Terms & Policies

Hamilton Health & Wellness, LLC Terms of Use
Last Updated: September 15, 2023

These terms and conditions of use (“Terms of Use”) govern your use of online interfaces and properties (e.g., websites and applications) that are owned and controlled by Hamilton Health & Wellness, LLC (“The Practice” “we,” “us,” and “our”), including the website https://www.hamiltontelehealth.com website (the “Site”), as well as the services (“Services”) available to users through the Site or through any other means, including mobile phone applications. The terms “you” and “your” means you, your dependent(s) or representative(s) if any, and any other person accessing your account on the Site or Services. Your acceptance of, and compliance with, these Terms of Use is a condition to the use of the Site and Services. By using the Site or Services, you acknowledge that you have read, understand, and expressly agree to all terms and conditions contained within the Terms of Use and Privacy Policy. If you do not agree to be bound by these terms, you are not authorized to access or use this Site or Services for any purpose; promptly exit the Site or Services.

USER REPRESENTATIONS: You represent and warrant that you are at least eighteen (18) years of age to register on the Site, to enroll for the Services and/or use the Services. You further represent and warrant that: (i) you have the legal ability and authority to agree to these Terms of Use and use the Site and Services; (ii) the information you provided during your registration is accurate and complete; (iii) you will comply with all applicable laws as they relate to the Site and/or Services; and (iv) you will not interfere with, disrupt, or replicate, or attempt to interfere with, disrupt, or replicate this Site and Services and its security measures and protocols. If any information you provided to us becomes inaccurate, incomplete, or otherwise false and/or misleading, you will immediately notify us. You are responsible for ensuring that any information you provide is complete, up to date, and accurate.

MODIFICATION OF TERMS: We reserve the right to update and/or modify the Terms of Use at any time
and for any reason, without penalty or liability to you or any third party. Any changes of the
Terms of Use are effective immediately upon posting. By continuing to access and use the Site or
Services, you expressly agree to follow and be bound by all applicable updates and changes to the
Terms of Use.

MODIFICATION OF TERMS: We reserve the right to update and/or modify the Terms of Use at any time and for any reason, without penalty or liability to you or any third party. Any changes of the Terms of Use are effective immediately upon posting. By continuing to access and use the Site or Services, you expressly agree to follow and be bound by all applicable updates and changes to the Terms of Use.

MODIFICATION OF SITE AND SERVICES: We reserve complete and sole discretion with respect to the operation of the Site and the Services. We may withdraw, suspend, or otherwise discontinue any functionality or feature of the Site or the Services. We reserve the right to maintain, delete, or destroy all communications and user content posted or uploaded to the Services pursuant to applicable law and our internal record retention and/or destruction policies. Occasionally, we may perform maintenance on or upgrade the Site or Services or the underlying structure that enables use of the Site or Services. This may require us to temporarily suspend or limit your use of the Site or Services until such time the maintenance or upgrade is completed. To the extent possible and unless otherwise stated, we will endeavor to publish the time and date of such expected suspension or limitation of the Site or Services in advance when possible. You agree that you are not entitled to claim any damages for such suspension or limitation during such maintenance or upgrade.

LICENSE: Upon accepting the Terms of Use, you are granted a limited, non-assignable, non- sublicensable, non-exclusive license to use the Site or Services on a personal computer, mobile phone, or other electronic device for personal, non-commercial use through your individual account. You agree not to grant any right to third-parties to your personal use of our Site or Services.

USE OF SERVICES: You are required to provide us with your name, email address, and phone number upon registering for a user account. We will use your email address or phone number to send you important updates about the Site and Services, as well as notifications when information and documents are added that you need to be aware of (e.g. forms, updated terms, etc.). In some instances, but not all, registered users may be permitted to opt out of receiving certain emails.

Use of the Site and Services described herein are subject to our Privacy Policy. The Privacy Policy is hereby incorporated by reference into these Terms of Use.

Portions of the Site or Services are only available to users who have registered and created an account with an appropriate username and password (“Registered Users”). Each Registered User is responsible for controlling the privacy, dissemination, access to, and use of their username and password, and/or personal information necessary for verification, and promptly informing us of any need to deactivate a password or account. You also agree to promptly notify us of any unauthorized use of your username, password, or any other breach of security that you become aware of involving or relating to the Site or Services by faxing your request to 828-248-0502. We explicitly disclaim liability for any and all losses and damages arising from your failure to comply with this section.

Neither the Site nor Services are intended to support or carry emergency calls to any law enforcement or health care provider or entity. In the event of a medical emergency, dial 911 immediately.

PROFESSIONAL SERVICES: By requesting a medical consultation with a provider through the Site, you are requesting to enter into a clinician/patient relationship with a licensed provider (“Provider”), who shall be solely responsible for the provision of professional medical services. You will only receive medical care once a bona fide clinician/patient relationship with a medical professional is established by mutual acceptance. You agree that you will be financially responsible for the provision of professional medical services by a Provider.

The Practice makes certain general educational resources available to you and facilitates your access to telehealth services. We are independent from the Providers who render telehealth services and The Practice is not responsible for such Providers’ acts, omissions or for any content of the communications made by them. We do not engage in the practice of medicine. By accepting the Terms of Use and using the Site and Services, you acknowledge and agree that The Practice does not provide professional medical services, is not a healthcare provider, does not hire healthcare providers, and that by using the Site and Service, you are not entering into a provider-patient relationship with The Practice.

If you engage in a medical encounter with a Provider, we may collect a medical encounter fee from you prior to the encounter. We will transmit the medical encounter fee to your treating Provider. The medical encounter fee is non-refundable upon the initiation of a provider-patient relationship with a Provider.

MEDICAL DISCLAIMERS: We make no representation or warranty as to the content or quality of any treatment decision, recommendation, or response from any Provider. Providers utilize the Site to connect with you. Providers do not render services on behalf of The Practice. You and the Provider are solely responsible for all information and/or communication sent during a telephone or web video consultation, secure e-mail, or other communication, and the subsequent result. We do not make any representation that a telephone or web video consultation or secure e-mail is the appropriate course of treatment for your particular health care situation or needs. You acknowledge and agree that this Site is not a replacement for your existing relationship with your physician or healthcare provider. You will contact your physician immediately should your condition change or your symptoms worsen. If you require emergency care, you will contact your local emergency services immediately.

