Consent to Treatment

Per this Informed Consent to Telehealth and Related Healthcare Services ("Informed Consent for Telehealth Services"), I hereby give my informed consent for medical treatment and procedures ("Informed Consent") to be administered by the healthcare professionals at Circle Medical Care Group, P.A., a Florida professional association; Circle Medical Group of California, a California professional corporation; Circle Medical Care Group of New Jersey, P.C.; and Circle Medical Care of New York, P.C. (collectively, "Circle Medical").

I understand that certain healthcare services may also be provided by affiliated medical groups, including Cloud Health Medical Group, P.A., a Florida professional association; Cloud Health Medical Group of California, P.C.; Cloud Health Medical Group of New Jersey, P.A.; and Cloud Health Medical Group of Kansas, P.C. (collectively, "Cloud Health Medical").

Circle Medical and Cloud Health Medical may be referred to individually as a "Medical Group" and collectively as the "Medical Groups," which terms include their affiliated providers and contractors.

By agreeing to this Informed Consent, I elect to receive healthcare services via telehealth. Such services may include, as determined appropriate by my provider:

• evaluation and treatment by a licensed healthcare provider;
• remote physiological monitoring ("RPM") services;
• chronic care management ("CCM") services; and
• other related clinical and care coordination services (collectively, "Telehealth Services").

Telehealth Services may be delivered using a variety of technologies and methods, including real-time audio and/or video communication, asynchronous communication, and the transmission of medical data, images, and health information, as determined appropriate by my provider. The specific services I receive will depend on my medical needs and my Provider's clinical judgment, and I understand that the use of Telehealth Services does not guarantee that a provider will be able to diagnose or treat my condition.

I understand that Telehealth Services are not intended for the diagnosis or treatment of emergency medical conditions, and in the event of a medical emergency, I will call 911 or seek immediate in-person care.

All capitalized terms used in this Informed Consent but not defined herein shall have the meanings assigned to them in this Informed Consent for Telehealth Services or the applicable Notice of Privacy Practices. I understand that my participation in Telehealth Services is voluntary and that I may choose to seek in-person care where available. I consent to receive communications electronically in connection with my care, including through the Circle Medical and Cloud Health Medical application and email. I understand that certain communications may also be sent via text message if I have opted in to receive such messages.

I should review this Informed Consent carefully and only proceed if I have made an informed decision that Telehealth Services are appropriate for me. If I have any questions, please email us at [email protected].

I understand and acknowledge the following:

I understand that by signing this form, I am authorizing Medical Groups and their healthcare providers to provide medical treatment, primarily via Telehealth Services as described in this Consent, conduct diagnostic tests, and perform necessary procedures to diagnose and treat my medical condition. I understand that the practice of medicine is not an exact science and that diagnosis and treatment may involve risks, including the possibility of injury or death, and no guarantees have been made regarding the outcome of any treatment.

I acknowledge that Medical Groups may employ a variety of medical treatments, including those delivered via Telehealth Services, which may include examinations, diagnostic tests, medical procedures, surgeries, administration of medication, and the use of medical devices. I understand that alternative treatments, risks, and potential complications will be discussed with me before any procedures are performed.

I understand and agree that RPM technology, to the extent used by Medical Groups, is not an emergency response unit and I will call 911 for immediate medical emergencies. Medical Group providers will determine, in their sole discretion, whether RPM is appropriate for my condition and may require an in-person examination prior to initiating services. I understand that response times may vary and accept associated risks, including delays in care. The RPM Technology is the property of the applicable Medical Group, and I will not tamper with it or misuse it, and I am responsible for any related costs. No warranty or guarantee has been made regarding outcomes.

If I have questions about use of the RPM Technology itself and whether it is appropriate for my medical condition, the risks associated with using the RPM Technology, or the provider's credentials and professional background, I will ask my Medical Group provider.

I understand that use of the RPM Technology has risks associated with it, such as:

• information transmitted through RPM Technology may be insufficient to allow for appropriate medical decision-making by a Medical Group provider;
• failures of equipment or infrastructure may cause delays in medical evaluation and treatment, or loss of information; and
• unauthorized access to my medical information.

I acknowledge that, although Medical Groups and their RPM Technology vendors strive to prevent unauthorized access to information about me through encryption of information transmitted by RPM Technology and other security measures, Medical Groups and their vendors cannot guarantee that my use of RPM Technology and the information will be private or secure, and I consent to this risk. I understand and consent to the risks associated with the use of RPM Technology.

