Telehealth Consent & Authorization

1. Consent to Telehealth Services

1.1 Nature of Telehealth

Telehealth involves the delivery of healthcare services using electronic communications, information technology, or other means between a healthcare provider and a patient who are not in the same physical location. Telehealth may be used for diagnosis, treatment, follow-up, patient education, and other healthcare services. You understand and consent to the use of telehealth technologies, including but not limited to asynchronous communication (store-and-forward), synchronous communication (real-time audio/video), and remote patient monitoring, as part of your medical care.

1.2 Consent to Treat

You hereby consent to receive medical evaluation, diagnosis, and treatment through telehealth services provided by licensed healthcare providers ("Providers") who are independently contracted with a licensed provider group. You understand that the Provider will review your medical intake information, health history, current medications, allergies, and any other relevant clinical information to determine whether treatment is medically appropriate for you. You consent to the Provider exercising their independent clinical judgment in all aspects of your care, including the decision to prescribe, modify, or discontinue any medication or treatment.

1.3 Limitations of Telehealth

You acknowledge and understand that:

• Telehealth has limitations compared to in-person medical evaluations, including the inability to perform a hands-on physical examination
• The Provider may determine that telehealth is not appropriate for your condition and may recommend an in-person visit with a local healthcare provider
• Technical difficulties, including but not limited to internet connectivity issues, software malfunctions, or hardware failures, may occur and could interrupt or prevent the consultation
• In rare cases, information transmitted may not be sufficient to allow for appropriate medical decision-making
• Delays in medical evaluation and treatment could occur due to deficiencies or failures of electronic equipment or communication technology
• Security protocols could fail, causing a breach of privacy of personal medical information

1.4 Right to Withdraw Consent

You have the right to withhold or withdraw your consent to telehealth services at any time without affecting your right to future care or treatment. Withdrawal of consent must be communicated in writing to ScriptsRx Direct. Withdrawal of consent does not affect any services already rendered or medications already prescribed and dispensed prior to the withdrawal.

2. Provider-Patient Relationship

2.1 Establishment of Relationship

You understand that a provider-patient relationship is established directly between you and the treating Provider, not with ScriptsRx Direct, Breakthrough Health LLC, or any affiliated management services organization. ScriptsRx Direct is a technology platform that facilitates the connection between patients and licensed healthcare providers; it does not practice medicine, diagnose conditions, prescribe medications, or provide medical advice.

2.2 Provider Independence

All medical decision-making, including the decision to prescribe any medication, rests solely with the licensed healthcare Provider conducting your medical evaluation. The Provider exercises independent clinical judgment and is not directed, controlled, or influenced by ScriptsRx Direct, Breakthrough Health LLC, or any non-clinical entity in their medical decision-making. The Provider has sole authority to determine whether any medication is medically appropriate, to select the specific medication, formulation, and dosing, and to decide whether to prescribe, modify, or discontinue any treatment.

3. Data Sharing and Authorization

3.1 Consent to Share Information

You hereby authorize and consent to the sharing of all personal, medical, and health-related information you provide through ScriptsRx Direct with the following parties for the purposes of facilitating your medical care, treatment coordination, prescription fulfillment, and administrative support:

• Provider Group: The licensed medical provider group with which your treating Provider is affiliated
• Treating Provider: The licensed healthcare Provider who conducts your medical evaluation and makes prescribing decisions
• Administrative Staff: Authorized administrative personnel who support care coordination, order processing, and customer service
• Healthcare Technology Platform (Gen-Health): The electronic health record (EHR) and practice management platform used to manage your medical records, consultations, and prescriptions, including any parties affiliated with or having authorized access to Gen-Health for purposes of administration, technical support, IT maintenance, and system operations
• Pharmacy Partners: Licensed 503A compounding pharmacies that prepare and dispense your prescription medications, which may include VitaScripts Pharmacy (Tampa, FL), VIOS Compounding (Livonia, MI), Empower Pharmacy (Houston, TX), Hallandale Pharmacy (Hallandale Beach, FL), and other licensed pharmacy partners as needed based on your location and prescription requirements
• Laboratory Partners: CLIA-certified laboratories that process your blood test kits and deliver results to your Provider

3.2 Scope of Shared Information

The information shared may include, but is not limited to: your full name, date of birth, contact information, shipping address, medical history, current medications, allergies, health conditions, symptoms, treatment goals, laboratory results, prescription information, payment information (excluding full credit card numbers), and any other information you provide during the medical intake process or subsequent communications.

3.3 Purpose of Data Sharing

Data sharing is conducted for the following purposes: medical evaluation and treatment, prescription fulfillment, care coordination, laboratory ordering and result delivery, billing and payment processing, quality assurance, regulatory compliance, and administrative support. All data sharing is conducted in accordance with applicable HIPAA regulations and our Notice of Privacy Practices.

