I understand that Patient, which may be defined as me, my child, or a child for whom I have legal responsibility, needs medical care and treatment, and I consent to such treatment at VirtualCare2Go^®. Treatment provided by medical providers, nurses, and medical assistants at VirtualCare2Go^® may include evaluation and management, vaccinations, laboratory and other testing; routine medical, nursing, and medical assistant care and procedures. I understand that photos or videos of the Patient may be taken in connection with such treatment and for operational, quality improvement, and education purposes. I understand that VirtualCare2Go^® is affiliated with a teaching institution and agree that resident physicians, fellows, and students may observe and participate in the Patient’s care and treatment under appropriate supervision.

No Guarantee

I acknowledge that no guarantees or warranties have been made with respect to treatment or services to be provided by VirtualCare2Go. I understand that all supplies, medical devices, and other goods provided to the Patient are provided by VirtualCare2Go^® AS IS and VirtualCare2Go disclaims any expressed or implied warranties.

Patient Rights

I have been provided with information regarding Patient Rights and Responsibilities. This information tells me how to register a complaint or grievance that I might have relating to the Patient’s care at VirtualCare2Go^®.

Communicable Disease Testing

I agree that if a VirtualCare2Go^® employee or provider is exposed to the Patient’s blood or other bodily fluid, pursuant to Texas law, VirtualCare2Go^® may test the Patient to determine the presence of communicable diseases, including Human Immunodeficiency Virus (HIV) and hepatitis. I understand that these test results will be kept confidential.

Specimen Disposal

I acknowledge that VirtualCare2Go^® may, in its sole discretion, remove, retain, or dispose of any tissue or body parts removed from the Patient.

Text Messaging

I understand that VirtualCare2Go^® can provide notifications to my cell phone. These texts are Do Not Reply texts for informational purposes only and are not intended as a form of two-way communication. I acknowledge that standard text messaging rates and fees will apply, text messaging utilizes a public telephone network, and full security is not guaranteed. Any person with access to my phone will be able to see these messages unless I take steps to protect my phone with a password or PIN.

Protected Health Information

Notice of Privacy Practices

I have received the VirtualCare2Go^® Notice of Privacy Practices. Any questions or concerns may be directed to the VirtualCare2Go^® Privacy Officer.

Use and Disclosure of Information

I understand that the Patient’s medical records are confidential and cannot be disclosed without my written authorization except as authorized by law. Authorized disclosures are addressed in the Notice of Privacy Practices I have received. I understand that the Patient’s medical information includes past, present, and future information and may include genetic testing/counseling, communicable disease information (including HIV/AIDS), records related to mental health treatment/psychiatric care, and alcohol/substance abuse diagnosis or treatment (collectively, Medical Information). I authorize the release of that Medical Information as part of the Patient’s medical record. I understand that VirtualCare2Go^® must keep the Patient’s medical records for a time period required by law and may dispose of them as permitted or required by law.

Consent for Electronic Sharing and Health Information Exchange

I authorize VirtualCare2Go^® to use the Patient’s Medical Information for treatment and related services. Unless I object below, I authorize VirtualCare2Go to release and send the Patient’s Medical Information to non-VirtualCare2Go health care providers electronically and/or through a Health Information Exchange. Disclosed Medical Information may be used for treatment, payment, and operational purposes. This disclosed Medical Information may become part of non-VirtualCare2Go providers' records and may be re-disclosed, no longer protected by state or federal privacy laws.

I understand that I can withdraw this authorization at any time, but VirtualCare2Go^® cannot take back information that has already been electronically shared. This consent is valid unless I withdraw it.

• I do not authorize VirtualCare2Go^® to send text messages to my cell phone number.
• I do not want the Patient’s Medical Information shared electronically with non-VirtualCare2Go health care providers unless required by law.
• I do not want the Patient’s Medical Information shared with Health Information Exchanges unless required by law.

