Telehealth Consent & Open Payments

Authorization to use and disclose my medical information and consent to telehealth

By clicking “I agree,” checking a related box to signify your acceptance, using any other acceptance protocol presented through the Service, or otherwise affirmatively accepting this consent, you acknowledge that you have read, accepted, and agreed to be bound by this consent. If you do not agree to this consent, do not create an account or use the Service.

If you are experiencing a life-threatening situation, such as contemplating suicide, call 911 or the 988 Suicide & Crisis Lifeline at 988.

Purpose

This consent form (“Consent”) gives you information about telehealth and obtains your informed consent to the use of telehealth in the delivery of healthcare services to you by physicians, physician assistants, nurse practitioners, and other licensed clinicians (“Providers”) through the platform operated by Bespoke and the partner brands that use it (the “Service”). In this Consent, “you” and “your” refer to the person using the Service, who must be at least 18 years old and located in a state where Bespoke provides services.

Use of telehealth

Telehealth is the delivery of healthcare services using electronic communications, information technology, or other means between a Provider and a patient who are not in the same physical location. It may be used for diagnosis, treatment, follow-up, and patient education, and may include electronic transmission of medical records, photos, personal health information, or other data; interactions by audio, video, or data communications such as secure messaging or email; and output data from medical devices. Alternatives such as in-person care may be available to you, and you may choose an alternative at any time. Always discuss alternative options with your Provider.

Anticipated benefits

Telehealth may make it easier and more efficient for you to access medical care and treatment for the conditions treated by your Provider, at times that are convenient for you, without the need for an in-office appointment.

Potential risks

There are potential risks associated with telehealth and other technology, including but not limited to:

• the quality, accuracy, or effectiveness of the services you receive could be limited;
• technology, including the Service, may contain bugs or other errors that limit functionality, produce erroneous results, make the Service unavailable, or cause records, transmissions, data, or content to be incorrect, corrupted, or lost;
• technology failures may affect your Provider’s ability to correctly diagnose or treat your condition;
• your Provider cannot conduct certain tests or assess vital signs in person, which may in some cases prevent a diagnosis or treatment, or prevent the Provider from identifying the need for emergency care;
• your Provider may not be able to treat your particular condition, and you may need to seek other healthcare or emergency services;
• delays in evaluation or treatment could occur because a Provider is unavailable or because of technology failures;
• security protocols could fail, causing a breach of privacy of your medical or other information, and data sent electronically, such as by email, may be more susceptible to unintended disclosure;
• regulatory requirements in some states may limit your Provider’s diagnosis or treatment options, especially for certain prescriptions; and
• a lack of access to all of your medical records may result in adverse drug interactions, allergic reactions, or other judgment errors.

Life-threatening and other emergency situations; follow-up care

If you are experiencing a life-threatening situation, such as contemplating suicide, call 911 or the 988 Suicide & Crisis Lifeline at 988. If the situation is an emergency, call 911. Telehealth is not appropriate for every situation. If you need immediate or urgent care, go to an emergency room or another provider equipped to deliver urgent or emergency care. Providers may not respond promptly to messages you send through the Service. If you do not need urgent care, you can contact your Provider through the secure messaging in the Service.

Data privacy and protection

The electronic systems used in the Service incorporate network and software security protocols to protect the privacy and security of your information, including measures to safeguard data against intentional or unintentional corruption. Information that identifies you or contains protected health information will not be disclosed to any third party without your consent, except as authorized by law for consultation, treatment, payment and billing, certain administrative purposes, and as required by law, or as described in our Privacy Policy. The Service may send you email that includes protected health information. Bespoke does not and cannot guarantee the security or privacy of the services you use to receive communications, such as your email provider.

Laboratory products and services

Some services provided by Providers through the Service may include laboratory testing (“Lab Testing Services”), which may require a blood draw. Risks of a blood draw include discomfort, bruising, redness, or swelling at the site, bleeding, lightheadedness, and rarely infection. Laboratory tests are performed by affiliated or third-party laboratories, and neither Bespoke nor your Provider can guarantee their accuracy or reliability. Where you receive laboratory products or services through the Service, they are products or services of the laboratory, with Bespoke acting as a collection conduit. Tests can produce false negative, false positive, or inconclusive results.

Laws in some states may require a delay before certain results are released so the ordering provider can review them with you. You elect to exercise your direct right of access to test results under federal law, waive any such release requirement, and ask to receive results as soon as the report is available.

Test results are confidential, but will be shared as needed among the Service, its affiliated Providers, and the laboratory that processes your sample, and otherwise only as you authorize or as required or permitted by law. You are responsible for sharing results with your primary care or other personal physician and for arranging follow-up care. The Service is not a laboratory and is not responsible for retaining your specimen; contact the laboratory with questions about how your sample is retained or disposed of. Laboratory testing is voluntary.

Open Payments notice

For informational purposes, the federal Physician Payments Sunshine Act requires that detailed information about payments and other transfers of value over ten dollars ($10) from manufacturers of drugs, medical devices, and biologics to physicians and teaching hospitals be made available to the public. You can search this information in the Centers for Medicare & Medicaid Services Open Payments database at openpaymentsdata.cms.gov.

Your acknowledgments

By accepting this Consent, you agree and consent to the following:

• Healthcare services provided to you by Providers through the Service will be provided by telehealth.
• Your treating Provider may be a nurse practitioner or physician assistant rather than a physician, and you agree to be treated by non-physician Providers where applicable.
• Technology used to deliver care, including the Service, may contain bugs or other errors, and diagnostic testing services may contain defects, either of which could affect the quality, accuracy, or effectiveness of your care.
• Telehealth is an evolving field and may involve uses of technology not specifically described in this Consent.
• No benefits or specific results can be guaranteed. Your condition may not be cured or improved, and in some cases may get worse.
• You may not be able to receive diagnosis or treatment through telehealth for every condition.
• You have the opportunity to discuss telehealth, its benefits and risks, and alternatives with your Provider.
• There will be no recording of any online treatment sessions by your Provider or you.
• Your Provider will assess, in their sole discretion, whether it is medically appropriate to diagnose or treat your condition by telehealth. By continuing to use the Service, you agree to receive diagnosis or treatment by telehealth.
• You may withdraw your consent to telehealth at any time without affecting your right to future care or treatment, but Providers who use the Service do not offer in-person treatment. A withdrawal takes effect when your Provider receives written notice and does not affect actions taken in reliance on this Consent before then.
• Use of the Service involves electronic communication of your personal medical information, including by email.
• You must give Bespoke and your Provider truthful, accurate, and complete information, including relevant information about care you have received or are receiving from other providers.
• Your Provider may decide your condition is not suitable for telehealth and that you need to seek care from a specialist or other provider.
• You are free to obtain a medical examination from a healthcare provider not associated with Bespoke.
• Bespoke uses licensed pharmacy partners to ship your order to your door. You are free to fill your prescription at any pharmacy of your choice by contacting our support team at support@bespokeprescriptions.com. Prescriptions may be filled by, and transferred between, pharmacy partners on your behalf.
• You must pay the full cost of using the Service, including any prescription you receive, and you will not submit a claim to Medicare, any other federal payor, or any state or private insurer.