3.4 Pharmacy Partner Disclosures

ScriptsRx Direct partners with multiple licensed 503A compounding pharmacies to ensure timely and compliant prescription fulfillment across all 50 states. Our pharmacy partners include, but are not limited to:

• VitaScripts Pharmacy — Tampa, FL. Licensed 503A compounding pharmacy, licensed in all 50 states. Specializes in compounded weight loss medications, peptide therapies, and hormone replacement treatments.
• VIOS Compounding — Livonia, MI. PCAB-accredited 503A compounding pharmacy providing customized compound medications with full-line compounding capabilities.
• Empower Pharmacy — Houston, TX. 503A compounding pharmacy and FDA-registered 503B outsourcing facility. One of the nation's largest compounding pharmacies.
• Hallandale Pharmacy — Hallandale Beach, FL. Licensed 503A compounding pharmacy specializing in custom compounding with USP compliance.

The specific pharmacy that fills your prescription will be determined based on your state of residence, the medication prescribed, and availability. All pharmacy partners are licensed by the applicable state board(s) of pharmacy, comply with USP compounding standards, and are subject to state and federal regulatory oversight. You may contact ScriptsRx Direct to inquire about which pharmacy will fulfill your specific prescription.

4. Self-Pay Disclosure and Financial Agreement

4.1 Self-Pay Services

All services provided through ScriptsRx Direct are self-pay. Insurance, Medicare, Medicaid, TRICARE, and all other third-party payers are not accepted. You acknowledge and agree that you are paying for the all-in expense of the following:

• The licensed healthcare Provider's medical evaluation and clinical services
• The Provider group's administrative and clinical oversight
• The telehealth service and technology platform access
• The electronic health record (EHR) system access and maintenance
• Administrative support, care coordination, and customer service
• The cost of prescription medication, if prescribed, including compounding, dispensing, and shipping
• Laboratory blood test kits and processing, if applicable

4.2 No Insurance Billing

You understand that ScriptsRx Direct and its affiliated Provider groups do not bill insurance for any services rendered. All marketing materials and service descriptions clarify that insurance is not an accepted form of payment. You are solely responsible for all charges associated with your care.

4.3 Pricing and Charges

All prices are displayed at the time of purchase and are subject to change. You agree to pay the stated price for all products and services at the time of order placement. Prices include the bundled cost of the medical consultation, medication (if prescribed), and related services as described above.

5. Waiver and Non-Dispute of Charges

5.1 Acknowledgment of Services Rendered

You acknowledge that once a licensed healthcare Provider or any medical professional has performed any task in relation to your care — including but not limited to reviewing your medical intake, conducting a medical evaluation, making a clinical determination, writing a prescription, ordering laboratory tests, or providing medical advice — services have been rendered and value has been delivered regardless of the outcome of the evaluation.

5.2 Waiver of Right to Dispute Charges

Once a Provider or any medical professional has performed any task in relation to your care as described in Section 5.1, you waive your right to dispute, charge back, or seek reversal of any charges associated with the services rendered. This waiver applies to charges for the medical consultation, administrative services, and platform access. If a prescription is issued and the medication has been compounded and shipped, you additionally waive your right to dispute charges for the medication, as compounded medications cannot be returned, restocked, or reused due to patient safety regulations.

5.3 Refund Eligibility

Refunds may be issued at ScriptsRx Direct's sole discretion in the following limited circumstances: (a) if a Provider determines that no medication is medically appropriate and no prescription is issued, a refund for the medication cost may be provided; (b) if a technical error results in a duplicate charge. Consultation fees are generally non-refundable once a medical evaluation has been initiated. Medications that have been compounded and shipped are non-refundable.

6. Indemnification

6.1 Indemnification of Provider Group and Provider

To the fullest extent permitted by applicable law, you agree to indemnify, defend, and hold harmless the Provider group, the treating Provider, and their respective officers, directors, employees, agents, successors, and assigns from and against any and all claims, demands, damages, losses, liabilities, costs, and expenses (including reasonable attorneys' fees and court costs) arising out of or related to:

• Your use of telehealth services
• Any inaccurate, incomplete, or misleading information you provide during the medical intake or at any time during your care
• Your failure to follow medical advice, treatment protocols, or prescribed dosing instructions
• Your failure to disclose relevant medical history, current medications, allergies, or contraindications
• Your use or misuse of any prescribed medication
• Any adverse reaction or side effect resulting from your use of prescribed medication, except to the extent caused by the Provider's gross negligence or willful misconduct
• Your violation of any applicable law or regulation

6.2 Indemnification of ScriptsRx Direct

You agree to indemnify, defend, and hold harmless ScriptsRx Direct, Breakthrough Health LLC, and their respective officers, directors, employees, agents, and affiliates from and against any and all claims, damages, losses, liabilities, costs, and expenses arising out of or related to: (a) your use of the Services; (b) your violation of this Consent or any other applicable terms; (c) any inaccurate information you provide; or (d) your infringement of any third-party rights.