To the extent applicable to my care, I hereby consent to receive Chronic Care Management ("CCM") services from Medical Groups as defined by the Centers for Medicare & Medicaid Services ("CMS") under CPT codes 99490, 99439, 99487, 99489, and 99491, and as recognized by my health insurance plan. CCM services may include:

• at least 20 minutes of clinical staff time directed by a physician or qualified healthcare professional per calendar month;
• non-face-to-face coordination and communication, including telephone calls, secure messaging, and review of medical data;
• maintenance and regular review of a comprehensive electronic care plan; and
• coordination with other healthcare professionals and community resources involved in my care.

I acknowledge and understand that:

• CCM services are performed under the direction and general supervision of my treating Medical Group provider;
• Only one provider may bill for CCM services for me during a given calendar month, and by signing this consent, I authorize Medical Groups to furnish and bill for these services until I revoke this consent;
• I may revoke this consent at any time by providing written notice to the applicable Medical Group, and such revocation will be effective at the end of the month in which notice is received;
• Participation in CCM is voluntary, and refusal or withdrawal will not affect my eligibility for other medical care or services;
• CCM services may be subject to cost-sharing, including applicable copayments, coinsurance, or deductibles, as determined by my insurance plan (including Medicare and private/commercial insurers);
• I authorize Medical Groups to bill Medicare and/or my private or commercial insurance for CCM services rendered and agree to pay any patient-responsible amounts in accordance with my insurance benefits; and
• I understand that Medical Groups and their clinical staff may use and disclose my protected health information (PHI) as necessary to provide, coordinate, and bill for CCM services in compliance with applicable HIPAA privacy and security regulations.

Telehealth Services involve interactive video conferencing equipment and devices that let my health care provider deliver health care services to me from a location that is different than my location, and I confirm that I have read this form (or had it explained to me) and understand the following:

• I will not be physically in the same room as my health care provider during the visit, and I will be told about and asked for my consent before any other Medical Group staff or trainees actively assist my health care provider during this visit.
• There are risks and limitations associated with Telehealth Services, including, but not limited to:
  • disruption of the appointment caused by technology failures;
  • the limited ability of my health care provider to respond to emergencies during the visit;
  • interruption or violations of confidentiality by unauthorized individuals, and while Medical Groups take reasonable steps to secure telehealth visits and breaches are rare, no technology is completely secure;
  • the possibility that I or my provider may determine that the video conferencing equipment or connection is not adequate and may stop the visit, switch to an alternate Medical Group-approved platform, or make other arrangements to continue care;
  • the possibility that my provider may not identify medical conditions that could otherwise be identified during an in-person visit; and
  • delays, interruptions, or failures in technology that may impact the quality, timing, or availability of care, or result in loss of data or information.
• I have the right to refuse to participate in or stop participating in a telehealth visit, and my refusal will be documented in my medical record. I understand that my refusal may impact my ability to receive future care or treatment from Medical Groups.
• The laws that protect the privacy and confidentiality of my health care information apply to Telehealth Services.
• My health care information may be shared with other individuals for scheduling and billing purposes.
• I understand that health plan payment policies for telehealth visits may differ from policies for in-person visits.
• I understand that I am responsible for any out-of-pocket costs, including copayments or coinsurance, that apply to my telehealth visit.
• I understand that during the telehealth visit, I must be physically located in a state where my provider is licensed, or the visit will need to be rescheduled. If I am in a different state than previously provided, I will inform my provider before the visit to confirm that they are able to treat me.
• I have had all my questions about Telehealth Services answered to my satisfaction, and the risks, benefits, and alternatives to telehealth visits have been explained to me in a language I understand.
• Telehealth visits are not recorded by Medical Groups unless otherwise disclosed to me. Any recording of visits by me requires the prior consent of my provider.

I understand that all medical treatments and procedures carry risks and potential benefits, and while Medical Groups take precautions to minimize risks, no guarantees can be made regarding outcomes. I authorize the exchange of my medical information with other providers, health information exchanges ("HIEs"), and health plans for treatment, payment, and operations.

I understand that certain categories of sensitive health information, including but not limited to HIV status, behavioral health information, or psychotherapy notes, may be subject to additional protections under applicable state and federal law and will not be disclosed without my authorization except as required by law.

