Telehealth Consent Open Payments

AUTHORIZATION TO USE AND DISCLOSE MY MEDICAL INFORMATION AND CONSENT TO TELEHEALTH

OPEN PAYMENTS NOTICE

Last updated: September 10, 2025

BY CHOOSING “I AGREE,” CHECKING A RELATED BOX, COMPLETING ANY OTHER ACCEPTANCE METHOD OFFERED THROUGH THE SERVICE, OR OTHERWISE GIVING YOUR EXPLICIT CONSENT, YOU CONFIRM THAT YOU HAVE READ, UNDERSTOOD, AND AGREE TO BE BOUND BY THIS AUTHORIZATION. IF YOU DO NOT ACCEPT THESE TERMS, DO NOT CREATE AN ACCOUNT OR USE THE SERVICE. YOU ALSO GRANT AUTHORITY TO ANY INDIVIDUAL ACTING ON YOUR BEHALF WHO INDICATES ACCEPTANCE BY CLICKING “I AGREE” OR USING ANOTHER METHOD OF CONFIRMATION. Read more: Terms and Conditions of Use.

IF YOU ARE IN AN EMERGENCY SITUATION OR EXPERIENCING SUICIDAL THOUGHTS, CALL 911 OR THE 988 SUICIDE & CRISIS LIFELINE IMMEDIATELY.

AUTHORIZATION TO USE AND DISCLOSE MY MEDICAL INFORMATION

By signing this Authorization, I permit US Quick Health LLC (“US Quick Health”), including its affiliates and subsidiaries (“Receiving Entities”), to use and share my Medical Information, including my Protected Health Information (collectively referred to as “Personal Information”), for the following purposes:

• To provide me with information relevant to my health condition and to support disease management;

• To inform me about products, services, or programs offered by pharmaceutical manufacturers and other third parties that may be of interest to me;

• To enable pharmaceutical manufacturers, their affiliates, and authorized representatives to receive information about me for the purpose of operating patient support programs. These may include, but are not limited to: identifying healthcare providers involved with such programs to improve educational resources, reviewing inventory and dispensing data to enhance supply forecasting, and supporting my overall pharmacy and treatment experience. Such services may include copay assistance, reimbursement support, drug coverage verification, nurse educator services, and adherence programs; and/or

• To send me promotional and informational materials concerning products and services of pharmaceutical manufacturers;

• To support the proper administration of the federal 340B Drug Pricing Program when I obtain products from pharmaceutical manufacturers through US Quick Health. The 340B Program, created by the United States government, requires manufacturers participating in Medicaid to provide outpatient medications at significantly reduced prices to eligible entities. To administer the program, manufacturers require specific data from pharmacies.

The following categories of individuals and organizations are permitted to access and utilize my Medical Information:

• Pharmaceutical manufacturers together with their subsidiaries, affiliates, representatives, and authorized agents;

• External service providers engaged in delivering patient support programs or performing functions such as storing, de-identifying, aggregating, or analyzing data on behalf of pharmaceutical manufacturers; and/or

• My health insurance providers or plans.

My Medical Information. I acknowledge that my medical information may include my full medical record as well as details related to mental health, substance use involving alcohol or drugs, family planning and pregnancy, communicable diseases (including HIV), results of genetic testing, genetic information, and developmental disabilities.

Remuneration. I understand that the Receiving Entities may receive compensation or other benefits from third parties, such as pharmaceutical manufacturers, in connection with obtaining this Authorization and/or sending me the communications described herein.

Right to Revoke Authorization. I am aware that I may revoke this Authorization at any time, except where US Quick Health LLC has already relied upon it to use or disclose my Medical Information. To revoke this Authorization, I must contact US Quick Health LLC at [[email protected]].

My Information May Be Re-Disclosed. I understand that once my Medical Information is disclosed under this Authorization, it may be shared again by the recipient. Such further disclosure may not be protected under applicable privacy regulations.