PRESCRIPTION PRODUCTS: The Practice does not guarantee a prescription. It is up to the Provider to recommend the best treatment for you. If a Provider determines a prescription product is appropriate for you and issues a prescription, you will receive information about your options for filling the order.

CALLING & SMS MESSAGES: You may have the option to receive telephone calls and text (SMS) messages from us. By enrolling to receive such calls or messages, you consent to receive these communications from us or our affiliates concerning your use of the Site and Services. These communications may include, but are not limited to, transactional messages related to your use of the Site and Services. You may unsubscribe from these communications at any time by following the instructions set forth on the enrollment page. Alternatively, you may unsubscribe from SMS messages by texting “STOP” to the message received, or by contacting us at 813-434-0357 to unenroll from these communications.

CONTENT OF COMMUNICATION: We do not endorse or take responsibility for the content of communications made using any portion of the Site. By using the Site, you agree that any content received or transmitted is entirely the responsibility of the individual from whom such content originated. You agree that you are solely responsible for the content you choose to upload onto the Site. You agree not to (i) access the Site or use the Services in any unlawful way or for any unlawful purpose; (ii) post or transmit (a) a message under a false name, or (b) any data, materials, content, or information (including, without limitation, advice, and recommendations) (collectively “Information”) which is (1) libelous, defamatory, obscene, fraudulent, false, or contrary to the ownership or intellectual property rights of any other person, or (2) contains or promotes any virus, worm, Trojan horse, time bomb, malware, or other computer programing or code that is designed or intended to damage, destroy, intercept, download, interfere, manipulate, or otherwise interrupt or expropriate the Site or the Services, personal information, software, equipment, servers, or Information or facilitate or promote hacking or similar conduct; (iii) impersonate or misrepresent your identity or falsely state or misrepresent your affiliation with a person or entity; (iv) tamper, hack, spoof, copy, modify, or otherwise corrupt the administration, security, or proper function of the Site or the Services; (v) use robots or scripts with the Site; (vi) attempt to reverse engineer, reverse assemble, reverse compile, decompile, disassemble, translate, or otherwise alter, defraud, or create false results from any executable code, information on, or received by this Site; (vii) incorrectly identify the sender of any message transmitted to the Site. You may not alter the attribution or origin of electronic mail, messages, or posting; (viii) harvest or collect protected health information about any other individual who uses the Site or the Services; (ix) infringe or facilitate infringement on any copyright, patent, trademark, trade secret, or other proprietary, publicity, or privacy rights of any party, including such rights of third parties. All information you provide to us or any third-party through the Site shall be true, accurate, current, and complete. Any information displayed on the Site is for informational purposes only. No content shall be construed as a professional opinion, medical advice, or relied upon to diagnose or treat any condition. No information provided on the Site shall be construed as a substitute for, nor does it replace, professional medical advice, diagnosis, or treatment.

PAYMENT: We may charge fees for your use of certain Services. Where applicable, you agree that we may charge your credit card or other payment mechanism on file for all amounts due and owing for the Services, including taxes and service fees, set up fees, subscription fees, or any other fee associated with use of your registered account. We may change prices at any time, including changing a free service to a paid service; provided, however, that we will provide you with prior notice and an opportunity to terminate your registered account. You agree that in the event we are unable to collect the fees owed for the Services through your account, we may take any other steps we deem necessary to collect such fees from you and that you will be responsible for all costs and expenses incurred by us in connection with such collection activity, including collection fees and court costs.

TERMINATION: Unless expressed otherwise in writing, we reserve the right to terminate, rescind, revoke, or modify your access to the Site or Services without notice at any time for any reason. Any violation of these Terms of Use will result in immediate termination. We shall not be liable to you or any third party for any such termination. You may opt out of the Site or Services at any time.

INTELLECTUAL PROPERTY: All materials on the Site or Services, including the design, layout, and organization (collectively referred to as “Materials”), except for data contained in user records, are owned and copyrighted by us or our affiliates and are protected by all applicable intellectual property laws. All rights and title to the Materials, trademarks and service marks herein remain with us or its licensors. You are authorized to view the Site or Services and Materials. All rights not expressly granted herein are reserved to us. You may not reproduce, retransmit, distribute, disseminate, sell, publish, broadcast, circulate or exploit for commercial gain any portion of the Site or Services or the Materials. You further agree that any information you provide or use on the Site or Services, and your use of the Site or the Services, will not infringe or facilitate infringement on any copyright, patent, trademark, trade secret, or other proprietary, publicity, or privacy rights of any party, including such rights of third parties. You further agree that you shall not, and shall not permit any individual or entity to (a) reverse engineer, disassemble, decompile, decode, or adapt the Site, Services, or Materials, or otherwise attempt to derive or gain access to the source code of the Site, in whole or in part; (b) bypass or breach any security device or protection used for or contained in the Site or Services; (c) use the Site or Services for purposes of: (i) benchmarking or competitive analysis of the Site; (ii) developing, using or providing a competing software product or service; or (iii) any other purpose that is to our commercial disadvantage; or, (d) use the Site, Services, or Materials for any other purpose or application not expressly permitted by this Agreement.

COPYRIGHT NOTICES: The Practice reserves the right to remove any content or any other material or information available on or through our Services, at any time, for any reason. The Practice otherwise complies with the provisions of the Digital Millennium Copyright Act (“DMCA”) applicable to Internet service providers and responds to clear notices of alleged copyright infringement. If you have objections to copyrighted content or material made available on or through our Site or Services, you may submit a notification to Hamilton Health & Wellness, LLC 1317 Edgewater Drive, Suite 3483, Orlando, Florida 32804.

TRADEMARKS: Our name, and all related names, logos, product and service names, designs, and slogans are trademarks of The Practice or its affiliates or licensors. You must not use such marks without our prior written permission. All other names, logos, product and service names, designs, and slogans on this Site are the trademarks of their respective owners.

THIRD PARTY WEBSITES: We may provide external links to third party web sites. These Terms of Use apply only to your relationship with us and the Site or Services, and do not describe the terms and conditions, privacy policies or other policies of third parties. Your use of third-party websites is at your own risk and subject to the third party’s terms and conditions. We disclaim all liability for any information set forth on linked sites.

NO ENDORSEMENT: Information provided on the Site is for your convenience only. We do not endorse the promotions, products, publications, or services of any third parties. We do not warrant or validate the advertisements, promotions, communications, or other materials of any third party. Any views expressed by third parties on this Site or Services are solely the views of such third party and we assume no responsibility or liability for the accuracy of any statement made by such third party.