I acknowledge that Medical Groups are committed to protecting the privacy and confidentiality of my personal health information in accordance with applicable laws and regulations. I authorize the collection, use, and disclosure of my health information for the purposes of treatment, payment, and healthcare operations. I understand that Medical Groups may use third-party service providers and technology vendors to support the delivery of healthcare services, including Telehealth Services, and that my information may be shared with such parties in accordance with applicable law.

I understand that Medical Groups may use artificial intelligence ("AI") tools to support clinical care and administrative functions, including but not limited to medical documentation, summarization of medical information, and operational support. I understand that any AI-based tools are used as a support to, and not a replacement for, clinical decision-making by my healthcare provider. My provider will exercise independent professional judgment in all clinical decisions.

I consent to the use of AI-based tools in connection with my care and understand that information generated or processed through such tools may become part of my medical record. I further understand that my information may be used in accordance with applicable law, including HIPAA, for healthcare operations, including improving tools and services used to support patient care, subject to applicable privacy and security protections.

I understand that I am financially responsible for all medical services rendered by Medical Groups. I agree to pay all charges for services not covered by my insurance, including deductibles, co-pays, and any outstanding balances. I understand that it is my responsibility to understand my insurance coverage, including which providers and services are covered.

I may refuse or withdraw my consent for medical treatment at any time. I understand that this decision may have consequences and that I should discuss any concerns or questions with my healthcare provider.

I understand the importance of open and honest communication with my healthcare provider. I agree to provide accurate and complete information about my medical history, current medications, allergies, and other relevant details. I understand I should follow any post-treatment instructions and attend follow-up appointments as recommended. I understand that it is my responsibility to notify my provider if I believe information in my medical or billing record is inaccurate and to request corrections as appropriate.

I authorize Medical Groups and their providers to make necessary medical decisions on my behalf if I cannot do so, based on their professional judgment and in accordance with applicable laws and regulations.

If I receive a prescription as a result of my use of the Telehealth Services, I may choose to have my prescription fulfilled through the pharmacy of my choice. I consent to the transmission and disclosure to the pharmacy of my choice of all information provided by me, my health care records, and other applicable health and personal information (including my name, location, and demographic information) as necessary for me to receive pharmacy services.

• If I am experiencing a medical emergency, I will dial 911 immediately, and I understand that my Provider cannot directly connect me to local emergency services.
• I may elect to seek services from a medical group or provider with in-person clinics as an alternative to receiving Telehealth Services.
• I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time. I understand that doing so will not affect my right to receive care, but may require me to seek in-person services or limit the availability of certain services through Medical Groups.
• Federal and state law requires health care providers to protect the privacy and the security of health information. I am entitled to all confidentiality protections under applicable federal and state laws. I understand all medical reports resulting from the telehealth visit are part of my medical record. Medical Groups will take steps to make sure that my health information is protected in accordance with applicable laws.
• Telehealth may involve electronic communication of my personal health information to other health practitioners who may be located in other areas, including out of state.
• There is no guarantee that I will be treated by any particular Medical Group provider. My provider reserves the right to deny care for potential misuse of Telehealth Services or for any other reason if, in the professional judgment of my provider, the provision of the Telehealth Services is not medically or ethically appropriate.

As a patient treated by a Medical Group provider, I have rights and responsibilities intended to ensure safe, effective, and high-quality care.

My Rights. I have the right to:

• Receive Quality Care within the scope of services provided by Medical Groups. Medical Groups strive to provide high-quality, evidence-based, and personalized care. If my health needs exceed the scope of services provided, I may be referred to other providers or specialists to ensure appropriate care. Medical Groups may recommend referral to specialists or other providers where clinically appropriate.
• Be Treated With Respect and Fairness. I have the right to be treated without discrimination based on race, color, national origin, age, disability, sex, gender identity, sexual orientation, religion, or other protected characteristics under applicable law. Medical Groups are committed to maintaining a safe and respectful care environment.
• Understand the Benefits and Risks of the treatment proposed by my provider.
• Be Involved in Decisions about my health and treatment.
• Request a Change of Provider.
• Refuse Any Treatment or Service, consistent with applicable law.
• Receive Care in a Language That I Understand, where reasonably available.
• Expect That My Privacy Will Be Protected, including the safeguarding of my medical records in accordance with applicable law.
• Receive a Copy of My Medical Records, subject to applicable laws and procedures.
• Receive a Clear Explanation of and Access to My Billing Information.
• File a Complaint or Grievance regarding my care without fear of retaliation and receive information on how to do so.
• Know the Identity, Credentials, and Licensure of my healthcare provider.
• Receive Information Necessary to make informed decisions about my care and to provide informed consent.
• Receive Reasonable Accommodations and Access Services, including language assistance and disability accommodations, where available.
• Receive a Copy of This Patient Rights and Responsibilities Document.

