Telehealth Consent Form

Consent to Telehealth Services

Telehealth involves the delivery of healthcare services using electronic communications, including video, audio, and messaging technology, to facilitate clinical consultations between patients and licensed healthcare providers when both parties are not in the same physical location.

By using the Prometheuz platform, you consent to receiving healthcare services via telehealth. You understand and agree that:

• Telehealth services may be delivered by video consultation, asynchronous messaging, or other electronic means.
• Your provider may determine that telehealth is not appropriate for your condition and may refer you to an in-person provider.
• Technical difficulties may occasionally disrupt or prevent telehealth services.
• The laws and regulations governing telehealth vary by state, and your care will be provided in accordance with applicable law.
• A record of your telehealth encounter may be created and maintained as part of your medical record.

Treatment-Specific Consent

You consent to the evaluation, diagnosis, and treatment recommended by your assigned provider on the Prometheuz platform. This includes, but is not limited to, hormone replacement therapy (including testosterone replacement therapy), prescription medications, and related wellness protocols.

You acknowledge that:

• Your provider will explain the proposed treatment, its benefits, known risks, and alternatives before initiating care.
• You have the right to ask questions and receive complete information about your treatment.
• You may decline any recommended treatment at any time.
• All treatments are individualized and results may vary.
• You will promptly inform your provider of any changes in your health status, medications, or relevant medical history.

Known Risks and Benefits

As with all medical treatments, telehealth-delivered care carries potential risks. These include, but are not limited to: adverse reactions to medications, incomplete physical examination compared to in-person visits, delays in diagnosis due to technological limitations, and risks specific to the prescribed treatment (which your provider will discuss with you in detail). Benefits include improved access to specialized care, convenience, and reduced travel burden.

Consent to Electronic Communication

By using the Prometheuz platform, you consent to receive communications from us and your care team via email, SMS text message, push notification, and in-app messaging. These communications may include:

• Appointment reminders and scheduling confirmations.
• Lab result notifications and clinical updates from your provider.
• Prescription and pharmacy coordination updates.
• Billing and subscription information.
• Service-related announcements and platform updates.
• Health and wellness educational content (with your consent).

You understand that electronic communications, including email and SMS, may not be fully encrypted and carry some inherent privacy risks. You may opt out of non-essential communications at any time by contacting us at [email protected]. Opting out of certain clinical communications may affect your ability to receive care.

Authorization to Use and Disclose Medical Information

You authorize Prometheuz and OpenLoop Healthcare Partners, PC, to use and disclose your Protected Health Information (PHI) as described in our HIPAA Notice of Privacy Practices. This includes sharing your health information with:

• Licensed providers on the Prometheuz platform who are involved in your care.
• Third-party laboratory partners for the purpose of ordering and receiving lab results.
• Partner pharmacies for the fulfillment of prescribed medications.
• Health information exchanges and other healthcare providers as necessary for coordinated care.
• Business associates who assist in operating the platform, subject to appropriate safeguards.
• Government agencies and other entities as required by law.

You have the right to revoke this authorization at any time by submitting a written request to [email protected]. Revocation will not affect uses or disclosures made prior to your request or those that are necessary to complete treatment already in progress.

Assignment of Benefits

If applicable, you assign to OpenLoop Healthcare Partners, PC, any insurance benefits, payments, or reimbursements owed to you for services rendered through the Prometheuz platform. This assignment authorizes your insurer or other third-party payer to pay benefits directly to your provider.

You understand that Prometheuz is currently a self-pay platform and does not directly accept insurance. You are responsible for all fees associated with your subscription and care. We provide itemized receipts that you may submit to your insurer for potential out-of-network reimbursement at your discretion.

Patient Rights and Responsibilities

Your Rights

• To receive respectful and dignified care from your provider.
• To receive complete information about your diagnosis, treatment options, and prognosis.
• To participate in decisions about your care and to consent to or refuse treatment.
• To have your health information kept private and confidential in accordance with applicable law.
• To access your medical records upon request.
• To receive a referral to an in-person provider if your condition is not appropriate for telehealth.
• To withdraw consent to telehealth services at any time.

Your Responsibilities

• Provide accurate and complete health and personal information.
• Inform your provider of all current medications, supplements, and known allergies.
• Follow your provider's recommended treatment plan or communicate any concerns.
• Keep scheduled appointments and respond to provider communications in a timely manner.
• Seek emergency care immediately if you experience a medical emergency.
• Notify your provider of any significant changes in your health status.

Withdrawal of Consent

You may withdraw your consent to telehealth services at any time by notifying your care team in writing at [email protected]. Withdrawal of consent will not affect the validity of any consents given or services rendered prior to withdrawal. Upon withdrawal, you will no longer have access to telehealth services through the Prometheuz platform.

Acknowledgment

By using the Prometheuz platform and proceeding with enrollment or treatment, you confirm that:

• You have read and understood this Telehealth Consent Form in its entirety.
• You have had the opportunity to ask questions and have them answered to your satisfaction.
• You voluntarily consent to telehealth services, treatment, and the use and disclosure of your health information as described above.
• You are at least 18 years of age and have the legal capacity to provide this consent.
• You understand that this consent does not replace the need for an in-person visit when clinically indicated.

Questions or Concerns

If you have questions about this Consent Form, please contact our care team before proceeding:

• Email: [email protected]
• Provider: OpenLoop Healthcare Partners, PC

Last updated: September 24, 2025. For related documents, see our HIPAA Notice of Privacy Practices, Privacy Policy, and Terms of Service.