GEOGRAPHIC RESTRICTION: We provide this Site for use only by persons located in certain locations of the United States. We make no claims that the Site and Services herein provided are accessible or appropriate outside of those locations within the United States. If you access the Site or Services from outside the United States, you do so on your own initiative and are responsible for compliance with local laws.

INDEMNIFICATION: You hereby agree to hold harmless, defend and indemnify us, our principals, owners, officers, directors, managers, employees, contractors, agents, other affiliated companies, suppliers, successors, and assigns from all liabilities, claims, demands, and expenses, including attorney’s fees, that arise from or are related to (a) your use or misuse of the Site or Services, (b) your breach of these Terms of Use, (c) the content or subject matter of any information you provide to us, and/or (d) any negligent or wrongful act or omission by you in the use or misuse of the Site or the Services, including without limitation, infringement of third party intellectual property rights. You agree to waive, to the fullest extent permitted by law, all laws that may limit the efficacy of such indemnifications or releases.

LIMITATION ON LIABILITY: IN NO EVENT SHALL WE BE LIABLE FOR ANY DIRECT, INDIRECT, SPECIAL, PUNITIVE, INCIDENTAL, EXEMPLARY, OR CONSEQUENTIAL DAMAGES, OR ANY DAMAGES WHATSOEVER RESULTING FROM ANY LOSS OF USE, LOSS OF PROFITS, LITIGATION, OR ANY OTHER PECUNIARY LOSS, WHETHER BASED ON BREACH OF CONTRACT, TORT (INCLUDING NEGLIGENCE), PRODUCT LIABILITY, OR OTHERWISE, ARISING OUT OF OR IN ANY WAY CONNECTED WITH THIS SITE OR THE PROVISION OF OR FAILURE TO MAKE AVAILABLE ANY SERVICES, EVEN IF ADVISED OF THE POSSIBILITY OF SUCH DAMAGES. WE ARE NOT LIABLE TO YOU OR ANYONE ELSE FOR ANY DECISION MADE OR ACTION TAKEN BASED ON USE OF THIS SITE OR SERVICES, EXCEPT AS REQUIRED BY LAW.
Your acceptance of this limitation of liability is an essential term and We would not grant You access to the Site(s) without your agreement to this essential term of these Terms of Use. If you are a California resident, you waive your rights with respect to California civil code section 1542, which indicates “a general release does not extend to claims which the creditor does not know or suspect to exist in his favor at the time of executing the release, which, if known by him must have materially affected his settlement with the debtor.” Because some states or jurisdictions do not allow the exclusion or the limitation of liability for consequential or incidental damages, in such states or jurisdictions, our liability shall be limited to the maximum extent permitted by law.

DISCLAIMER: THE SITE OR SERVICES ARE PROVIDED BY US ON AN “AS IS” AND “AS AVAILABLE” BASIS. WE MAKE NO REPRESENTATIONS OR WARRANTIES OF ANY KIND, EXPRESS OR IMPLIED, INCLUDING, BUT NOT LIMITED TO, THE IMPLIED WARRANTIES OF MERCHANTABILITY AND FITNESS FOR A PARTICULAR PURPOSE. WE DO NOT WARRANT THAT THE SITE OR SERVICES WILL BE UNINTERRUPTED, FREE FROM ERROR, OR FREE FROM VIRUSES OR OTHER HARMFUL COMPONENTS.

We will use reasonable efforts to keep the Site or Services content timely and accurate, but we make no guarantees, and disclaim any implied warranty or representation about its accuracy, relevance, timeliness, completeness, or appropriateness for a particular purpose. We assume no liability arising from or relating to the delay, failure, interruption, or corruption of any data or other information transmitted in connection with use of the Site or Services.

TO THE FULLEST EXTENT PROVIDED BY LAW, WE WILL NOT BE LIABLE FOR ANY LOSS OR DAMAGE CAUSED BY A DISTRIBUTED DENIAL-OF-SERVICE ATTACK, VIRUSES, OR OTHER TECHNOLOGICALLY HARMFUL MATERIAL THAT MAY INFECT YOUR COMPUTER EQUIPMENT, COMPUTER PROGRAMS, DATA, OR OTHER PROPRIETARY MATERIAL DUE TO YOUR USE OF THE WEBSITE OR ANY SERVICES OR ITEMS OBTAINED THROUGH THE WEBSITE OR TO YOUR DOWNLOADING OF ANY MATERIAL POSTED ON IT, OR ON ANY WEBSITE LINKED TO IT.

YOUR USE OF THE WEBSITE, ITS CONTENT, AND ANY SERVICES OR ITEMS OFFERED THROUGH THE WEBSITE IS AT YOUR OWN RISK.

GOVERNING LAW: These Terms of Use shall be governed by and construed in accordance with State Laws as amended from time to time, without regard to principles of conflicts of law.

LIMITATION ON TIME TO FILE CLAIMS: ANY CAUSE OF ACTION OR CLAIM YOU MAY HAVE ARISING OUT OF OR RELATING TO THESE TERMS OF USE OR THE SITE OR SERVICES MUST BE COMMENCED WITHIN ONE (1) YEAR AFTER THE CAUSE OF ACTION OCCURS; OTHERWISE, SUCH CAUSE OF ACTION OR CLAIM IS PERMANENTLY BARRED.

AGREEMENT TO ARBITRATE, VENUE: YOU AGREE THAT ANY DISPUTE, CLAIM OR CONTROVERSY ARISING OUT OF OR RELATING TO THESE TERMS OF USE OR THE BREACH, TERMINATION, ENFORCEMENT, INTERPRETATION OR VALIDITY THEREOF OR THE USE OF THE SERVICES (COLLECTIVELY, “DISPUTE(S)”) WILL BE SETTLED BY BINDING ARBITRATION. This arbitration clause governs all disputes, except that each party retains the right: (i) to bring an individual action in small claims court, and (ii) to seek injunctive or other equitable relief in a court of competent jurisdiction to prevent the actual or threatened infringement, misappropriation or violation of a party’s copyrights, trademarks, trade secrets, patents, or other intellectual property rights (the action described in the foregoing clause (ii), an “IP Protection Action”).

