Telehealth Authorization and Informed Consent

Introduction

This Telehealth Authorization and Informed Consent (“Consent”) describes the nature of telehealth services provided by Ezra Health of Florida PLLC (“Ezra Health”), a physician-owned professional limited liability company. By agreeing to this Consent, you authorize Ezra Health to provide telehealth services in connection with scan services available through Function Health, Inc.

Telehealth services are not intended for emergency care or as a substitute for primary care. Ezra Health does not provide ongoing treatment or comprehensive medical management.

Nature and Scope of Telehealth Services

Telehealth involves the use of electronic communications to enable healthcare providers to share medical information for purposes of evaluation and consultation when the patient and provider are not in the same physical location.

Services provided by Ezra Health may include:

·   Review of medical questionnaires to determine eligibility for imaging

·   Asynchronous and/or synchronous consultations, when clinically appropriate

·   Issuance of medical orders for imaging studies where medically appropriate

·   Review and explanation of radiology reports and findings

·   Provision of general follow-up recommendations

·   Optional follow-up communications via video, phone, or secure messaging

Corporate Structure and Provider Relationships

Ezra Health is a physician-owned professional entity that provides clinical telehealth services. Certain non-clinical administrative, operational, and management services may be provided by affiliated entities, including Ezra AI, Inc. and Function Health, Inc., under a management services arrangement. All clinical decisions are made solely by licensed healthcare providers.

Imaging and Radiology Services

You understand and acknowledge that imaging studies (e.g., MRI scans) are performed by independent imaging facilities.

Radiology interpretations may be provided either by (i) radiologists employed by or directly affiliated with Ezra Health (“Ezra Radiologists”), or (ii) independent third-party radiologists, including contracted teleradiology providers (“Contracted Radiologists”), who may be located remotely.

Ezra Radiologists are part of Ezra Health’s clinical organization and provide services under its professional structure.

Contracted Radiologists and imaging facilities are independent providers and are not owned, operated, or controlled by Ezra Health. Ezra Health does not control the technical performance of imaging or the independent medical judgment of Contracted Radiologists.

Benefits and Risks of Telehealth

Benefits of telehealth include increased access to care, convenience, and efficiency. Risks may include technical failures, limitations of remote evaluation, data security risks, and the possibility that incomplete or inaccurate medical information could affect clinical decisions.

You may discontinue telehealth services at any time if you or the provider determine it is not appropriate.

State Law Disclosures

Telehealth services will be provided in accordance with applicable state laws and regulations governing telehealth, including requirements related to informed consent, privacy, and provider licensure. The provider delivering services will be licensed in the state where you are located at the time of the telehealth encounter, as required by law.

Alternatives to Telehealth

You may seek care through in-person providers at any time as an alternative to telehealth services.

Follow-Up Care and Emergencies

Ezra Health does not provide in-person care or primary care, emergency care, or ongoing disease management, and does not prescribe medications in connection with these services.

You are responsible for obtaining follow-up care with your primary care provider or a specialist.

IF YOU ARE EXPERIENCING A MEDICAL EMERGENCY, CALL 911 IMMEDIATELY.

Financial Responsibility

You are responsible for all fees associated with telehealth services. These services are not billed to insurance, and you agree not to submit claims for reimbursement to any commercial or governmental health plan.

Privacy and Communication

Telehealth services are subject to applicable privacy laws. Communications may occur via electronic means, including email, phone, or SMS. You acknowledge and accept the potential risks associated with unencrypted communications.