Informed Consent for Remote Healthcare Services

Informed Consent to Receive Remote Healthcare from Mayo Clinic and its affiliated entities and
Providers (“Mayo Clinic”).

Brief Summary

Please read the full Informed Consent for important details.

  • The Platform provides access to Remote Healthcare Services, which does not allow for an in-
    person physical examination by the treating Provider.
    • The absence of an in-person physical examination may affect the Provider’s ability to
      diagnose any potential condition, disease, or injury and may not reveal potentially
      serious medical conditions.
    • Your Provider may not be able to diagnose or treat you if you present with potential
      symptoms or conditions that we do not treat remotely based on our medical policies
      and Provider judgment.
    • Providers may be limited by applicable law, regulations, policies, and standards in
      prescribing certain medications to you without first conducting an in-person physical
      examination.
  • Care that you receive is based on your symptoms and other information you provide or
    upload to the Platform or share with your Provider(s) and care team as well as your pre-
    existing Mayo Clinic medical record. Information you provide using the Platform must be true,
    accurate, and complete, and may serve as the basis of any diagnosis and treatment by your
    Provider.
  • You may stop using the Remote Healthcare Services and choose alternative modes of care,
    such as an in-person visit, at any time.
  • The Remote Healthcare Services may only be used when you are physically located in
    Wisconsin, Minnesota, or Iowa.

Before you give your informed consent to request and receive healthcare services remotely (“Remote
Healthcare Services”), please be aware of how obtaining health services remotely from physicians and
other licensed health care professionals affiliated with Mayo Clinic (together, the “Providers”) through
an online virtual care platform offered by K Health, Inc. (the “Platform”) differs from in-person care.
Some of the risks associated with receiving Remote Healthcare Services are described in this Informed
Consent. There may be other risks to Remote Healthcare Services that are not currently known.

In this Informed Consent, the terms “we”, “us”, or “our” refer to Mayo Clinic and its affiliated Providers
for Remote Healthcare Services provided through the Platform. The terms “you” and “yours” refer to
the patient using the Platform to request Remote Healthcare Services from Providers. Please read each
item carefully.

Emergencies

The Platform should not be utilized in a medical emergency. If this is a medical emergency, dial 911 or
visit an emergency room. If you are experiencing emotional distress or a mental health crisis, please
contact the National Suicide Prevention Hotline: text 988 or text “Home” to 741-741, to obtain
immediate assistance.

Service Description

The Platform is part of an overall primary care practice. It is not a remote full-service medical practice.
Your use of the Remote Healthcare Services offered through the Platform and the Platform technology
(collectively the “Services”) is voluntary. You may seek in-person treatment at any time.

The Platform is a Remote Healthcare Service, which does not allow for an in-person physical
examination by the treating Provider. The absence of an in-person physical examination may affect the
Provider’s ability to diagnose any potential condition, disease, or injury and may not reveal potentially
serious medical conditions. The diagnosis you receive may be limited. The Services are not intended in
all cases to replace a full medical evaluation, or an in-person visit with a healthcare provider. Your
Provider may not be able to diagnose or treat you if you require an in-person physical exam, a test that
requires a follow-up visit, or if you present with potential symptoms or conditions that we do not treat
remotely based on our medical policies and Provider judgment.

Providers may be limited by applicable law, regulations, policies, and standards in prescribing certain
medications to you without first conducting an in-person physical examination. Providers do not
prescribe U.S. Drug Enforcement Administration controlled substances, such as those containing
opioids. Providers reserve the right to deny care for actual or potential misuse of the Service.

The health information you provide through the Platform, and your pre-existing Mayo Clinic medical
record, may be the only source of information used by Providers during your evaluation and treatment
through the Platform. Providers may not have access to any other information held by your non-Mayo
Clinic medical providers (e.g., allergies, drug reactions, etc.). Care that you receive is based on your
symptoms and other information you provide or upload to the Platform or share with your Provider(s)
and care team. Information you provide using the Platform must be true, accurate, and complete, and
may serve as the basis of any diagnosis and treatment by your Provider. If you provide false, misleading,
or incomplete information to a Provider, it may have a negative effect on your treatment and your
health. If you refuse to provide requested information, you may not be considered to be under the care
of the Provider and the Provider may refuse to treat you (or continue to treat you, as applicable).

A variety of alternative methods of medical care may be available to you, including an in-person visit.
You may stop using the Services and choose one or more of these alternative modes of care at any
time.

Use of the Services may involve asynchronous communications, such as completing forms and
messaging your care team, as well as direct virtual, synchronous, communications and the electronic
transmission of medical information and other data between you and the Provider(s).

As part of the Remote Healthcare Services, you may not be able to select a specific Provider. Due to
emergencies, scheduling, and other circumstances, there may be times that the Services are unavailable.

The Remote Healthcare Services may only be used when you are physically located in Wisconsin,
Minnesota, or Iowa. Please notify your Provider immediately if at the time of the Remote Healthcare
visit you are no longer located in the state you indicated as your location.

Nature of Electronic Services

The electronic nature of the Services means that there is a greater risk to the privacy of your electronic
health information relative to receiving in-person care. For information about the privacy and security
practices as well as our information sharing practices, please read our Notice of Privacy Practices.

The information transmitted may not be sufficient (e.g. poor resolution of images) to allow for
appropriate medical or healthcare decision making by the Provider. In addition, technical failures could
lead to delays in evaluation or to information lost due to such technical failures.

If you are experiencing technical difficulties through the Platform, you may email
support@primarycareondemand.mayoclinic.org.

In connection with the Service:

  1. Data, chat text, audio, video, and/or digital photos may be recorded;
  2. Details of your medical information may be discussed with you and the Providers via the Service using electronic technology, including chat, audio, video, and/or graphics technology;
  3. Virtual examination of you may take place; and
  4. Medical personnel and non-medical technical personnel may join the visit, virtually, to aid in delivery of medical care to you, or for the purpose of improving the Service.

All communications in either electronic or paper format from us to you will be considered to be in
writing. Print or download a copy of this Informed Consent and any other electronic communication
that is important to you for your records.

By clicking on the “I Agree,” “Accept,” “Continue,” or any similar button provided in connection with this
Informed consent, you indicate your intent to receive electronic communications, and such action
constitutes your signature.

For additional information regarding your Platform account and electronic communications please refer
to K Health, Inc. Terms of Service Terms of Service.

You acknowledge and agree that (i) your consent is being provided in connection with a transaction
affecting interstate commerce that is subject to the federal Electronic Signatures in Global and National
Commerce Act; and (ii) you and the Providers, and their affiliates, agents, representatives, suppliers, and
service providers, intend that the Act apply to the fullest extent possible to validate the ability to
conduct business and communicate with you by electronic means.

Additional Consents

You hereby consent to the use of telehealth to examine, consult, diagnose, or treat you.

You further acknowledge and agree that:

  • You are at least eighteen (18) years of age;
  • At the time of your visit(s), you will be located in the state you indicated as the location for the
    Remote Healthcare Services;
  • You have read and understood the information above, including the benefits, risks and
    limitations of using the Platform for the Remote Healthcare Services and you agree to receive
    services via telehealth;
  • Our Providers may determine that our clinical services are not appropriate for some or all of
    your treatment needs and may elect not to provide Services to you through the Platform; and
  • This Informed Consent will become a part of your medical record.