Introduction

This consent form (“Consent”) outlines the consent you (referred to as “you” or “your”) provide to Color (as defined below) for provision of healthcare services, which may include but not be limited to laboratory testing, telehealth visits, telehealth services, clinical consultations, receipt of prescriptions and overall treatment (“Healthcare Services”) and describes the benefits and limitations of such Healthcare Services. 

Color’s Role

Color Medical, P.A., and its affiliated medical groups (“Color Medical”) provide Healthcare Services, which includes telehealth services. Color Diagnostics, LLC, is a laboratory providing testing services. Color Health, Inc. is a provider of administrative and management services. Reference to “Color”, “we”, “us” or “our”, shall include all aforementioned entities. 

Voluntary Participation

Your receipt of Healthcare Services is entirely voluntary. It is your choice whether to utilize our Healthcare Services or not based on your review of risks, benefits, and limitations of individual tests, treatments or other services, and your consultation with a healthcare provider. 

Procedure for Color Healthcare Services

You may have the opportunity to select specific tests, treatments, or other services, including, but not limited to, cancer screenings, genetic and other testing, and/or consultation with a healthcare provider regarding abnormal laboratory results or your health. Certain Healthcare Services may require additional consent from you, which will be obtained in advance of the Healthcare Services being provided.

You are encouraged to discuss any questions or concerns with a healthcare provider of your choosing.

When choosing to receive a specific Healthcare Service, you are representing that you have had an adequate opportunity to review the risks, benefits, and limitations of the Healthcare Service, and had the opportunity to discuss those with your healthcare provider, if desired, and you are providing your consent to Color to provide access to the selected Healthcare Service. In some cases, you may be asked to provide additional documentation of consent, by written or electronic means, for certain Healthcare Services (e.g., genetic testing).

Use of Generative AI 

Color Medical and its clinicians may use generative artificial intelligence (“AI”) to assist them in your healthcare. All AI use is subject to clinicians’ professional medical advice, diagnosis, and decision-making. We do not control or interfere with the practice of medicine by clinicians, who are solely responsible for the medical care and treatment they provide to you. 

Use of Telehealth Services

Telehealth services may include remote diagnosing and prescribing, appointment scheduling, health information sharing, and non-clinical services, such as patient education. The information you provide may be used for diagnosis, treatment, follow-up and/or patient education. Health information may be shared by you and the telehealth provider via any combination of the following: health records and test results; images and asynchronous communications; live two-way audio and video; interactive audio with store and forward; and output data from medical devices and sound and video files.

The laws that protect the privacy and confidentiality of healthcare information also apply to telehealth. Information on how we use or disclose your healthcare information is included in our Notice of Privacy Practices. 

There are benefits and risks to the use of telehealth. Potential benefits may include making it easier, more convenient, and more efficient to receive medical care and treatment. Telehealth services also allow you to seek care at times that are more convenient for you. Potential risks may include, without limitation:

• The information available to the telehealth provider may not be sufficient to allow the provider to make an appropriate medical decision, including diagnosis or treatment.
• The inability for the telehealth provider to conduct an in-person examination may in some cases prevent the provider from providing a diagnosis or treatment or from identifying the need for emergency medical care or treatment.
• Technology issues, such as disruptions of signals or problems with the internet’s infrastructure, may cause broadcast and reception problems (e.g., poor picture or sound quality, dropped connections, audio interference) that prevent effective interaction between you and the treating healthcare provider, and may lead to loss of information.

As with any internet-based communication, there is a risk of security breach. Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient data and will include measures to safeguard the data and to ensure its integrity. 

Individuals other than the telehealth provider may also be present or have access to your information for the telehealth session to assist with operation, delivery or maintenance of telehealth technologies. These individuals will adhere to applicable privacy and security policies. 

Deliveries 

If you purchase or order any Color test(s) or product(s) as part of the Healthcare Services, Color will facilitate the delivery of such products to the address it has on file via the U.S. Postal Service or a reputable third-party courier. These delivery services may use, access, or disclose your personal information pursuant to their privacy policies. 

By consenting to receive Healthcare Services, you represent and agree to the following: 

1. You have legal authority and capacity to consent to Healthcare Services.
2. Healthcare Services may not be appropriate for certain populations of people with certain conditions or symptoms. 
3. Prior to receiving Healthcare Services, you are free to consult with a healthcare provider of your choosing to determine what Healthcare Services are right for you. 
4. You have received information about the Healthcare Services you are receiving, and can ask questions at any time. 
5. Color will only have access to the health information you share with Color, and not to all of your medical records. 
6. Your healthcare information will be shared with your primary care provider upon your request. 
7. You will have access to all medical information resulting from the Healthcare Service or telehealth consultation as provided by applicable law for patient access. 
8. Color may share your personal information with the U.S. Postal Service or a third-party courier to facilitate the delivery of any at-home Healthcare Services, like testing kits.
9. You may decline or withdraw consent to any Healthcare Service, including telehealth, at any time. Decline or withdrawal of your consent to Healthcare Services, or to telehealth, may limit Healthcare Services available to you in the future. You will not be retaliated against for withdrawal of your consent.
10. Color’s Healthcare Services are not intended for emergency care or emergency health situations. In the event of a medical emergency or an adverse reaction to treatment, call 911.
11. You have received and have had an opportunity to review Color’s Terms of Service, Privacy Policy, and Notice of Privacy Practices, and that Color may use or disclose your information in accordance with such policies.
12. You understand that your electronic signature or acceptance has the same effect as your handwritten signature.

State-Specific Consents for Telehealth Services:

The following information applies to patients accessing telehealth services from the states listed below.

• New York: You understand that you can ask your telehealth provider how to verify his/her professional license.
• Texas:
  • NOTICE CONCERNING COMPLAINTS – Complaints about physicians, as well as other licensees and registrants of the Texas Medical Board, including physician assistants, acupuncturists, and surgical assistants may be reported for investigation at the following address: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018. Assistance in filing a complaint is available by calling the following telephone number: 1-800-201-9353, For more information, please visit our website at www.tmb.state.tx.us.
  • AVISO SOBRE LAS QUEJAS – Las quejas sobre médicos, así como sobre otros profesionales acreditados e inscritos del Consejo Médico de Tejas, incluyendo asistentes de médicos, practicantes de acupuntura y asistentes de cirugía, se pueden presentar en la siguiente dirección para ser investigadas: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018. Si necesita ayuda para presentar una queja, llame al: 1-800-201-9353, Para obtener más información, visite nuestro sitio web en www.tmb.state.tx.us.
• Utah: For additional information on telehealth website owner-operator, location, and contact information, contact privacy@color.com.

Acknowledgement

You (a) certify that you are the patient, or that you are authorized to provide consent on behalf of the patient as the patient’s representative or legal guardian, (b) acknowledge and accept the risks identified above and the terms associated with the receipt of Healthcare Services, including via telehealth services, and (c) give your informed consent to receive Healthcare Services under the terms described herein.