Financial Responsibility

I agree to pay the full billed charges associated with goods and services provided to the Patient, regardless of any applicable insurance or benefit payments. All amounts are due upon request and payable to VirtualCare2Go^®. Except as prohibited by law, I agree to pay charges not covered and covered charges not paid in full by insurance, including co-insurance, deductibles, and non-covered benefits due to policy or plan limitations. If the Patient’s account becomes delinquent and is referred to an attorney or agency for collection, I am responsible for all charges, reasonable attorney fees, costs, and collection expenses. I consent to credit bureau inquiries and to receiving calls, including auto-dialed calls, from VirtualCare2Go^® and its agents, including collection agents.

Medicare/Medicaid Patients Only

I understand that requested goods and services may not be covered under Medicare/Medicaid. If Medicare/Medicaid determines that certain goods and services are not medically necessary and I request them, I am solely responsible for payment. If the Patient is a Medicare/Medicaid managed care Patient, these provisions may not apply.

Notice to Patients – Third Party Payer Information

Based on the information I provided, VirtualCare2Go^® is/is not a participating provider under the Patient’s third-party payer coverage, insurance, or benefit plan.

Assignment of Benefits

I irrevocably assign and convey directly to VirtualCare2Go^®, and any provider that provides services to the Patient, all benefits, interest, and rights under any insurance policies or benefit plans for goods and services provided to the Patient by VirtualCare2Go^® and Providers. I also authorize direct payment to VirtualCare2Go^® for services provided. I authorize the Patient’s plan administrator, insurer, and/or attorney to release any Plan documents, summary benefit description, insurance policy, and settlement information upon request from VirtualCare2Go^® needed to claim medical benefits.

By using the VirtualCare2Go^® website, you agree to these terms and conditions. This Agreement also incorporates our Website Privacy Policy (available on the website). If you do not agree to these terms, please refrain from using the Website. Your use constitutes your agreement to all terms, conditions, and notices contained herein.

Conditions to Use our Website

Your permission to use the Website is conditioned upon your agreement that you:

• Will comply with these Terms of Use;
• Are 18 years of age or older, or accompanied by a parent/guardian with valid ID;
• Will not copy or distribute any part of the Website without prior consent;
• Will provide accurate information when creating an account or registering;
• Will not allow others to use the Website under your User ID and account;
• Are solely responsible for activity that occurs through your User ID;
• Will not use the Website for any commercial purposes other than specified;
• Are responsible for content provided by you, including compliance with licenses or rights necessary to use the work of others;
• Grant the Website and other users a non-exclusive license to read your materials and use them as necessary (not applicable to personal information);
• Agree we have the right to remove any of your content and terminate your account with or without prior notice.

Account/Profile

To access certain parts of the Website, we may require you to create an account and/or profile. You agree to keep all information accurate and up to date. Sharing User IDs is prohibited, and unauthorized access should be reported to info@VirtualCare2go.com.

Your Content

VirtualCare2Go^® reserves the right to publish User Generated Content ("UGC"). You agree not to post or use any UGC that infringes on third-party rights, is defamatory or inappropriate, or otherwise violates these Terms.

Termination

VirtualCare2Go^® reserves the right to alter or discontinue the Website or any services at any time without prior notice. This Agreement will automatically terminate if, in our sole discretion, you violate any terms. Termination will result in cessation of access, and all terms relating to content, warranty, and liability shall survive termination.

Disclaimers of Warranty and Limitations of Liability

VirtualCare2Go^® provides the Website and services "as is" and "as available," without guarantees of reliability, timeliness, or fitness for a particular purpose. You waive claims for any damages arising from your use of the Website to the fullest extent allowed by law.

Entire Agreement

This Agreement, including the Privacy Policy, constitutes the entire agreement with respect to its subject matter. No waiver of any breach is a waiver of any preceding or subsequent breach.

Choice of Law and Dispute Resolution

The laws of the State of Texas govern this Agreement. Claims or disputes will be decided exclusively in Dallas County, Texas.

Miscellaneous

Section headings are for convenience only. If any provision is held invalid, the remaining portions continue in full force. This Agreement cannot be assigned without prior written consent.