7. Emergency Situations

You understand that telehealth services are not intended for medical emergencies. If you experience a medical emergency, you should immediately call 911 or go to the nearest emergency room. Telehealth services do not replace emergency medical services. You should not delay seeking emergency care based on any information received through telehealth services.

8. Prescription Medication Acknowledgments

You acknowledge and agree to the following regarding prescription medications:

• All prescription medications require a valid prescription from a licensed healthcare Provider following a medical evaluation
• The availability of any product on the ScriptsRx Direct website does not guarantee that a prescription will be issued
• Compounded medications are not FDA-approved; the FDA does not verify the safety, efficacy, or manufacturing quality of compounded medications
• You will follow all dosing instructions, administration guidelines, and safety precautions provided by your Provider and pharmacy
• You will report any adverse reactions, side effects, or concerns to your Provider promptly
• You will not share, transfer, sell, or distribute any prescribed medication to any other person
• You will store all medications according to the storage instructions provided
• You will complete all required laboratory blood work as directed by your Provider

9. State-Specific Telehealth Disclosures

The following state-specific disclosures apply based on your state of residence or the state in which you are physically located at the time of your telehealth consultation. These disclosures are provided in addition to, and do not replace, the general terms of this Consent.

9.1 General State Compliance

All telehealth consultations are conducted in compliance with the telehealth laws and regulations of the state in which you are physically located at the time of the consultation. Providers are licensed in the applicable state. You are responsible for ensuring that you are physically located in a state where telehealth services are available through ScriptsRx Direct at the time of your consultation.

9.2 States Requiring Specific Informed Consent

Certain states require specific informed consent disclosures for telehealth services. By proceeding with telehealth services, you acknowledge the following state-specific requirements where applicable:

• California: You have the right to receive a copy of your medical records. You have the right to receive services from a provider who is physically present in the same room. Telehealth is an alternative to in-person care and may not be appropriate for all conditions.
• Texas: You consent to telehealth services as defined by the Texas Occupations Code. You understand that telehealth services do not preclude you from seeking in-person care. You have the right to request an in-person visit at any time.
• New York: You have the right to receive telehealth services in accordance with New York Public Health Law. You have the right to refuse telehealth services at any time.
• Florida: You consent to telehealth services in accordance with Florida Statutes Section 456.47. You understand the limitations of telehealth and your right to request in-person care.
• Illinois: You consent to telehealth services in accordance with the Illinois Telehealth Act. You have the right to refuse telehealth services and request an in-person visit.
• Ohio: You consent to telehealth services in accordance with Ohio Revised Code Section 4743.09. You understand that your Provider is licensed in Ohio.
• Missouri: You consent to telehealth services in accordance with Missouri Revised Statutes Section 191.1145 et seq. You understand that telehealth services are subject to the same standard of care as in-person services.
• All Other States: You consent to telehealth services in accordance with the applicable telehealth laws and regulations of the state in which you are physically located. You acknowledge that telehealth regulations vary by state and that you are responsible for understanding the laws applicable to your location.

10. Governing Law and Dispute Resolution

This Consent shall be governed by and construed in accordance with the laws of the State of Missouri, without regard to its conflict of law provisions. Any dispute, controversy, or claim arising out of or relating to this Consent shall be resolved through binding arbitration administered by the American Arbitration Association (AAA) in accordance with its Commercial Arbitration Rules. The arbitration shall be conducted in St. Charles County, Missouri. You agree to waive any right to a jury trial or to participate in a class action lawsuit.

11. Entire Agreement and Severability

This Consent, together with the Terms of Service, Privacy Policy, HIPAA Notice of Privacy Practices, and Disclaimer, constitutes the entire agreement between you and ScriptsRx Direct regarding the subject matter herein. If any provision of this Consent is found to be invalid or unenforceable, the remaining provisions shall continue in full force and effect.

12. Acknowledgment and Electronic Signature

By proceeding with any telehealth consultation, completing a medical intake form, placing an order, or otherwise using ScriptsRx Direct telehealth services, you acknowledge that:

• You have read and understand this Telehealth Consent and Authorization in its entirety
• You have had the opportunity to ask questions about this Consent
• You voluntarily consent to telehealth services and all terms described herein
• You consent to the sharing of your information as described in Section 3
• You agree to the self-pay terms and financial obligations described in Section 4
• You agree to the waiver and non-dispute provisions described in Section 5
• You agree to the indemnification provisions described in Section 6
• Your electronic acceptance (clicking "agree," "submit," or proceeding with services) constitutes a valid electronic signature under the Electronic Signatures in Global and National Commerce Act (E-SIGN Act) and the Uniform Electronic Transactions Act (UETA)

13. Contact Information

For questions about this Telehealth Consent and Authorization, please contact us at:

ScriptsRx Direct (operated by Breakthrough Health LLC)
6051 Mid Rivers Mall Drive
Cottleville, MO 63304
Email: [email protected]
Medical Director: Daniel Oliveros, MD