INFORMED CONSENT REGARDING USE OF TELEHEALTH TO DELIVER CARE PURPOSE

The purpose of this consent form (“Consent”) is to provide you with information regarding telehealth and to obtain your informed consent to the use of telehealth in the delivery of palliative care services to you by physicians, physician assistants, nurse practitioners, social workers, chaplains, and community health workers affiliated with

VyncaCare, PC (“Providers”) using the online platforms owned and operated by Vynca, Inc. (the “Service”).

USE OF TELEHEALTH

Telehealth involves the delivery of health care services using electronic communications, information technology or other means between a health care provider and a patient who are not in the same physical location. Telehealth may be used for diagnosis, treatment, follow-up and/or patient education, and may include, but is not limited to, one or more of the following: electronic transmission of medical records, photo images, personal health information or other data between a patient and a health care provider; interactions between a patient and health care provider via audio, video and/or data communications (such as secure messaging); use of output data from medical devices, sound and video files. Alternative methods of care may be available to you, such as in-person services, and you may choose an alternative at any time. Always discuss alternative options with your Provider.

ANTICIPATED BENEFITS

The use of telehealth may have the following possible benefits:

• Making it easier and more efficient for you to access palliative care services your Provider(s);
• Allowing you to obtain palliative care services by Provider(s) at times that are convenient for you; and
• Enabling you to interact with Provider(s) without the necessity of an in-office appointment.

POTENTIAL RISKS

While the use of telehealth in the delivery of care can provide potential benefits for you, there are also potential risks associated with the use of telehealth and other technology. These risks include, but may not be limited to the following:

• The quality, accuracy, or effectiveness of the palliative care services you receive from your Provider could be limited;
• Technology, including the Service, may contain bugs or other errors, including ones which may limit functionality, produce erroneous results, render part or all of such technology, including the Service, unavailable or inoperable, produce incorrect records, transmissions, data or content, or cause records, transmissions, data or content to be corrupted or lost;
• Failures of technology may also impact your Provider(s) ability to provide palliative care services;
• The inability of your Provider(s) to conduct certain tests or assess vital signs
• in-person may in some cases prevent the Provider(s) from identifying the need for emergency medical care or treatment for you;
• Your Provider(s) may not able to provide medical treatment for your particular condition and you may be required to seek alternative health care or emergency care services;
• Delays in medical evaluation/treatment could occur due to unavailability of your Provider(s) or deficiencies or failures of the technology or electronic equipment used;
• The electronic systems or other security protocols or safeguards used could fail, causing a breach of privacy of your medical or other information; and
• A lack of access to all of your medical records may result in adverse drug interactions or allergic reactions or other judgment errors.

FOLLOW-UP CARE; EMERGENCY SITUATIONS

If the situation is an emergency, call 911. In some situations, telehealth is not an appropriate method of care. If you require immediate or urgent care, you must seek care at an emergency room facility or other provider equipped to deliver urgent or emergent care. If you are not experiencing an emergency or do not require immediate or

urgent care, you can communicate with Providers through the Service. If a technical failure prevents you from communicating with your Providers through the Service, you should call the following number:

DATA PRIVACY AND PROTECTION

The electronic systems used in the Service will incorporate network and software security protocols to protect the privacy and security of your information, and will

include measures to safeguard data against intentional or unintentional corruption. Personal 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 the purposes of consultation, treatment, payment/billing, and certain administrative purposes, or as otherwise set forth in the Patient Rights and Responsibilities: Notice of Privacy Practices and HIPAA and Privacy Notice.

YOUR ACKNOWLEDGMENTS

Affirmatively accepting this consent, you acknowledge, understand, and are agreeing and providing your consent with respect to the following: Health care

services provided to you by Providers via the Service will be provided by telehealth.

Technology used to deliver care, including the Service, may contain bugs or other

errors, including ones which may limit functionality, produce erroneous results, render part or all of such technology unavailable or inoperable, produce incorrect records, transmissions, data or content, or cause records, transmissions, data or content to be corrupted or lost, any or all of which could limit or otherwise impact the quality, accuracy and/or effectiveness of the palliative care or other services that you receive from your Provider(s). Further:

• The delivery of health care services via telehealth is an evolving field and the use of telehealth or other technology to obtain palliative care services from Provider(s) may include uses of technology different from those described in this Consent or not specifically described in this Consent;
• No potential benefits from the use of telehealth or other technology or specific results can be guaranteed and your condition may not be cured or improved, and in some cases, may get worse;
• There are limitations in the provision of medical care and treatment via telehealth and technology, including the Service, and you may not be able to receive diagnosis and/or treatment through telehealth for every condition for which you seek diagnosis and/or treatment;
• There are potential risks to the use of telehealth and other technology, including but not limited to the risks described in this Consent and you have the opportunity to discuss the use of telehealth, including the Service, with your Provider(s), including the benefits and risks of such use and the alternatives to the use of telehealth;
• You have the right to withdraw your consent to the use of telehealth in the course of your care, without prejudice to any future care or treatment and without risking the loss or withdrawal of any health benefits to which your entitled, but you understand that the Providers who utilize the Service do not offer in-person treatment;
• Any withdrawal of your consent will be effective upon receipt of written notice to your Providers, except that such withdrawal will not have any effect on any action taken by Vynca, Inc. or your Provider(s) in reliance on this Consent before it received your written notice of withdrawal;
• Any withdrawal of your consent will not affect any other provision of this Consent, and you will continue to be bound by this Consent;
• Use of telehealth involves electronic communication of your personal medical information to Provider(s);
• It is your duty to provide Vynca, Inc. and your Provider(s) truthful, accurate and complete information, including all relevant information regarding care that you may have received or may be receiving from your Providers; and
• Each of your Provider(s) may determine in his or sole discretion that your condition is not suitable for palliative care services using telehealth technology, including the Service, and that you may need to seek medical care and treatment from your Provider(s), or a specialist or other health care provider, outside of such telehealth technology.

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