I Am Not Required to Sign this Authorization. I acknowledge that I am not obligated to sign this Authorization, and my decision not to sign will not limit my ability to receive treatment or services made available by US Quick Health LLC.

Right to Receive Copy of This Authorization. I understand that if I choose to sign this Authorization, I am entitled to receive a copy for my records.

Expiration Date. This Authorization will automatically expire one year from the date of my signature, or at the maximum time period permitted by applicable state law, unless I revoke it earlier.

INFORMED CONSENT REGARDING USE OF TELEHEALTH

PURPOSEThe purpose of this consent form (“Consent”) is to explain how telehealth works and to obtain your informed agreement to receive healthcare and/or mental health services through telehealth. These services may be provided by physicians, physician assistants, nurse practitioners, and/or licensed mental health professionals (“Providers”) using the online platforms owned and operated by US Quick Health LLC and/or its subsidiaries (the “Service”). Read more: Consumer Health Data We Collect Automatically and US Quick Health Privacy Policy.

In this Consent, the terms “you” and “your” refer to the individual using the Service. In cases where the Service is being accessed by or on behalf of a minor between the ages of thirteen (13) and eighteen (18), or the higher age of majority as defined under applicable state law, “you” and “your” shall refer to and include:

1. the parent or legal guardian who consents to the use of the Service by the minor or accesses the Service on behalf of the minor, and

2. the minor who is receiving consented services or on whose behalf the Service is being used.

USE OF TELEHEALTH

Telehealth refers to the delivery of healthcare and/or mental health services through electronic communication, digital technologies, or similar means that allow a patient and a healthcare or mental health provider to interact while not being in the same physical location. Telehealth may be used for purposes such as diagnosis, treatment, follow-up care, or patient education. This can involve, among other things, the electronic transfer of medical records, photographs, personal health data, or other information between patient and provider; real-time or asynchronous exchanges via audio, video, messaging, or email; as well as the use of information generated by medical devices, audio files, or video recordings.

Alternative methods of receiving care, such as in-person visits, may also be available to you, and you may choose an alternative at any time. You are encouraged to discuss these options directly with your Provider.

ANTICIPATED BENEFITS

The use of telehealth may provide certain benefits, including making it easier and more efficient for you to access medical care or other services and treatment for conditions managed by your Provider(s); allowing you to receive medical care or other services and treatment from your Provider(s) at times that are more convenient for you; and enabling you to communicate with your Provider(s) without the need for an in-office visit. Participation in mental health services through telehealth may also help to reduce stress and anxiety; decrease negative or harmful thought patterns; improve personal relationships; and increase comfort in a variety of situations.

POTENTIAL RISKS

While the use of telehealth in the delivery of care can offer potential benefits, there are also risks that may arise from the use of telehealth and related technologies. Such risks include, but are not limited to: the quality, accuracy, or effectiveness of the services provided by your Provider may be reduced; technology, including the Service, may contain defects, malfunctions, or other errors that limit functionality, generate incorrect outcomes, make all or part of the Service unavailable or unusable, create inaccurate records, transmissions, or data, or cause records, transmissions, or data to become corrupted or lost; technical failures may interfere with your Provider’s ability to properly diagnose or treat your condition; because your Provider cannot perform certain physical examinations or measure vital signs in person, they may be unable to provide a diagnosis, determine an appropriate course of treatment, or identify the need for emergency medical attention; your Provider may be unable to treat your specific condition and you may be required to seek in-person or emergency healthcare services; participation in mental health services may at times increase distress or lead to a temporary worsening of symptoms as therapy progresses; delays in medical evaluation or treatment could occur due to Provider unavailability or technological malfunctions; electronic systems, safeguards, or security protocols may fail, resulting in a potential breach of privacy or unauthorized disclosure of your medical or other personal information; data stored or transmitted electronically, including email communications, may carry an increased risk of unintended disclosure of protected health information to unauthorized third parties; due to regulatory restrictions in certain jurisdictions, your Provider’s ability to diagnose conditions or prescribe medications, including specific prescriptions, may be limited; and incomplete access to your full medical records may result in adverse drug interactions, allergic reactions, or other errors in clinical judgment.