Without limiting the foregoing, you may decline the above arbitration provisions and you may retain the right to litigate any other Dispute if you provide us with written notice of your desire to do so, by U.S. mail or express courier to the address contained in the “Notices” section below, within thirty (30) days following the date you first agree to these Terms of Use (such notice, an “Arbitration Opt-out Notice”). If you don’t provide us with an Arbitration Opt-out Notice within the thirty (30) day period, you will be deemed to have knowingly and intentionally waived your right to litigate any Dispute except as expressly set forth above. The exclusive jurisdiction and venue of any IP Protection Action or, if you timely provide us with an Arbitration Opt-out Notice, any other claims, will be the state and federal courts located in the State of Florida and each of the parties hereto waives any objection to jurisdiction and venue in such courts.

UNLESS YOU TIMELY PROVIDE US WITH AN ARBITRATION OPT-OUT NOTICE, YOU ACKNOWLEDGE AND AGREE THAT YOU AND WE ARE WAIVING THE RIGHT TO A TRIAL BY JURY OR TO PARTICIPATE AS A PLAINTIFF OR CLASS MEMBER IN ANY PURPORTED CLASS ACTION OR REPRESENTATIVE PROCEEDING. FURTHER, UNLESS BOTH YOU AND WE OTHERWISE AGREE IN WRITING, THE ARBITRATOR MAY NOT CONSOLIDATE MORE THAN ONE PERSON’S CLAIMS, AND MAY NOT OTHERWISE PRESIDE OVER ANY FORM OF ANY CLASS OR REPRESENTATIVE PROCEEDING. MOREOVER, THE ARBITRATOR WILL HAVE NO AUTHORITY TO AWARD PUNITIVE, EXEMPLARY, INDIRECT, SPECIAL DAMAGES OR ANY OTHER DAMAGES NOT MEASURED BY THE PREVAILING PARTY’S ACTUAL DAMAGES, EXCEPT AS REQUIRED BY LAW.

Any arbitration occurring pursuant to this section will be administered by the American Health Lawyers Association (“AHLA”) before a single arbitrator with the locale of all hearings requiring physical attendance of the parties to occur in Pasco County, in the State of Florida, or as otherwise mutually agreed upon by the parties. Any judgment award rendered by the arbitrator may be entered in any court having jurisdiction thereof.

This section will survive any termination of these Terms of Use.

ARBIRTRATION FEES: The costs of any arbitration, as described in the previous section, including without limitation, the fees of the arbitrator (but excluding each party’s attorney’s fees) shall be paid by the claimant who initiates an arbitration.

SEVERABILITY: If any provision of these Terms of Use is found to be invalid by any court having competent jurisdiction, the invalidity of such provision shall not affect the validity of the remaining provisions of these Terms of Use, which shall remain in full force and effect.

WAIVER: No delay by us in the exercise of any right shall be deemed a waiver thereof, nor shall the waiver of a right or remedy in a particular instance constitute a waiver of such right or remedy generally.

NOTICES: We may provide notice to you by e-mail at the e-mail address you provided during registration, by a general notice on the Site or Services, or by written communication delivered by first class U.S. mail or express courier to your address on record in your account information. You may give notice to us at any time, in writing, delivered by first class U.S. mail or express courier to: Hamilton Health & Wellness, LLC 1317 Edgewater Drive, Suite 3483, Orlando, Florida 32804.

Hamilton Health & Wellness, LLC Privacy Policy

Last Updated: October 2023

I.Introduction

We are committed to protecting the privacy of our visitors and users and providing them with detailed information as to how their information is used and protected.

This Privacy Policy describes how Hamilton Health & Wellness, LLC and its affiliates (collectively “The Practice” “we” or “us”) collect and process your personal information through our websites and services (together “Services”). This Privacy Policy is incorporated into our Terms of Use. By using our Services, you are consenting to the practices described in this Privacy Policy. If you do not agree with this Privacy Policy, do not access, or use the Services.

II. Protected Health Information

This Privacy Policy does not apply to information collected from you if you register and log-in to the password-protected and secure portions of our Services, which are intended to be used by potential patients of independent licensed clinicians for the provision of their respective professional services (the “Platform”). The Platform allows eligible patients to use certain Services related to the provision of the practice of medicine and other licensed medical professions. All information collected and stored by us or disclosed by you within the Platform is considered Protected Health Information (“PHI”) and/or medical information and shall be governed by applicable state and federal laws that apply to such information, including the Health Insurance Portability and Accountability Act (“HIPAA”). Privacy practices with respect to PHI and/or medical information are set forth in the Notice of Privacy Practices, which is available to users of the Platform within the Platform.

III. Information Collected by Us

We collect the following types of information:

Information You Disclose.

We receive information about you when you provide it through forms or surveys, and when you sign up for a user account and use our Services. In addition, we receive information about you when you use, edit, or access your account. As a result of those actions, you may supply us with certain information, including, but not limited to, your name, e-mail address, phone number, gender, date of birth, address, payment or financial information, and other information.

Information Automatically Collected.

We may automatically collect certain information resulting from your use of our Services. This information may include your IP address, login details, password, and the location of your device. We may also use device identifiers, cookies, web beacons, tokens, scripts, and other technologies on devices, applications, e-mails, and our web pages to collect information about your browsing actions and patterns, information about your devices (such as information related to your computer or device, internet connection, operating system, and internet browser type), or other technical information.

IV. Information Collected by Third Parties

When you use the Services, certain third parties may use automatic information collection technologies to collect information about you or your device. This Privacy Policy does not address, and we are not responsible for, the privacy, information, or other practices, including data privacy and security process and standards of any third parties, including physicians and other health care providers using the Services. These third parties may include: advertisers, ad networks, and ad servers; analytics companies; your mobile device manufacturer; and your mobile service provider. The information they collect may be personally identifiable and may include information about your online activities over time and across different websites, apps, and other online services websites. These third parties may use this information to provide you with interest-based advertising or other targeted content.

We do not control these third parties’ tracking technologies or how they may be used. If you have any questions about an advertisement or other targeted content, you should contact the responsible provider directly.

V. How We Use Your Information

We collect your information to provide and improve our Services. In addition, we may disclose your deidentified and anonymized information for research or commercial purposes, except for your payment and financial information, and information prohibited from disclosure pursuant to federal and state law.