My Responsibilities. I am responsible for:

• Providing accurate and complete information about my medical history, current condition, medications, allergies, and other relevant health information.
• Using approved communication channels, including the Circle Medical and Cloud Health Medical application, to communicate with my provider, except in emergencies or where otherwise instructed.
• Asking questions if I do not understand my treatment plan and actively participating in and following agreed-upon treatment recommendations.
• Understanding my insurance coverage, including notifying Medical Groups of any applicable coverage such as Medicare, Medicaid, or Medi-Cal.
• Attending scheduled appointments or canceling in accordance with applicable policies.
• Paying all applicable fees, copayments, and outstanding balances in a timely manner.
• Treating healthcare providers and staff with respect and maintaining appropriate conduct during all interactions. Behavior that compromises the safety of patients or staff may result in appropriate action, including limitation or termination of services.
• Using Telehealth Services in a safe and appropriate environment, including being in a private location where possible.
• Using Medical Groups’ services appropriately and not misusing the platform, including for inappropriate requests for medications or services.
• Complying with applicable policies related to technology use and communication.
• Not recording medical visits without prior consent from my provider.

The following consents apply to patients accessing Medical Groups’ services to participate in Telehealth Services, as required by the states listed below:

Alaska. I understand that my primary care provider may obtain a copy of my records of my telehealth encounter. I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website.

Arizona. I understand I am entitled to all existing confidentiality protections pursuant to A.R.S. § 12- 2292. I also understand all medical reports resulting from the RPM Services are part of my medical record as defined in A.R.S. § 12-2291. I also understand dissemination of any images or information identifiable to me for research or educational purposes shall not occur without my consent, unless authorized by state or federal law.

California. I understand that some or all of my CCM services may be provided using telehealth technologies. I consent to the use of telehealth for CCM services in accordance with California law. I also authorize Medical Group to share my health information among its affiliated entities and care team members for the purpose of coordinating my care, consistent with the California Confidentiality of Medical Information Act (CMIA).

Colorado. I consent to the use of telehealth for my CCM services. I understand that I will not be charged separately for the use of telehealth technology and that my privacy will be protected under Colorado law.

Connecticut. I understand that my primary care provider may obtain a copy of my records, my RPM services and my telehealth encounter.

Florida. To view my rights under Florida’s Patient Bill of Rights and Responsibilities, I should visit the Florida Agency for Health Care Administration. To view my rights under Florida’s Weight-Loss Consumer Bill of Rights, I should visit the agency’s consumer resources. I understand that my provider may not be physically located in Florida when telehealth CCM services are provided. I consent to receive these services under Florida’s Telehealth Practice Act.

Georgia. I have been given clear, appropriate, accurate instructions on follow-up in the event of needed emergent care related to the RPM Services.

Hawaii. I consent to the use of telehealth for CCM services as permitted by Hawaii law. I understand that my privacy will be protected under state and federal law and that I may withdraw consent at any time.

Idaho. I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website.

Illinois. I understand that telehealth may be used for parts of my CCM care. Participation is voluntary, and I may choose in-person visits when available. I consent to telehealth consistent with Illinois law.

Indiana. I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website.

Iowa. I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website.

Kansas. I understand that if I have a primary care provider or other treating physician, the person providing telemedicine services must send a report to such primary care or other treating physician of the treatment and services rendered to me during the telemedicine encounter within three days of me providing consent to the person providing telemedicine and RPM services to send such report.

Kentucky. I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website.

Maine. I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, or the Maine Board of Osteopathic Licensure’s website.

New Jersey. I understand I have the right to request a copy of my medical information and I understand my medical information may be forwarded directly to my primary care provider or health care provider of record, or upon my request, to other health care providers. I understand that some of my CCM services may be delivered using telehealth. I have been informed of my provider’s identity, credentials, and location, and I consent to receive telehealth services consistent with New Jersey law.

New Hampshire. I understand that my primary care provider or treating provider may obtain a copy of my records of my telehealth encounter.

New York. I consent to receive telehealth services for Chronic Care Management. I understand that all telehealth communications will be secure and that my information will remain confidential under New York law.

Ohio. I understand that my primary care provider may obtain a copy of my records of my telehealth encounter.

