Consent and Authorizations.

THIS CONSENT DESCRIBES HOW CARE IS DELIVERED TO YOU BY TELEHEALTH, WHAT IT CAN AND CANNOT DO, AND WHAT YOU ARE AGREEING TO. TELEHEALTH IS NEVER FOR EMERGENCIES. IF YOU HAVE A MEDICAL EMERGENCY, CALL 911.

This consent explains what it means to receive care by telehealth and asks you to agree before an encounter takes place. Read it in full. If anything is unclear, ask before you agree. You can also decline and be seen another way.

Who is treating you. Your care is provided by a licensed clinician at the practice you are a patient of. SOVRYN supplies the platform that practice uses to run the encounter, keep the record and route any prescription. Your clinical relationship is with your provider and their practice; questions about your treatment go to them.

Telehealth means your provider evaluates and treats you without being in the same room. Depending on what your visit is for and what your state permits, an encounter may involve any of the following:

• A live two-way video or audio conversation with your provider.
• Review of information you submit in advance: your history, current medications, allergies, and answers to questions about the treatment you are asking for.
• Review of photographs or images you upload, where these are relevant to the assessment.
• Discussion of test or laboratory results.
• A decision to authorize treatment, to decline it, or to ask you to be seen in person first.

Your provider decides whether telehealth is appropriate for your particular situation. They may conclude it is not, and ask you to be examined in person instead. That judgment is theirs to make and it is made in your interest.

Where it is clinically appropriate, care by telehealth can:

• Get you assessed sooner than waiting for an in-person appointment.
• Let you be seen at a time and place that fits around your work and travel.
• Give you access to a clinician licensed in your state who your practice might not otherwise have available on site.
• Keep the record of your assessment, the decision made and the reasoning in one place your practice can produce later.

Telehealth is not equivalent to being examined in person, and there are real limitations. Before you agree, understand that:

• Your provider cannot physically examine you. Some conditions cannot be assessed properly without touch, instruments, or tests done in person.
• If the video, audio or images are not good enough to judge safely, your provider may have to stop and reschedule, or send you for an in-person visit.
• Something that would be obvious during a physical examination may be missed. This includes findings that would change the treatment, or that would need urgent attention.
• If your provider does not have your full medical history, there is a greater chance of a drug interaction, an allergic reaction, or a decision made on incomplete information.
• Technology fails. A dropped connection, a failed upload or an outage can delay your care.
• No electronic system is perfectly secure. There is a small but real possibility that information about you could be exposed despite the safeguards in place.
• Wherever you take the call, other people may be able to overhear it. Choose somewhere private.

No treatment can be guaranteed to work, whether it is delivered by telehealth or in person.

Do not use telehealth for an emergency. If you think you are having one (chest pain, difficulty breathing, severe bleeding, signs of a stroke, thoughts of harming yourself, or anything else that feels urgent), call 911 or go to your nearest emergency department. Your provider cannot connect you to emergency services and cannot respond in real time to an emergency.

Clinicians are licensed by state, and your provider must generally be licensed in the state you are physically in at the time of the encounter, not the state you live in or where the practice is. You will be asked to confirm your location, and you must answer accurately. If you are somewhere other than where you said, your provider may not be permitted to treat you and the encounter may have to stop.

Your provider and SOVRYN are required by federal and state law to protect your health information. The platform uses encryption in transit and at rest, restricts access to those who need it, and keeps a record of who accessed what.

Information about you may be shared with others involved in your care or in running it, for example a pharmacy filling your prescription, a laboratory, or staff handling scheduling and billing. Where SOVRYN handles your protected health information on behalf of your practice, it does so as a business associate under HIPAA and under a written agreement with them.

If someone other than your provider needs to be present during the encounter, for example to operate the technology, you will be told. You may ask them to leave, ask that particular details not be discussed, or end the encounter.

Your provider is relying on what you tell them. They generally cannot verify it independently, and a telehealth assessment leans more heavily on your answers than an in-person one does.

Answer completely and truthfully, including your age, your medical history, everything you take (prescription, over-the-counter, supplements and recreational), and any allergies. If you submit photographs, they must be of you, taken recently, and unedited.

If you leave something out or give information that is not accurate, you may be prescribed something that is unnecessary, ineffective, or unsafe for you.

If your provider decides a prescription is appropriate, it is written by them and routed to a pharmacy licensed to dispense to you where you are. You are free to use a pharmacy of your choosing. Some medicines cannot be prescribed by telehealth in some states, and your provider will tell you if that applies to you.

You do not have to be seen by telehealth. You can ask to be seen in person instead, and you can ask to be referred elsewhere.

You may withdraw this consent at any time, including part-way through an encounter, without giving a reason. Doing so will not affect your right to care in future, and it will not be held against you. Tell your provider or your practice.

The encounter is documented in your medical record in the same way an in-person visit would be. You may request a copy of your records; a reasonable charge may apply for preparing and sending them. Your practice holds those records, so ask them.

By agreeing to this consent, you are confirming that:

• You have read this document, you understand it, and you have had the chance to ask questions.
• You consent to being assessed and treated by telehealth by a licensed clinician.
• You understand telehealth is not for emergencies and that you will call 911 if you have one.
• You will confirm your physical location accurately at the time of the encounter.
• You understand the limits and risks set out in Section 3, and that no outcome is guaranteed.
• The information and any images you provide are accurate, complete and your own.
• You understand your provider may decline to treat you by telehealth and may require an in-person visit.
• You understand you may withdraw this consent at any time.
• You understand your care is provided by your practice and its clinicians, not by SOVRYN.

Questions about your treatment go to your provider or your practice. Questions about the platform, your account, or how your information is handled can be sent to:

• Sovryn Group, PA
• 16220 N Scottsdale Rd, Suite 300, Scottsdale, AZ 85254
• care@sovryn.health