Information you disclose is used to provide, improve, and develop our Services. We, our partners, contractors, or agents, may use personal information about you for various purposes, including, but not limited to:

• Conducting internal research and development and making business decisions about current and future product and Service offerings;

• Responding to your comments, questions and requests and providing customer service; • Communicating with you about products, services, offers, promotions, rewards and events and providing news and information we think will be of interest to you;

• Managing your online account(s) and sending you technical notices, updates, security alerts and support and administrative messages;

• Personalizing your online experience and providing advertisements, content or features that match your profile and interests;

• Monitoring and analyzing trends, usage and activities;

• Complying with any court order, law, or legal process, and responding to any government or regulatory request;

• Enforcing or applying our Terms of Use; and/or

• Fulfilling any other purpose for which you provided the information.

Information automatically collected is used generally to improve our Services. In addition to the uses related to information you disclose, as outlined above, we may use information automatically collected in a similar manner. We may also combine this information with other information we collect about you and use it for various purposes, such as improving our websites and your online experience,

understanding which areas and features of our sites are popular, counting visits, tailoring our communications with you, determining whether an email has been opened and links within the email have been clicked and for other internal business purposes.

VI. How Collected Information Is Shared by Us

We may share your personal information with our affiliates, partners and other third parties, including subcontractors, to:

• assist us with the maintenance and operation of the Services;

• market and promote the Services, including the measurement of the success of such efforts; • comply with any court order, law, or legal process, including to respond to any government or regulatory request; to enforce or apply our Terms of Use;

• protect our, our customers’, or others rights, property, or safety; or

• to disclose to a buyer or other successor entity in the event of a merger, divestiture, restructuring, reorganization, dissolution, or other sale or transfer of some or all our assets, whether as a going concern or as part of bankruptcy, liquidation, or similar proceeding, in which personal information held by us is among the assets transferred.

In addition, we may disclose your deidentified and anonymized information for commercial purposes, except for payment and financial information, and information prohibited from disclosure pursuant to federal and state law.

VII. Privacy and Security

We design our systems with your security and privacy in mind, and we maintain administrative, technical, and physical safeguards to protect your personal information from unauthorized access, use, or disclosure. These safeguards vary based on the sensitivity of the information that is collected.

The safety and security of your information also depends on you. Where we have given you (or where you have chosen) a password for access to certain parts of our Services, you are responsible for keeping this password confidential. Do not share your password with anyone.

Unfortunately, the transmission of information via the internet is not completely secure. Although we do our best to protect your personal information, we cannot guarantee the security of your personal information transmitted through our website. Any transmission of personal information is at your own risk. We are not responsible for circumvention of any privacy settings or security measures contained on the website.

VIII. Notification of Changes

We reserve the right to change this Privacy Policy from time to time in our sole discretion. Your continued use of our Services indicates your consent to the Privacy Policy as posted. The date the Privacy Policy was last revised is identified at the top or bottom of this page. If we make material changes to how we treat our users’ personal information, we will notify you by email or through a notice on our website. You are responsible for ensuring we have an up-to-date active and deliverable

email address for you, and for periodically visiting our website and this Privacy Policy to check for any changes.

IX. Accessing/Deleting your Personal Information

You may be able to update, correct, or delete your personal information by contacting us. We may not be able to delete your information, personal or otherwise, without also deleting your account, and we may not accommodate a request to change or delete information if we believe the change would violate any law or legal requirement or cause the information to be incorrect.

X. Retention of Your Information

We keep your information for no longer than necessary for the purposes for which it is processed. The length of time for which we retain information depends on the purposes for which we collected and use it and/or as required to comply with applicable laws.

XI. California Residents

Consumers residing in California are afforded certain additional rights with respect to their personal information under the California Consumer Privacy Act (“CCPA”). If you are a California resident, this section may apply to you at such time that we become subject to CCPA. At this time, we are not subject to the CCPA.

If you are a California resident, and if the CCPA applies to us, you can make certain requests regarding your personal information. We will fulfill each of these requests to the extent required and permitted by law.

You can ask us what personal information we have about you, including a list of categories of your personal information that we have sold and a list of categories of your personal information that we have shared with another company for business purposes. If you make this request, and to the extent required by law, we will return to you any of the following, as applicable: the categories of personal information we have collected about you; the categories of sources from which we collect your personal information; the business or commercial purpose for collecting or selling your personal information; the categories of third parties with whom we share personal information; the specific pieces of personal information we have collected about you; a list of categories of personal information that we have sold, along with the category of any other company we sold it to; and, a list of categories of personal information that we have disclosed for a business purpose.

You can ask us to provide you with this information up to two times in a rolling twelve-month period. When you make this request, the information provided may be limited to personal information we collected about you in the previous 12 months.

In addition, you have the right to ask us to delete your personal information. Once we receive a request, we will delete the personal information (to the extent required by law) we hold about you as of the date of your request from our records and direct any service providers to do the same. In some cases, deletion may be accomplished through de-identification of the information. Choosing to delete your personal information may impact your ability to use our websites and online features.

Finally, you can ask that we stop selling your personal information or disclosing it for a business purpose. We share or sell your personal information as described in the “How Collected Information is Shared by Us” section of this policy.

We will not discriminate against any consumer for exercising their rights under the California Consumer Privacy Act. This generally means we will not deny you goods or services, charge different prices or rates, provide a different level of service or quality of goods, or suggest that you might receive a different price or level of quality for goods.

You can make these requests by calling 813-434-0357or faxing your request to: 828-824-0502.

XII. Your State Privacy Rights

Certain states afford their residents additional rights with respect to their personal information. Colorado, Connecticut, Virginia, and Utah each provide their state residents with rights to: • Confirm whether we process their personal information.

• Access and delete certain personal information.

• Data portability.

• Opt-out of personal data processing for targeted advertising and sales.

Colorado, Connecticut, and Virginia also provide their state residents with rights to:

• Correct inaccuracies in their personal information, considering the information’s nature processing purpose.

• Opt-out of profiling in furtherance of decisions that produce legal or similarly significant effects.

To exercise any of these rights please contact us at: 813-434-0357.

Nevada provides its residents with a limited right to opt-out of certain personal information sales. Residents who wish to exercise this sale opt-out rights may submit a request to this designated address contact us at: 813-434-0357.

XIII. Children Under 13

We do not knowingly collect personally identifiable information from children under the age of 13 without parental consent. If we learn we have collected or received personal information from a child under 13 without verification of parental consent, we will delete that information.