IF YOU ARE EXPERIENCING A LIFE-THREATENING EMERGENCY, INCLUDING BUT NOT LIMITED TO SUICIDAL THOUGHTS OR ACTIONS, YOU SHOULD IMMEDIATELY CALL 911 OR CONTACT THE 988 SUICIDE & CRISIS LIFELINE BY DIALING 988; TELEHEALTH SERVICES PROVIDED BY US QUICK HEALTH LLC ARE NOT DESIGNED TO ADDRESS URGENT OR EMERGENCY MEDICAL NEEDS AND SHOULD NEVER BE RELIED UPON AS A SUBSTITUTE FOR EMERGENCY CARE; IN CERTAIN CIRCUMSTANCES, YOUR PROVIDER MAY RECOMMEND THAT YOU OBTAIN IN-PERSON EVALUATION OR FOLLOW-UP CARE, AND IT IS YOUR RESPONSIBILITY TO SEEK SUCH ADDITIONAL MEDICAL ATTENTION WHEN ADVISED.

If the situation is an emergency, you should immediately call 911 or dial the 988 Suicide & Crisis Lifeline; in certain circumstances, telehealth may not be an appropriate form of care; if you require urgent or emergent medical attention, you must seek treatment at an emergency department or from another provider properly equipped to deliver such services; Providers using the Service may not be able to respond promptly to communications you submit through the platform; if you are not experiencing an emergency and do not require urgent medical care, you may communicate with Providers through the secure messaging function available in the Service; if a technical issue prevents you from contacting your Providers through the Service, you should reach out to US Quick Health LLC at [email protected] during business hours (M - F, 9AM - 5PM PT).

DATA PRIVACY AND PROTECTION

The electronic systems used in connection with the Service employ network and software security protocols designed to protect the privacy and security of your information and to safeguard data against intentional or accidental corruption; personal information that identifies you or includes protected health information will not be disclosed to any third party without your consent, except as permitted by law for purposes such as consultation, treatment, payment and billing, certain administrative functions, or as required by law to share information obtained in the course of providing mental health services (for example, if there is a risk of harm to yourself or others, or in cases of mandatory reporting involving child, elder, or vulnerable adult abuse), or as otherwise set forth in your Provider’s Notice of Privacy Practices; use of the Service may involve email communications to and from you that could include your protected health information; you acknowledge and understand that US Quick Health LLC cannot and does not guarantee the security or confidentiality of the services you use to access such communications, including, for example, your personal email service provider.

MEDICAL SERVICES DISCLAIMER

Healthcare and mental health services made available through the Service are provided by independent licensed physicians, physician assistants, nurse practitioners, and/or mental health professionals (“Providers”); US Quick Health LLC does not itself provide medical care and is not responsible for the medical judgment, advice, diagnoses, or treatment decisions made by Providers; Providers are solely responsible for the healthcare services they deliver to you, and any questions or concerns regarding your medical care should be directed to your Provider, not to US Quick Health LLC.

PHARMACY PRODUCTS AND SERVICES

Medications prescribed through the Service are dispensed and supplied by independent third-party pharmacies; US Quick Health LLC does not manufacture, compound, or dispense medications and cannot guarantee the availability, timely delivery, or proper handling of such medications by these pharmacies; any issues regarding fulfillment, delays, or product quality must be addressed directly with the dispensing pharmacy, and US Quick Health LLC disclaims responsibility for errors, omissions, or failures that may occur in connection with pharmacy services.

OPEN PAYMENTS NOTICE

For informational purposes only, a link to the federal Centers for Medicare & Medicaid Services (CMS) Open Payments webpage is provided here; the federal Physician Payments Sunshine Act requires manufacturers of drugs, medical devices, and biologics to publicly report detailed information regarding payments and transfers of value greater than ten dollars ($10) made to physicians and teaching hospitals; this information is made available through the Open Payments database, which is a federal resource that allows the public to search payments reported by drug and device manufacturers to physicians and teaching hospitals; US Quick Health LLC does not make or receive such payments and provides this notice solely to inform you of the availability of the federal database, which can be accessed at https://openpaymentsdata.cms.gov.

