or advertising-platform lead form.

9. Others Present; Interpretation; Recording

I understand that the Provider may be in a remote private location. If another person is present with the Provider, such as a translator, chaperone, care coordinator, trainee, technical-support person, or other authorized individual, I will be informed of that person's presence and role when required or appropriate.

I may have a support person, interpreter, caregiver, or other person present with me if appropriate and if I notify the Provider. I understand that a person I invite into the encounter may hear or see my health information.

The Practice will not record an audio or video telehealth visit unless it provides any notice, obtains any consent, and follows any safeguards required by applicable law. If a recording is proposed, I may ask questions about its purpose, retention, access, and my options. Any use of clinical documentation tools or other technology must be separately disclosed if required by law or the Practice's policy.

10. Prescriptions, Pharmacies, and Medications

I understand that a telehealth visit does not guarantee that I will receive a prescription, refill, medication, treatment recommendation, or referral. A Provider may prescribe only if the Provider determines that doing so is clinically appropriate and permitted by applicable law, professional standards, and the Provider's scope of practice. The Provider may require further assessment, medical records, an in-person examination, laboratory or diagnostic information, or other follow-up before prescribing or continuing a medication.

I understand that medications may have risks, side effects, contraindications, drug interactions, and alternatives. I will read medication guides and pharmacy information, disclose all medications and allergies, and contact the Provider or pharmacist with questions. I will seek emergency care for a suspected serious reaction or emergency.

A Provider may discuss or prescribe a medication for a use that is not specifically approved by the U.S. Food and Drug Administration for that particular use when the Provider determines that use is clinically appropriate. The Provider should discuss material risks, benefits, alternatives, and questions relevant to my care.

If I receive a prescription for a compounded medication, I understand that compounded drugs are not approved by the U.S. Food and Drug Administration in the same manner as commercially available approved drugs. I understand that a compounded medication may be appropriate only when determined by my Provider and dispensed by an appropriately licensed pharmacy. I will receive or have access to treatment-specific information and may ask questions before starting the medication.

I understand that pharmacies are independent. A pharmacy is responsible for dispensing, medication counseling, shipping, storage instructions, fulfillment, pricing, substitutions permitted by law, and pharmacy-specific terms. I may ask to use a pharmacy of my choice, subject to legal, clinical, operational, and prescription-transfer limitations. I am responsible for receiving and storing any temperature-sensitive medication according to the pharmacy's instructions and for keeping medications out of the reach of children and others for whom they are not prescribed.

11. Treatment-Specific Disclosures

A Provider may require additional informed-consent documentation for the particular service, medication category, condition, or treatment recommended to me. This may include additional disclosures for medical weight-management services, compounded medications, hormone-related care, sexual-health care, dermatologic care, mental or behavioral-health care, substance-use-disorder treatment, peptide or wellness therapies, or another clinically relevant category.

I understand that those additional documents, medication guides, pharmacy information, and discussions with my Provider are part of the informed-consent process when applicable. I will not begin a recommended treatment until I have had an opportunity to review the applicable information and ask questions. Nothing in this general Consent replaces a state-required consumer disclosure or a treatment-specific consent.

12. Cash-Pay Financial Responsibility

Unless a written disclosure states otherwise, services are cash-pay and are not billed to insurance by RubyMD. The Practice, pharmacy, or other third party may charge separate fees. I am responsible for reviewing the price disclosures presented before purchase and for paying amounts due for services I select.

I understand that RubyMD does not guarantee reimbursement by insurance, a health savings account, flexible spending account, employer plan, or another third party. I understand that clinical fees, pharmacy charges, medication prices, shipping charges, and other disclosed third-party charges may be separate. RubyMD's general website refund policy does not replace the Practice's or pharmacy's policies for clinical services, prescriptions, medication, fulfillment, or other third-party charges.

13. Appointment, Treatment, and Care-Related Communications

I authorize the Practice and its service providers, including RubyMD when acting as a non-clinical service provider for the Practice, to contact me using the telephone number, email address, portal account, and mailing address I provide for care-related and administrative purposes, including:

• appointment scheduling, confirmations, changes, and reminders;
• secure portal access and account verification;
• messages about a consultation, treatment plan, follow-up, refill request, prescription coordination, or care transition;
• pharmacy fulfillment, shipment, and medication-related updates when applicable;
• billing, payment, receipt, and customer-service messages;
• patient satisfaction or quality-improvement requests; and
• legally required notices and security communications.

I understand that standard telephone, text-message, and data rates may apply. I understand that text messages and ordinary email may not be completely secure and may be seen by a person with access to my device or account. I may request reasonable alternative communication methods by contacting the Practice. I may opt out of nonessential text or email communications using the instructions provided, but I understand that doing so may limit the Practice's ability to send reminders or other nonurgent communications.

This section does not authorize marketing text messages. Any marketing text-message consent must be presented separately, be optional, and not be a condition of receiving care.

14. Access to Records, Follow-Up, and Complaints

I may request access to or a copy of my medical record, request correction of information, request confidential communications, and exercise other privacy rights as described in the Practice's Notice of Privacy Practices and applicable law. I may ask the Practice to send my medical record to another provider or my primary-care provider where permitted by law and appropriate authorization or consent is provided.

I may contact the Practice about follow-up care, records, privacy, billing, or concerns using the information below. I understand that RubyMD customer support cannot provide medical advice or change a Provider's clinical decision.

15. State-Specific Disclosures and Addendum

Telehealth rules vary based on the patient's physical location at the time of care. The Practice will provide and maintain a state-specific addendum, dynamically displayed or otherwise delivered before care, for each state in which it offers services. That addendum addresses state-specific requirements concerning, as applicable, informed consent, provider identification and licensure, patient records, follow-up, primary-care-provider coordination, prescribing, complaint information, privacy, billing, medical-weight-management disclosures, mental-health services, substance-use-disorder records, and other required notices.

The following baseline rights apply regardless of state: I may ask questions; I may request information about the Provider; I may seek in-person care; I may request records as permitted by law; I may stop a telehealth encounter; and I may make a complaint to the Practice or the relevant professional licensing authority. The state-specific addendum controls if it provides an additional right or disclosure.

16. Consent, Electronic Signature, and Copy

I acknowledge that I have read and understand this Consent. I voluntarily consent to receive telehealth services from the Practice and its Providers when they determine telehealth is appropriate. I understand that I may obtain a copy of this Consent and the Notice of Privacy Practices by using the contact information above.

When I accept this Consent through the secure enrollment workflow, the Practice and RubyMD record my full legal name, date of birth, physical location at the time of consent, the date and time of acceptance, my electronic signature or affirmative-acceptance record, and the version of this Consent presented, so that my acknowledgment can be verified.