Oklahoma. I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, or the Oklahoma Board of Osteopathic Examiners’ website.

Oregon. I consent to receive telehealth Chronic Care Management services under Oregon law. I understand that these services will follow all confidentiality and coordination-of-care rules applicable in Oregon.

Rhode Island. If I use email or text-based technology to communicate with my health care provider, then I understand the types of transmissions that will be permitted and the circumstances when alternate forms of communication should be utilized. I have also discussed security measures, such as encryption of data, password protected screen savers and data files, or utilization of other reliable authentication techniques, as well as potential risks to privacy. I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website.

South Carolina. I understand that my medical records may be distributed only with my consent and in accordance with applicable laws and regulations to other treating health care practitioners.

South Dakota. I have received disclosures regarding the RPM Services RPM Technology and limitations.

Texas. I understand that with my consent my medical records may be sent to my primary care physician within 72 hours after receiving Services. I consent to the use of telecommunication technology, including telephone or electronic communications, as part of my Chronic Care Management services. I understand that these services will comply with Texas Medical Board telemedicine standards and that I may decline telehealth at any time. I have also been informed of the following notice:

NOTICE CONCERNING COMPLAINTS — Complaints about physicians, as well as other licensees and registrants of the Texas Medical Board, including physician assistants, acupuncturists, and surgical assistants may be reported for investigation at the following address: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018. Assistance in filing a complaint is available by calling the following telephone number: 1-800-201-9353. For more information, please visit www.tmb.state.tx.us.

AVISO SOBRE LAS QUEJAS — Las quejas sobre médicos, así como sobre otros profesionales acreditados e inscritos del Consejo Médico de Tejas, incluyendo asistentes de médicos, practicantes de acupuntura y asistentes de cirugía, se pueden presentar en la siguiente dirección para ser investigadas: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018. Si necesita ayuda para presentar una queja, llame al: 1-800-201-9353. Para obtener más información, visite nuestro sitio web en www.tmb.state.tx.us.

Utah. I understand (i) any additional fees charged for RPM Services, if any, and how payment is to be made for those additional fees; (ii) to whom my health information may be disclosed and for what purpose, and have received information on any consent governing release of my patient-identifiable information to a third party; (iii) my rights with respect to patient health information; (iv) appropriate uses and limitations of the RPM Technology, including emergency health situations. I understand that the RPM Services Medical Group provides meets industry security and privacy standards, and comply with all laws referenced in the Utah regulations. I was warned of: potential risks to privacy notwithstanding the security measures and that information may be lost due to technical failures, and agree to hold Provider harmless for such loss. I have been provided with the location of Medical Group’s website and contact information. I am able to (i) access, supplement, and amend my patient-provided personal health information; and (ii) obtain upon request an electronic or hard copy of my medical record documenting the RPM Services, including the Consent provided; and (iii) request a transfer to another provider of my medical record documenting the telemedicine services.

Virginia. I acknowledge that I have received details on security measures taken with the use of RPM Technology, as well as potential risks to privacy notwithstanding such measures. I agree to hold harmless Medical Group for information lost due to technical failures; and I provide my express consent to forward patient-identifiable information to a third party. I consent to the use of telemedicine for my CCM services, consistent with Virginia law. I understand that telehealth services will be conducted securely and documented in my record.

Vermont. I understand that I have the right to receive a consult with a distant-site provider and will receive one upon request immediately or within a reasonable time after the results of the initial consult. I understand that receiving telemedicine services via the telehealth platform does not preclude me from receiving real-time telemedicine or face-to-face services with the distant provider at a future date. I have been informed that if I want to register a formal complaint about a provider, I should visit the Vermont Board of Medical Practice website or the Vermont Board of Osteopathic Examiners.

Washington. I consent to receive telemedicine as part of my Chronic Care Management services. I understand that this consent will be recorded in my medical record, and that telehealth services will meet Washington privacy and security requirements.

Washington, D.C. I consent to receive telehealth services as part of my Chronic Care Management. I understand that my provider may not be located in the District of Columbia at the time of service.

I have read and understood this Informed Consent for Telehealth Services, including the Patient Rights and Responsibilities Section set forth above, and I voluntarily consent to receive healthcare services, including Telehealth Services, from Medical Groups. I understand that this Informed Consent for Telehealth Services may be executed electronically, including by checking a box or otherwise indicating acceptance, and that my electronic acceptance has the same legal effect as a handwritten signature under applicable law.

Effective date: April 30, 2026