MINDSPAN INFORMED CONSENT

Mindspan Group, Inc. and its affiliated health care practices and health care providers (“Mindspan PC”) provide cognitive care services to patients (“Mindspan Services”) at local clinics or using telehealth technology (“Telehealth Technology”). By agreeing to this informed consent (“Consent”), you have elected to receive Mindspan Services from Mindspan PC. If you have questions about use of the Telehealth Technology itself and whether it is appropriate for your medical condition, the risks associated with using the Telehealth Technology, or the provider’s credentials and professional background, please ask your Mindspan PC provider. All capitalized terms used in this Consent but not defined herein will have the meanings provided in the Terms of Use or Privacy Notice. Only use the Mindspan Services if you have read this information and subsequently made an informed decision that the Mindspan Services are right for you. If you have any questions, please email us at legal@mindspan.co.

As a prerequisite to your use of the Telehealth Technology to receive Mindspan Services, you acknowledge and agree to the following terms and conditions of this Consent:

1. Consent to Treatment at your in-person Mindspan clinic

You voluntarily consent to receive cognitive medical care and treatment from Mindspan PC at your in-person clinic. You understand that this consent includes in-person diagnostic procedures, tests and treatments that may be deemed necessary by your Mindspan PC healthcare providers.

You understand that you will be educated on any potential risks and benefits prior to any treatments and have the right to ask for a document detailing any such considerations. You understand that you are free to discuss any alternative treatments and will take the time to discuss them with your healthcare providers.

You acknowledge that you are free to refuse treatment and/or or request alternatives at any time. You also understand that you can withdraw your consent at any time.

2. Use of Telehealth

THE MINDSPAN SERVICES ARE NOT AN EMERGENCY RESPONSE UNIT. YOU MUST DIAL 911 IMMEDIATELY FOR MEDICAL EMERGENCIES.

“Telehealth” consists of the use of electronic information and communication technologies by providers to deliver health care services to patients not at the same physical location, which may include the assessment, diagnosis, consultation, treatment, education, care management and/or self-management of a patient. Such communication can include electronic transfer of medical records, images/photographs, health information, or other Personal Information between you and the Providers, live conversations or other interactions between you and the Providers via audio, video, and/or other media-based interactive communication modalities, and use and analysis of output data from medical or wearable devices, sound, video, and other related files.

While the provision of health care services using telehealth may offer certain potential benefits, there are also potential risks associated with the use of telehealth, which are listed in more detail below. The telehealth services are not a substitute for in-person health care in all cases. In order to use the Services, you must review and agree to this Informed Consent.

3. Risks Associated with Telehealth

As with any in-person health care encounter, there are potential risks associated with the use of telehealth. These risks may include, but are not limited to:

• Limitations on the availability and/or appropriateness of specific health services that may be hindered as a result of the Services being offered remotely (e.g., information transmitted to the Providers may not be sufficient to allow for appropriate medical decision making by the Providers and the inability of your Providers to conduct certain tests or assess vital functions and signs in-person may prevent the Providers from providing a diagnosis or treatment)
• Confidentiality and security of your health information, including Personal Information, through use of potentially unsecure electronic and telecommunication technologies
• Technological issues during your telehealth visit (but note that alternative communication methods may be provided if you are having connectivity issues)
• Given regulatory requirements in certain jurisdictions, the Provider’s treatment options, especially pertaining to certain prescriptions, may be limited

4. Privacy and Confidentiality

You understand that the laws that protect the privacy and the confidentiality of health information also apply to Mindspan Services. You also understand that Mindspan Services may involve electronic transmission of your personal health information to health care providers who may be located in other areas, including out of state, and that your health care provider may disclose your personal health information, except as prohibited by federal or state law.

5. Consent to Electronic Communications

You agree that we may contact you via messaging, email, phone, text, or mail. Those communications may be through our website, app, or otherwise, including electronic communications about your healthcare which may include Personal Information. You understand that communicating via email, text messages, and other electronic means may not be secure, and could be viewed by unintended persons, and you agree to communicate with us via these electronic means. You agree to update your contact information as needed to ensure accuracy in our communications to you. You can opt out of communications from Mindspan PC at any time.

6. Accuracy of Information Submitted to Mindspan PC Provider

You acknowledge and agree that you are solely responsible for ensuring that the information submitted by you through the Telehealth Technology is accurate, complete and current. You understand that Mindspan PC providers will rely on this information to diagnose and prepare a treatment plan for your medical condition and your failure to provide accurate, complete and current information may lead to a delay in your treatment or a misdiagnosis.

7. Release and Waiver

You acknowledge and agree to limit, disclaim, and release Mindspan PC from liability in connection with the Telehealth Technology’s use, and the provision of Mindspan Services more broadly.

8. Expenses

You understand and agree that you are responsible for the cost of all professional fees associated with your use of the Mindspan Services, which may change from time to time, and the cost of any medications or supplies prescribed by any Mindspan PC provider, if applicable.

9. Other Legal Terms

This Consent cannot be amended except in writing by mutual agreement of Mindspan PC and you. If any provision is or becomes unenforceable or invalid, the other provisions will continue with the same effect.