XIV. Contact Information

If you have any questions about this Privacy Policy, please contact us at: 813-434-0357. You may also request that we help you access, modify, or delete your data, or ask that we not sell or share your data, by contacting us using the information provided above.

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE
USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS
INFORMATION. PLEASE REVIEW IT CAREFULLY.
*****This notice is for reference only and supplements the Practice’s existing Notice of Privacy Practices.*****

*****In the event of a conflict, the Practice’s existing Notice shall govern.*****

WHO WILL FOLLOW THIS NOTICE:
This notice addresses the use of your medical information by your physician (the “Practice,” “we” or
“us”) and its business associates.
We may use your medical information, also known as protected health information (“PHI”), for
treatment, payment, operations, or research purposes as described in this notice. All employees of the
Practice follow these privacy practices. The practitioners on our staff will also follow this notice when
they work at the Practice.
ABOUT THIS NOTICE
This notice will tell you about the ways we may use and disclose medical information about you. We
also describe your rights and certain obligations we have regarding the use and disclosure of medical
information.
We are required by law to:
• make sure that medical information that identifies you is kept private;
• give you this notice of our legal duties and privacy practices with respect to your medical
information;
• follow the terms of the notice that is currently in effect; and
• notify individuals, either known or reasonably believed to be affected, following a breach of
unsecured protected health information.
HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU
The following categories describe different ways that we use and disclose medical information. For
each category of uses or disclosures, we will explain what we mean and give examples. Not every use
or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose
information will fall within one or more of the categories.

• For Treatment. We may use medical information about you to provide you with medical
treatment or services. We may disclose medical information about you to physicians, nurses,
technicians, medical students, or other Practice personnel who are involved in your care.
Different departments and personnel of the Practice also may share medical information about
you to coordinate the different services you may need, such as prescriptions, lab work and
imaging services. We also may disclose medical information about you to people outside the
Practice who may be involved in your medical care.

• For Payment. We may use and disclose medical information about you so that we may bill
for treatment and services you receive at the Practice and collect payment from you, an
insurance company or another party. For example, we may need to give information about the
medical care you received at the Practice to your health plan so that the plan will pay us or
reimburse you for the applicable treatment. We may also tell your health plan about a treatment
you are going to receive to obtain prior approval or to determine whether your plan will cover
the treatment. We may also disclose information about you to other healthcare facilities for
purposes of payment as permitted by law.

• For Healthcare Operations. We may use and disclose medical information about you for
operations of the Practice. These uses and disclosures are necessary to run the Practice and
make sure that all of our patients receive quality care. For example, we may use medical
information to evaluate the performance of our staff in caring for you or the outcome of your
treatment. We may also combine medical information about many patients to decide what
additional services the Practice should offer, what services are not needed and whether certain
new treatments are effective. We may also combine medical information we have with medical
information from other practices to compare our performance and to make improvements in
the care and services we offer. We may also disclose information to doctors, nurses,
technicians, medical students, and other Practice personnel for educational purposes. We may
also disclose information about you to other healthcare facilities as permitted by law.

• Appointment Reminders. We may use and disclose medical information to contact you to
remind you that you have an appointment for treatment or medical care.

• Treatment Alternatives. We may use and disclose medical information to tell you about
possible treatment options that may be of interest to you.

• Health-Related Benefits and Services. We may use and disclose medical information to tell
you about health-related benefits or services that may be of interest to you.

• Individuals Involved in Your Care or Payment for Your Care. We may release medical
information about you to a friend or family member who is involved in your medical care. We
may also give information to someone who helps pay for your care. In addition, we may
disclose medical information about you to an entity assisting in a disaster relief effort so that
your family can be notified about your condition, status and location.

• Research. In certain circumstances, we may use and disclose PHI about a patient for research
purposes. For example, a research project may involve comparing the health and recovery of
all patients who received one medication to those who received another for the same
condition. All research projects, however, are subject to an approval process. This process
evaluates a proposed research project and its use of PHI to balance research needs with

patients’ needs for privacy. Before we use or disclose PHI for research, the project will be
approved through this process. However, we may disclose medical information a patient to
people preparing to conduct a research project, for example, to help them look for patients
with specific medical needs, so long as the PHI they review does not leave the Practice
premises. When required by law, we will ask for specific written authorization if the researcher
will: (i) have access to a patient’s name, address or other information that reveals who the
patient is, or (ii) be involved in patient care at the Practice.

• As Required by Law. We will disclose medical information about you when required to do
so by federal, state, or local law.

• To Avert a Serious Threat to Health or Safety. We may use and disclose medical
information about you when necessary to prevent a serious threat to your health and safety or
the health and safety of the public or another person.
SPECIAL SITUATIONS

• State Law. In certain states, special privacy protections apply to certain information, including
genetic, sexually transmitted disease, or mental health information. Some parts of this general
Notice of Privacy Practices may not apply to these types of information. If your treatment
involves this information, and if applicable state laws govern, such information will be further
protected pursuant to applicable state law. For further information, please contact us using
the contact information listed on the last page of this Notice.

• Drug and Alcohol Abuse Information. The confidentiality of alcohol and drug abuse
patient records is protected by Federal law and regulations. Generally, a health care provider
may not say to a person outside a treatment program that a patient attends a program, or
disclose any information identifying a patient as an alcohol or drug abuser unless:

• The patient consents in writing:
• The disclosure is allowed by a court order; or
• The disclosure is made to medical personnel in a medical emergency or to qualified
personnel for research, audit, or program evaluation.

• Organ and Tissue Donation. If you are an organ or tissue donor, we may release medical
information about you to organizations that handle organ procurement or organ, eye or tissue
transplantation or to an organ donation bank.

• Military and Veterans. If you are a member of the armed forces of the United States or
another country, we may release medical information about you as required by military
command authorities.

• Workers’ Compensation. We may release medical information about you for workers’
compensation or similar programs.

• Public Health Risks. We may disclose medical information about you to authorized public
health or government officials for public health activities. These activities generally include the
following:

• to a person subject to the jurisdiction of the Food and Drug Administration (FDA)
for purposes related to the quality, safety or effectiveness of an FDA-regulated product
or service;
• to prevent or control disease, injury or disability;
• to report disease or injury;
• to report births and deaths;
• to report child abuse or neglect;
• to report reactions to medications and food or problems with products;
• to notify people of recalls or replacements of products they may be using;
• to notify a person who may have been exposed to a disease or may be at risk for
contracting or spreading a disease or condition;
• to notify the appropriate government authority if we believe a patient has been the
victim of abuse, neglect or domestic violence. We will only make this disclosure if you
agree or when required or authorized by law.