YOUR ACKNOWLEDGMENTS

By clicking “I Agree,” checking a related box to indicate your acceptance, using any other acceptance protocol offered through the Service, or otherwise affirmatively agreeing to this Consent, you acknowledge and agree to the following: healthcare and mental health services you receive through the Service will be provided via telehealth; in certain cases, your treating Provider may be a nurse practitioner or physician assistant rather than a physician, and by using the Service you consent to treatment by non-physician Providers where applicable; for therapy services, your treating Provider will be a licensed mental health professional, such as a counselor or therapist; certain technologies used in connection with the Service may still be in development or beta phases and not yet final products; technology used to deliver care, including the Service, may contain bugs or errors that limit functionality, generate incorrect results, render part or all of the Service unavailable or unusable, create inaccurate records, transmissions, or data, or cause records, transmissions, or data to become corrupted or lost, all of which could reduce or otherwise impact the quality, accuracy, and effectiveness of the medical or mental health services you receive from your Provider(s); the delivery of healthcare through telehealth is an evolving field, and the use of telehealth in your diagnosis or treatment may include applications of technology different from or not specifically described in this Consent; no outcomes, benefits, or results can be guaranteed from the use of telehealth, including any diagnoses, treatments, or prescriptions; your condition may not improve or be cured and, in some cases, may worsen; limitations exist in the provision of medical and mental health care through telehealth and the Service, and it may not be possible to receive a diagnosis or treatment for every condition via telehealth; there are potential risks in using telehealth and related technology, including but not limited to those described in this Consent; you have the opportunity to discuss the use of telehealth, including benefits, risks, and alternatives, with your Provider(s); no online treatment session will be recorded by you or your Provider(s); each Provider will assess your condition and, in their sole discretion, decide whether it is medically appropriate to diagnose and/or treat your condition using telehealth technology and whether you have sufficient ability to use such technology for your care; by continuing to use the Service, you agree with your Provider’s assessment and consent to receive diagnosis and/or treatment via telehealth technology; you have the right to withdraw your consent to telehealth at any time without prejudice to future care and without risk of losing health benefits, but you acknowledge that Providers using the Service do not offer in-person treatment; any withdrawal of your consent becomes effective upon receipt of written notice by your Provider(s) and does not affect any action already taken by US Quick Health LLC or your Provider(s) in reliance on this Consent prior to such notice; withdrawal of consent does not affect the validity of any other provision of this Consent, which remains binding; you understand that use of the Service involves electronic communication of your personal medical information, including through email; you agree to provide US Quick Health LLC and your Provider(s) with truthful, accurate, and complete information, including all relevant details of care you are receiving or have received from other healthcare or mental health providers, as well as emergency contact information; each of your Provider(s) may determine in their sole discretion that your condition is not suitable for telehealth-based diagnosis or treatment, in which case you may be referred to an in-person healthcare or mental health provider or specialist; prescriptions issued through the Service may be fulfilled by independent third-party pharmacies that partner with US Quick Health LLC, and such prescriptions may also be transferred between partner pharmacies on your behalf; you remain free to obtain your prescription from a pharmacy of your choice by contacting US Quick Health LLC support, but you are responsible for the full cost of the Service, including any prescription costs, and you agree not to attempt to submit claims to Medicare, any other federal healthcare program, or any state or private insurance plan in connection with the Service.

If you have a concern about a medical professional, you may contact the appropriate Medical Board in your state; for California residents, physicians and midwives are licensed and regulated by the Medical Board of California (www.mbc.ca.gov, phone (800) 633-2322), and marriage and family therapists, educational psychologists, clinical social workers, and professional counselors are licensed and regulated by the California Board of Behavioral Sciences (www.bbs.ca.gov, phone (916) 574-7830).