MARYLAND MEDICAL SPECIALIST’S INFORMED CONSENT

Effective Date: 11/08/2024

I, as the individual (or his or her legal representative) receiving services, agree to receive the services provided by Maryland Medical Specialists, Inc, hereinafter referred to as (“we” “us” or “MMS”) or its business services provider LetsBeSafe Health, Inc. I agree that the services may include health care provider education sessions, physician consultations via telemedicine (“Consults”), any customer support or counseling, and any other related services provided by MMS via telemedicine such as ordering laboratory tests (“Tests”), including, without limitation, physician oversight, for the ordering of Tests, the results of the Tests, the (“Results”)and any other related services provided by MMS directly or through its business services provider, LetsBeSafe Health, Inc. (the “Services”).

I acknowledge and agree to the following:

• I have read, understand, and had the opportunity to ask questions about the information provided about MMS’s Services.
• My medical history is correct to the best of my knowledge. I will not hold MMS, its business associates, its business services provider, or its physicians, nurse practitioners, or employees responsible for any errors or omissions that I may have made in providing such information.
• (“Health Care Providers”) means MMS, its physicians, nurse practitioners, and employees.
• I authorize MMS and its affiliates, and third-party business services provider LetsBeSafe Health, Inc., the owner and operator of LetsBeSafe.com, (“MMS’s Care Coordination Team”), business associates, professional corporations, Health Care Providers, staff, and agents to view and use my health information, including any Test Results in furtherance of its healthcare operations.
• Only MMS physicians diagnose conditions, disease, or illness.
• If I receive an abnormal Result on a Test I understand that a member of MMS’s Care Coordination Team will attempt to call me to review the Results, offer education and explain the next steps I should take. MMS’s Care Coordination Team may leave me a voice message at my designated telephone number. I also understand that if I am not able to be reached, MMS’s Care Coordination Team will mail a follow-up letter to my designated address (the letter will not include my Test Results). If I receive an abnormal Result and have not connected with MMS’s Care Coordination Team, I understand that I should not delay following up with my personal physician.
• I understand that after receiving my Results for an STD Test, including HIV, I will have the opportunity for a telemedicine Consult. I understand that after receiving my Results for non-STD Tests, I will have the opportunity for either an education session with a member of MMS’s Care Coordination Team, a Health Care Provider, or a telemedicine Consult with a MMS Health Care Provider, as appropriate under applicable law. If my Results show that I have Chlamydia, Gonorrhea, Herpes Simplex 2, or Trichomoniasis (the “Treatment Conditions”), the physician may be able to prescribe medication during the Consult, if appropriate. I understand that if my Results show that I have one of the Treatment Conditions, it is important to schedule a Consult as soon as possible or obtain other treatment.
• I certify that throughout the duration of my Consult I will be physically present in the state of residence I provided or other state of which I have notified MMS.
• MMS’s Health Care Providers are responsible for sharing information regarding any Consults and forwarding any Results to my primary care or other personal physician after providing such Consults or receiving such Results. I am responsible for initiating follow-up care with my physician or any other specialist physician. I will let MMS’s Care Coordination Team know of my desire to have my information forwarded to my primary care or other personal physician, and I will fill out the required release form.
• I will not make medical decisions without consulting a healthcare provider or disregard medical advice from my healthcare provider or delay seeking such advice based on information I receive as a result of my Consult.
• If I receive an abnormal Result on certain STD Tests, my name and Result will be disclosed to my state health agency in accordance with applicable law.
• If I receive an abnormal result on an STD Test, it is important that I notify my sexual and needle sharing partners and follow up with my personal physician to receive treatment.
• I understand that MMS Consults are delivered by MMS’ Health Care Providers who are not in the same physical location as I am, using electronic communications, information technology or other means, including the electronic transmission of personal health information, and that they may not have the opportunity to perform an in-person examination of me. I also understand that a MMS’s Health Care Provider will determine whether or not treatment is appropriate for me, based on information I provided.
• For Consults, the scope of Services will be at the sole discretion of the Health Care Provider treating me, with no guarantee of diagnosis, treatment, or prescription, and the standard of care will be the same as it would be if I were receiving such services in-person. The MMS’s Health Care Provider will determine whether or not the condition being diagnosed and/or treated is appropriate for a telemedicine encounter.
• I have the right to withdraw my consent to use telemedicine in the course of my care at any time by contacting MMS’s Care Coordination Team by calling (800) 243-4052 or service@letsbesafe.com
• Any video feed from the Consult will not be retained or recorded by MMS.
• My health and wellness information pertaining to telemedicine services are governed by MMS’s Notice of Privacy Practices.
• I may need to see a healthcare provider in person for diagnosis, treatment and care.
• There are potential risks associated with the use of technology that are beyond MMS’s and any healthcare provider’s control, including disruptions, loss of data, and technical difficulties.
• There are alternative services available to me if I experience medical symptoms that require immediate attention, such as visiting a primary care provider, an emergency room, or an urgent care facility; however, I voluntarily choose to proceed with MMS’s Services at this time.

I understand that if I have any questions before or after my Test, I can contact MMS’s Care Coordination Team by calling (800) 243-4052 or service@letsbesafe.com.

I authorize MMS to use the email address and phone number I provided in connection with my account and to contact me in connection with my Consult including follow-up after the Consult. I am responsible for contacting MMS’s Care Coordination Team by calling (800) 243-4052 or service@letsbesafe.com to notify them of any changes to my mailing address, email address, phone number, medical history or other information that I provided in connection with the Services.

I have read this Informed Consent carefully, and all my questions were answered to my satisfaction. I hereby consent to receive Services from MMS pursuant to the terms, conditions, standards, and requirements set forth herein.