• Health Oversight Activities. We may disclose medical information about you to a health
oversight agency for activities authorized by law. These oversight activities include, for
example, audits, investigations, inspections, and licensure.

• Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose medical
information about you in response to a court or administrative order. We may also disclose
medical information about you in response to a subpoena, discovery request or other legal
demand by someone else involved in the dispute, but only if efforts have been made to tell
you about the request or to obtain an order protecting the information requested.

• Law Enforcement. We may release medical information about you if asked to do so by a law
enforcement official:
o in response to a court order, subpoena, warrant, summons or similar process;
o to identify or locate a suspect, fugitive, material witness or missing person;

o about the victim of a crime if, under certain circumstances, we are unable to obtain
the person’s agreement;
o about a death we believe may be the result of criminal conduct;
o about criminal conduct at the Practice or by healthcare providers affiliated with the
Practice;
o in emergency circumstances to report a crime, the location of the crime or victims, or
the identity, description or location of the person who committed the crime; and
o to authorized federal officials so they may provide protection for the President and
other authorized persons or conduct special investigations.

• Coroners, Medical Examiners and Funeral Directors. We may release medical
information about you to a coroner or medical examiner. This may be necessary, for example,
to identify a deceased person or determine the cause of death. We may also release medical
information to funeral directors so they can carry out their duties.

• National Security and Intelligence Activities. We may release medical information about
you to authorized federal officials for intelligence, counterintelligence and other national
security activities authorized by law.

• To a School. We may disclose information to a school, about an individual who is a student
or prospective student of the school, if:
o The protected health information that is disclosed is limited to proof of
immunization;
o The school is required by State or other law to have such proof of immunization prior
to admitting the individual; and
o The covered entity obtains and documents the agreement to the disclosure from
either:
▪ A parent, guardian, or other person acting in loco parentis of the individual, if
the individual is an un-emancipated minor; or
▪ The individual, if the individual is an adult or emancipated minor.

• Other Uses and Disclosures. Other uses and disclosures not described in this Notice will
be made only with your written authorization, and you may revoke such authorization
provided under this section at any time, provided that the revocation is in writing, except to
the extent that we have taken action(s) in reliance upon your authorization; or if the
authorization was obtained as a condition of obtaining insurance coverage.
YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU
You have the following rights regarding medical information we maintain about you:

• Right to Inspect and Copy. You have the right to inspect and copy medical information that
may be used to make decisions about your care. Usually, this includes medical and billing
records. This right does not include psychotherapy notes, information compiled for use in a
legal proceeding or certain information maintained by laboratories. In order to inspect and

copy medical information that may be used to make decisions about you, you must submit
your request in writing to the Privacy Officer listed at the end of this Notice. If you request a
copy of the information, we may charge a fee for the costs of copying, mailing or other supplies
associated with your request. We may deny your request to inspect and copy in certain limited
circumstances. If you are denied access to medical information, you may request in writing
that the denial be reviewed. To request a review, contact the Privacy Officer. A licensed
healthcare professional will conduct the review. We will comply with the outcome of the
review.

• Right to Amend. If you think that the medical information we have about you is incorrect or
incomplete, you may ask us to amend the information. You have the right to request an
amendment for as long as the information is kept by or for the Practice. To request an
amendment, your request must be made in writing and submitted to the Privacy Officer, listed
on the last page of this Notice, for the location at which you were treated. In addition, you
must give a reason that supports your request. We may deny your request for an amendment
if it is not in writing or does not include a reason to support the request. In addition, we may
deny your request if you ask us to amend information that:
o was not created by us, unless the person or entity that created the information is no
longer available to make the amendment;
o is not part of the medical information kept by or for the Practice;
o is not part of the information that you would be permitted to inspect and copy; or
o is accurate and complete.
We will provide you with written notice of action we take in response to your request for an
amendment.

• Right to an Accounting of Disclosures. You have the right to request an “accounting of
disclosures.” This is a list of certain disclosures we made of medical information about you.
We are not required to account for any disclosures you specifically requested or for disclosures
related to treatment, payment or healthcare operations or made pursuant to an authorization
signed by you. To request an accounting of disclosures, you must submit your request in
writing to the Privacy Officer. This contact information is listed at the last page of this Notice.
Your request must state a time period, which may not be longer than six years. We will attempt
to honor your request. If you request more than one accounting in any 12-month period, we
may charge you for our reasonable retrieval, list preparation and mailing costs for the second
and subsequent requests. We will notify you of the costs involved and you may choose to
withdraw or modify your request at that time before any costs are incurred.
• Right to Request Restrictions. You have the right to request a restriction or limitation on
the medical information we use or disclose about you for treatment, payment, or healthcare
operations. You also have the right to request a limit on the medical information we disclose
about you to someone who is involved in your care or the payment for your care, such as a
family member or friend. Additionally, you can request restrictions on medical information
disclosed to a health plan if the disclosure is for the purpose of carrying out payment or health
care operations and is not otherwise required by law, and the information pertains solely to a
health care item or service for which you, or person other than the health plan on your behalf,

has paid us in full. To request a restriction, you must contact the Privacy Officer. This contact
information is listed on the last page of this Notice.

• We are not required to agree to your request. If we agree to your request, we will
comply with your request unless the information is needed to provide you emergency
treatment. You may terminate the restriction at any time. If we terminate the
restriction, we will notify you of the termination. We are not able to terminate or
refuse your request for restrictions to disclosures to health plans if the disclosure is for
the purpose of carrying out payment or health care operations and is not otherwise
required by law, and the information pertains solely to a health care item or service for
which you, or person other than the health plan on your behalf, has paid us in full.

• Right to Request Confidential Communications. You have the right to request that we
communicate with you about medical matters in a certain way or at a certain location. For
example, you can ask that we only contact you at work or by mail. To request confidential
communications, you must submit a written request to the Privacy Officer. This contact
information is listed at the end of this Notice. We will not ask you the reason for your request.
Your request must specify how or where you wish to be contacted. We will attempt to
accommodate reasonable requests.

