Cecelia Health (“Cecelia”) uses the internet and other types of electronic communications to connect users to health care providers (“HCPs”) to enable those providers to evaluate the individual’s medical information for the purpose of providing care (“Telehealth/Telemedicine Services”).

Cecelia’s participants have established an account and are assigned an HCP. The Telehealth/Telemedicine Services may include, review of health records and test results, health information sharing (e.g., sharing exercise or food diary or log), viewing images and conducting asynchronous communications; live two-way audio and video; interactive audio with store and forward; and output data from medical devices and sound and video files; clinical support services; and patient education.

Any Telehealth/Telemedicine Services are in addition to, and not a replacement for, care you receive or received from an in-person visit to a physician or other health care providers on whom you may rely for medical services. Responsibility for your overall medical care should remain with your primary care provider, if you have one, and we strongly encourage you to locate one if you do not. You may contact the Cecelia Health telehealth HCPs with follow-up questions with respect to the Telehealth/Telemedicine Services and treatment provided by the HCPs. However, if you are experiencing a medical emergency, you should dial 911 or go to your nearest emergency room or urgent care center immediately.

The Health Insurance Portability and Accountability Act of 1996 are the privacy and information security laws that apply to collection, use, disclosure and maintenance of information during telehealth/telemedicine visits. Information obtained during telehealth/telemedicine that identifies you will not be given to anyone without your consent except for the purposes of treatment, payment and healthcare operations.

By agreeing to use the Telehealth/Telemedicine Services, I am consenting to Cecelia sharing of my protected health information with certain third parties as more fully described in Cecelia’s Privacy Policy.

I understand, agree, and expressly consent to Cecelia obtaining, using, storing, and disseminating to necessary third parties, information about me, video recordings, audio recordings, including images of me, as necessary to provide the Telehealth/Telemedicine Services.

In order to proceed, you must acknowledge that you have read, understand, and agree to this Consent for Telehealth/Telemedicine Services.

• I understand the risks and benefits of using the Telehealth/Telemedicine Services offered through the Platform. I also understand that none of the benefits of the Telehealth/Telemedicine Services are guaranteed and that the treatment provided may not necessarily improve any of my medical conditions.

• I consent to receive services using telehealth/telemedicine technologies. I understand that Telehealth/Telemedicine Services do not replace the overall medical care provided by from my in-person physician or care provider. I understand that, in the case of a medical emergency, I should dial 911 or go to the nearest emergency room or urgent care center immediately.

• I understand that I am responsible for providing the HCPs with complete, truthful, and accurate information, and I acknowledge that the HCP will rely on the information I provide in the delivery of Telehealth/Telemedicine Services to me.

• I understand that the inaccuracy of any information I provide to the HCP may impact the efficacy of the Telehealth/Telemedicine Services. I understand that an HCP will determine whether or not my specific needs are appropriate for a telehealth encounter and may decide I need to seek treatment from a different provider. and that the HCP or I can discontinue any telehealth encounter.

• I understand that there is a risk of technical failures during the Telehealth/Telemedicine Services that may be beyond Cecelia’s control. I agree to hold Cecelia and the HCPs harmless for any delays in evaluation or for information lost due to such technical failures.

• I understand there may be side effects from certain medications prescribed, and that the Cecelia Health HCP will specifically address these risks when prescribing such medications. I further understand that there is no guarantee that I will be given any prescription for medication.

• I understand that federal and state laws require health care providers to protect the privacy and security of health information. I understand that Cecelia and the HCPs will take reasonable and appropriate steps to make sure that my health information is not seen by anyone who should not see it. I understand that telehealth may involve electronic communication of my personal medical information to other health practitioners who may be located in other areas, including other states.

• I understand that I have the right to request a copy of my medical records, which, will be provided to me at reasonable cost of preparation, shipping, and delivery.

• I give my informed consent to Telehealth/Telemedicine Services as an acceptable form of delivering health care services to me, and I understand that this consent will cover any and all Telehealth/Telemedicine Services provided to me through Cecelia.

• I understand that either the HCP or I can discontinue any telehealth encounter. I further understand that I may withdraw my consent at any time by discontinuing services through Cecelia and I can deactivate my Account.

As with any Internet-based communication, I understand that there is a risk of security breach. Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption, loss or misuse. Individuals other than my clinical care team or consulting providers may also be present and have access to my information for the telehealth/telemedicine session. This is so they can operate or repair the video or audio equipment used. These persons will adhere to applicable privacy and security policies.

Telehealth/telemedicine sessions may not always be possible. Disruptions of signals or problems with the Internet’s infrastructure may cause broadcast and reception problems (e.g., poor picture or sound quality, dropped connections, audio interference) that prevent effective interaction between consulting clinician(s), participant, patient or care team.

I hereby release and hold harmless Cecelia and all members of my care team from any loss of data or information due to technical failures associated with the telehealth/telemedicine service. I understand and agree that the health information I provide at the time of my telehealth/telemedicine service may be the only source of health information used by the medical professionals during the course of my evaluation and treatment at the time of my telehealth/telemedicine visit, and that such professionals may not have access to my full medical record or information held at Cecelia.

I understand that I may be given information about test(s), treatments(s) and procedures(s), as applicable, including the benefits, risks, possible problems or complications, and alternate choices for my medical care through the telehealth/telemedicine visit.

I have the right to withhold or withdraw consent to the use of telehealth/telemedicine services at any time and revert back to traditional in-person clinic services. I understand that if I withdraw my consent for telehealth/telemedicine, it will not affect any future services or care benefits to which I may be entitled.

I acknowledge that I have had the opportunity to ask any questions about using telehealth/telemedicine services and all of my questions have been answered to my satisfaction. I hereby consent to the use of telehealth/telemedicine in the provision of care and the above terms and conditions. By signing below, I certify that I am the legal representative of the participant or that I am the patient and am eighteen (18) years of age or older, or otherwise legally authorized to consent. I have carefully read and understand the above statements.

I understand that this informed consent will become a part of my medical record.