10. Right to Revoke

You understand that you can revoke this Consent by sending written notice to Mindspan PC (“Revocation”). You agree that your Revocation must contain your name and your address. You also understand that your Revocation means that you are not permitted to receive care using Telehealth Technology. Your Revocation will be effective upon Mindspan PC’s receipt of your written notice, except that your Revocation will not have any effect on any action taken by Mindspan PC providers in reliance on this Consent before it received your written notice of Revocation.

11. Insurance & Patient Responsibility

Mindspan PC currently accepts payment for Mindspan Services from select federal and state health care programs, such as Medicare and Medicaid as well as certain insurance plans. You understand and agree that Mindspan PC will attempt to bill any insurance, including federal or state health care programs, for Mindspan Services rendered. In the event that Mindspan Services are not covered by insurance or there is patient responsibility due to the practice, Mindspan PC may have to unenroll the user from the program and terminate our relationship.

12. Additional State-Specific Consents

The following consents apply to users accessing Mindspan Services for the purposes of participating in a telehealth consultation as required by the states listed below:

Alaska: I understand my primary care provider may obtain a copy of my records of my telehealth encounter. (Alaska Stat. § 08.64.364).

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. (Ariz. Rev. Stat. Ann. § 36-3602).

Connecticut: I understand that my primary care provider may obtain a copy of my records of my RPM Services. (Conn. Gen. Stat. Ann. § 19a-906).

District of Columbia: I have been informed of alternate forms of communication between me and a physician for urgent matters. (D.C. Mun. Regs. tit. 17, § 4618.10).

Georgia: I have been given clear, appropriate, accurate instructions on follow-up in the event of needed emergent care related to the RPM Services. (Ga. Comp. R. & Regs. 360-3-.07(7)).

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, here: https://medicalboard.iowa.gov/consumers/filing-complaint

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, here: https://bom.idaho.gov/BOMPortal/AgencyAdditional.aspx?Agency=425&AgencyLinkID=650

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, here: https://www.in.gov/attorneygeneral/2434.htm

Kansas: I understand that if I have a primary care provider or other treating physician, the person providing RPM Services must send within three business days a report to such primary care or other treating physician of the treatment and services rendered to me during the RPM Services. (Kan. Stat. Ann. § 40-2,212(2)(d)(1)(A)).

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, here: https://kbml.ky.gov/grievances/Pages/default.aspx

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, here: https://www.maine.gov/md/discipline/file-complaint.html

New Hampshire: I understand that the Mindspan PC provider may forward my medical records to my primary care or treating provider. (N.H. Rev. Stat. § 329:1-d).

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. (N.J. Rev. Stat. Ann. § 45:1-62).

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, here: http://www.okmedicalboard.org/complaint.

Rhode Island: If I use e-mail or text-based technology to communicate with my Mindspan PC 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.

South Carolina: I understand my medical records may be distributed in accordance with applicable law and regulation to other treating health care practitioners. (S.C. Code Ann. § 40-47-37).

South Dakota: I have received disclosures regarding the RPM Services RPM Technology and limitations. (S.D. SB136 (not yet codified)).

Texas: I understand that my medical records may be sent to my primary care physician. (Tex. Occ. Code Ann. § 111.005). I have 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 our website at www.tmb.state.tx.us.

Utah: I understand (i) any additional fees charged for Mindspan 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 Mindspan Services Mindspan PC 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 Mindspan PC’s website and contact information. I am able to a (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 Telehealth Services, including the Consent provided; and (iii) request a transfer to another provider of my medical record documenting the telemedicine services. (Utah Admin. Code r. 156-1-602).

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 Mindspan PC for information lost due to technical failures; and I provide my express consent to forward patient-identifiable information to a third party. (Virginia Board of Medicine Guidance Document 85-12).

13. CONSENT

By accepting this Informed Consent, you confirm your understanding and agreement to the following:

• I give my informed consent to receive in-person treatment at a Mindspan PC clinic.
• I give my informed consent to the use of Telehealth Technology by Mindspan PC.
• I have read the above information and have had an opportunity to ask questions.
• I understand the benefits and risks of receiving Mindspan Services via Telehealth Technology.
• I understand that the provider may determine in his or her sole discretion that my condition is not suitable for treatment using Telehealth Technology, and that I may need to seek medical care and treatment in-person or from an alternative care source.
• I understand that I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time by contacting Mindspan PC at legal@mindspan.co with such instruction; otherwise, this consent will be considered renewed upon each new telehealth encounter with a Mindspan PC provider.
• I understand that while the use of Telehealth Technology may provide potential benefits to me, as with any medical service, no such benefits or specific results can be guaranteed.
• I understand that I have the right to access my health and wellness information pertaining to the Mindspan Services delivered via telehealth in accordance with applicable laws and regulations.
• I agree and authorize the Mindspan PC providers to release information regarding the Mindspan Services to Mindspan and its affiliates.
• Mindspan and our Partner Organizations including ianacare may contact me in-person, by phone, by email, or using audio-visual technology (such as Telehealth) for communication related to GUIDE services.
• I authorize Mindspan PC to contact my healthcare professionals on file and to obtain copies of any medical records that could be useful in assisting with the success of my treatment. I also acknowledge that I can rescind my authorization to obtain my medical records at any time.

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