Urgent Care & TeleHealth Urgent Care & Telehealth

1387 East 2nd St 2360 1st St

Benicia, CA 94510 Napa, CA 94559

CONSENT FOR TREATMENT & NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT

Consent for Treatment | Financial Obligation

I hereby consent to face-to-face or telehealth medical evaluations, testing, and/or treatment provided by the staff of this
medical facility. I understand that prior to treatments, procedures or receiving medications and vaccines I will be informed of
the benefits, risk and possible side effects and allowed to ask questions for full knowledge to give informed consent. I
understand that it is my responsibility to provide any information relevant to health history, possible medication interactions
and allergies.

I hereby authorize the facility to accept assignment of contracted insurance benefits and I understand that I am responsible for
co-insurance, co- payments, and/or deductibles at the time of service. I understand that if my insurance is a non-contracted
plan (out-of-network), the facility will courtesy file the claim for services rendered and any monies received by the facility will
be reimbursed to me. In the event that I have no insurance coverage, I understand that fees are due at the time of service I
understand that previous balances owed to the facility will be requested at time of registration and any outstanding balance
will be billed with accrued interest.

I understand that if the provider has ordered additional laboratory test that the collected specimens will be sent to a local
laboratory for testing. The facility will forward my payer information to the laboratory, but I will be responsible for the charges
incurred for these services and will receive a separate bill from the laboratory. I understand that there may be a portion of the
cost of durable medical equipment that is not covered by my insurance company and I will be responsible for the balance.

I understand that the company may use or disclose my Protected Health Information (PHI) necessary to carry out treatment,
payment, or healthcare operations or in other instances as permitted by HIPAA. For treatment purposes, the facility may
request and utilize my medication history from other health care providers or third-party pharmacy benefit payers. I hereby
authorize the facility to e-prescribe my prescriptions. I understand that the provider may use photographs of my injury, wound,
etc. for treatment consultation or specialist referrals. I understand that I may be referred to a health care provider for follow up
care and that I will be given the freedom of choice in referral selection. If I do not have an established health care provider and
have no preference in selection, I understand that my PHI may be sent to an affiliated health care organization to follow up
with me to help coordinate my care. I understand that my insurance may not cover the services for which I am being referred
and that I should verify coverage with that provider prior to my visit.

Telehealth Services

Telehealth is the delivery of healthcare services using technology when the healthcare provider and patient are not in the same
physical location, and/or the virtual delivery of healthcare services, including by a medical provider or via digital or automated
tools, including without limitation tools for medical or health-related diagnosis and treatment. The telehealth services may be
used for diagnosis, treatment, care management, follow-up and/or patient education, and may include, without limitation, the
following: electronic transmission of patient medical records, medical images, and/or other patient data or information;
synchronous (i.e., "real time") and asynchronous (i.e., non-"real time") interactions via audio, video, text, and/or data or other
electronic communications; automated, electronic or digital tools or services for diagnosis, care, treatment and/or
communication pertaining to healthcare or medical matters; and output, transmission or exchange of data from medical
devices, sound and video files.

I understand that my health care provider may wish to engage in a telehealth visit or series of visits, and my health care
provider has determined such visit is an appropriate form of medical care at the current time. The treating health care
practitioner intends the telehealth encounter to take the place of a face-to-face visit.

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Urgent Care & TeleHealth Urgent Care & Telehealth
1387 East 2nd St 2360 1st St
Benicia, CA 94510 Napa, CA 94559

I consent to receive emails or other electronic communications from Urgent Care & Telehealth pertaining to my care and my
health, which may include PHI. I understand that virtual encounters via phone, email, video, or otherwise, could involve, and I
hereby consent to the use of, automated tools for diagnosis, care, treatment, or communication pertaining to healthcare
matters. I also acknowledge that such virtual encounters may involve care by a variety of Providers including Physicians,
Registered Nurses, Nurse Practitioners, Physician Assistants, Therapists, and other support or medical personnel.

I understand that my condition may not be treated via the telehealth or that information transmitted through telehealth may
not be sufficient or of too poor of image quality, or insufficient information or data to allow for appropriate medical decision
making. Accordingly, I may be required to seek additional in-person medical care, alternative healthcare, or emergency
services. If my health or medical problem or condition persists after use of telehealth services, I agree to immediately contact
my medical services provider and seek appropriate additional in-person medical care or emergency care, as appropriate.
Additionally, I understand security protocols could fail in rare circumstances causing a breach of patient privacy.

Patient Rights

I have the option to refuse treatment, whether administered face-to-face or via telehealth, and to revoke my consent at any
time without affecting my right to receive future care or treatment. In situations when the asynchronous store and forward
system is used, I must be notified of my right to have interactive communication with the distant specialist at the time of the
consultation or within 30 days of notification of the results of the consultation.

Validity of Consent

I understand my consent under this form is indefinite unless otherwise revoked, amended, or is no longer effective under
appliable law.

Patient Acknowledgment of the Notice of Privacy Practices

I acknowledge that I was provided the Notice of Privacy Practices, the Notice of Nondiscrimination and the Patient Rights and
Responsibilities. I have been allowed the opportunity to ask questions, to file a complaint for my concerns to be addressed, to
submit a special written request and to object to the release of my PHI to a specific person if I so choose.

SMS Consent

The user consents to receive test results and other communications containing personal health information (PHI) via
SMS and other electronic delivery from the Telehealth & Urgent Care and/or from Solv Health, Inc. (“Solv”) as a third
party services provider to Telehealth & Urgent Care . The user specifically agrees that Solv Health Inc. is an
intended third party beneficiary of this consent and that Solv may rely upon this consent when communicating such
information with user on behalf of Telehealth & Urgent Care .
The user agrees to provide an accurate phone number and other electronic delivery method, if applicable, for the
purposes of this communication and will promptly update the provider and Solv if this information changes or is no
longer accurate.
The user is responsible for maintaining the security of the information received via SMS or other electronic delivery
and understands that SMS and email are not secure methods of receiving PHI.