• Right to a Paper Copy of This Notice. You have the right to a paper copy of this Notice
upon written request from the Practice or at your first treatment encounter with the Practice.
You may get an additional copy of this Notice at any time by contacting us. This contact
information is listed at the end of this Notice.
CHANGES TO THIS NOTICE
We reserve the right to change this Notice. We reserve the right to make the revised or changed Notice
effective for medical information about you we already have as well as any information we receive in
the future. We will post copies of the current Notice at the Practice. The Notice will contain the
effective date. In addition, each time you register with the Practice for treatment or healthcare services,
we will make available copies of the current Notice. Any revisions to our Notice will also be posted
on our website.
COMPLAINTS
If you believe your privacy rights have been violated, you may file a complaint with the Practice or
with the Secretary of the Department of Health and Human Services, Office of Civil Rights. To file a
complaint with the Practice, please call or write to the Privacy Office. This contact information is
listed at the end of this Notice. You will not be penalized for filing a complaint.
OTHER USES OF MEDICAL INFORMATION
Other uses and disclosures of medical information not described in this Notice or the laws that apply
to us will be made only with your written authorization on a Practice authorization form. If you
provide us authorization to use or disclose medical information about you, you may revoke that
authorization, in writing, at any time. If you revoke your authorization, we will no longer use or

disclose medical information about you for the reasons covered by your written authorization.
However, we may continue to use or disclose that information to the extent we have relied on your
authorization. You also understand that we are unable to take back any disclosures we have already
made with your authorization, and that we are required to retain our records of the care that we
provided to you.

HIPAA Notice of Privacy Practices
***************************

Acknowledgement of Notice of Privacy Practices

Patient Name: __________________________
Electronic Acknowledgement accepted in lieu of wet signature.
Date ________ /________ /________
The Notice of Privacy Practices describes how Protected Health Information about you may be used and disclosed and
how you can get access to this information. Please review it carefully.
We are required by law to protect the privacy of health information that may reveal your identity, and
to provide you with a copy of this notice, which describes the health information privacy practices of
our practice, its medical staff, and affiliated health care providers that jointly perform payment
activities and business operations with our Practice. “Protected Health Information” is information
about you, including demographic information that may identify you and genetic information, and
that relates to your past, present or future physical or mental health or condition and related health
care services.
Electronic Acknowledgement accepted in lieu of wet signature.

TELEMEDICINE CONSENT HAMILTON HEALTH & WELLNESS, LLC / PROVIDER

Telemedicine is the delivery of healthcare services when the healthcare provider and the patient (the “Patient”) are not in the same physical location and communicate through technology. Electronically transmitted information may be used for diagnosis, treatment, follow-up, prescribing, or education and may include medical records, medical images, interactive audio, video and/or data communications, and output data from medical devices, sound, and video files.

The Patient is hereby advised that the care provided by practitioners through HAMILTON HEALTH & WELLNESS, LLC (the “Practice”) is not a replacement for an in-person primary care relationship with a physician. If the Patient does not have a primary care practitioner, they are advised to seek the care of one.

The Patient understands the following with respect to telehealth offered by the Practice:
The Patient has elected to have a telehealth visit instead of an in-office visit at the Practice. The Patient agrees that the Practice will determine whether the Patient’s condition is appropriate for telehealth and acknowledges that the Practice may recommend an in-person visit.

The Patient has had an opportunity to review the Practice’s providers’ credentials and selected his or her preference for provider.

There are potential risks associated with the use of telehealth, including, but not limited to: the information transmitted may be less comprehensive than that available during an in-person visit and may therefore result in decreased accuracy of diagnosis or medical decision-making; delays in medical evaluation or treatment could occur due to deficiencies or failures of the telemedicine equipment; security protocols could fail, causing a breach of privacy.

The Patient understands that telehealth often involves electronic transmission of the Patient’s protected health information (“PHI”). The Patient’s PHI includes, but is not limited to, the Patient’s identifying information; medical history; diagnoses; communications to and from the Patient’s other health care provider(s); etc. The Patient understands that PHI may be lost due to technical failures, cyber intrusion or other issues disrupting the Patient’s telehealth visit or causing delays in response from the Practice. The Patient assumes these risks and holds the Practice and its providers harmless from any claims arising out of the use of telehealth to conduct the visit. The Patient understands that PHI obtained during the telehealth visit will not be disclosed to others without the Patient’s consent unless permitted by applicable law and in accordance with the Practice’s Notice of Privacy Practices. The Patient has the right to request that we submit information about his or her treatment with the Practice to his or her primary care physician. If the Patient makes such a request and consents to the disclosure of PHI, the Practice will send the Patient’s medical record, and/or a report containing an explanation of the
Patient’s treatment, to the Patient’s primary care physician within 72 hours of his or her consultation with the Practice.

The Patient has the right to withhold or withdraw consent for telehealth at any time without affecting the right to the Patient’s future care, treatment, benefits, or programs for which he or she is otherwise entitled. The Patient understands that if others are present at Patient’s location during the Patient’s telehealth visit, the confidentiality of the Patient’s telehealth visit may be compromised.

The Patient understands the alternatives to telehealth, such as an in-person encounter, as they have been explained, and in choosing to participate in a telehealth visit understands that some parts of the exam may require physical testing to be performed at another location at the direction of the Practice.

THE PATIENT UNDERSTANDS THE PATIENT WILL BE RESPONSIBLE FOR PAYMENT. THE PRACTICE DOES NOT ACCEPT INSURANCE. ALL OUT-OF-POCKET EXPENSES ASSOCIATED WITH THE TELEHEALTH VISIT ARE DUE PRIOR TO THE TELEHEALTH VISIT.

The Patient understands that he or she must be physically located in the state they have listed on their initial profile during his or her telehealth consultation(s) and represents that he or she is actively in that state during the entirety of each telehealth visit. The Patient understands that if he or she is not physically located in their home state, the Practice may decline to treat him or her via telehealth.

The Patient understands that the Practice’s healthcare professionals may prescribe medically appropriate medication to the Patient specifically to treat the Patient’s diagnosed condition, but there is no guarantee that the Patient will be prescribed medication. If medication is prescribed, the Patient, at all times, has the ability to request that his or her medication be fulfilled at the pharmacy provider of the Patient’s choice.

The Patient has been advised of all the potential risks, consequences, and benefits of telehealth. The Patient has been afforded the opportunity to ask questions about the information presented on this form. All the Patient’s questions have been answered, and he or she understands the information contained herein.

I can contact the Practice by faxing my request to (407) 550-5441 for a copy of this form.