Informed Consent To Treatment: Telehealth, Virtual Care, and Related Recording

Last Updated: August 15, 2025

PRSCA Medical Group, P.C.

A Delaware Corporation

PLEASE REVIEW IT CAREFULLY

Eligibility and Authorization

I am over the age of 18 and either:

The patient seeking evaluation and/or treatment ("Services") from PRSCA Medical Group, P.C., a Delaware corporation ("PRSCA");
The legal guardian or personal representative of such patient; or
The general, durable or healthcare power of attorney of such patient

(collectively, "I," "me," or "my").

I understand there are risks involved in any medical procedure or treatment. By acknowledging "I AGREE," I am consenting to, requesting, and authorizing PRSCA and its medical and non-medical professionals (individually, "Professional") to perform:

Consultations
Examinations
Diagnosis
Evaluations
Treatment services
Any other procedures as may be necessary in accordance with the judgment of the attending medical practitioner(s)

This includes procedures and/or treatment considered medically advisable to remedy conditions discovered during any procedure or treatment.

My Acknowledgments

I am responsible for providing accurate information about my health condition(s) and any symptom(s) I am experiencing
I am responsible for providing information about any healthcare providers who are currently or have previously treated such conditions and symptoms
No guarantee can be made or assurance of success be provided by anyone concerning the results of any treatment, diagnosis, examination, evaluation, or procedure

Understanding and Capacity

I confirm that:

I am not under the influence of any medications or other substances that could impair my understanding of this consent
I have had sufficient time to read and understand the information provided regarding the Services, including virtual care
I have had the opportunity to discuss this consent with my Professional
I have been given all opportunity required to ask questions, and such questions have been answered to my satisfaction in words I understand

Authorization to Obtain Medical Records

I hereby consent to, request, and authorize PRSCA to request and obtain copies of my medical records, including but not limited to:

Medical history
Laboratory test results
Diagnostic images
Other PHI
Progress notes from other healthcare providers who have treated me in the past

This information will be used to provide me with the best possible care and to ensure continuity of care.

I understand that the release of my medical records is voluntary. Please refer to our Notice of Privacy Practices for detailed information regarding the uses and disclosures of your protected health information.

I grant my permission for virtual care and/or other Services to be performed by PRSCA using remote electronic communications, such as audio and/or video communications, specifically through the use of the Prosper Medical Platform ("Site").

Services May Include

Diagnosis
Consultation
Treatment
Transfer of electronic medical records
Exchange of medical data

Authorization to Release Information

I authorize PRSCA to release Protected Health Information ("PHI") gained from the Services to:

My primary care physician(s)
Health care provider(s)
Insurance company (to assist with claim reimbursement, if relevant)

I understand and agree that my PHI will be kept for a period required by applicable federal and state law.

I understand other Professionals may join the virtual care session virtually to aid in the delivery of medical care.

Professional Availability

I understand and agree that:

I may not be able to select a specific Professional
Due to emergencies, scheduling, and other circumstances, PRSCA cannot warrant or guarantee that I will have access to PRSCA, including any specific Professional

Virtual Physical Examination

I acknowledge and accept that if my virtual care includes a physical examination portion:

It will be delivered wholly virtually through the Site
It relies upon video, images, telephone consultations, medical records and/or otherwise
It may be recorded

I accept this with full knowledge of all potential benefits and consequences from virtual care and deem this method of physical examination appropriate and complete.

⚠️ As with all medical or health care services provided, I may be subject to virtual care that may cause some harm, including potentially serious harm.

Alternative Methods of Care

I understand that:

A variety of alternative methods of medical care may be available to me
I may choose one or more of these at any time
The Professional has explained these alternatives to my satisfaction

Professional Clinical Judgment

I acknowledge that, in the exercise of their clinical judgment, a Professional may determine:

The nature of my problem is such that it is not professionally appropriate to assist me through virtual care
It may not be lawful for the Professional to diagnose or treat me virtually
Both of the above

Should the Professional make any such determination, they will be unable to assist me virtually and will confer with me about other possible approaches, such as referring me to my primary care physician.

Emergency Care Disclaimer

⚠️ Virtual care may not be appropriate or a substitute for emergency medical care.

In the event of an urgent health issue or concern, I acknowledge it is my responsibility to seek care at a facility delivering urgent or emergent care services.

My Responsibilities

Informing My Primary Care Provider

I understand it is my duty to inform my primary care provider of any electronic interactions regarding my health care with other health care providers, including PRSCA.

Providing Accurate Information

I will provide my Professional and PRSCA with the names and contact information for other relevant healthcare providers
My Professional may communicate with them
It is my responsibility to provide accurate information and keep it updated

Third-Party Presence and Confidentiality

I understand:

It is my choice to have someone else present during my virtual care session
Anyone who sits in on the virtual session will have access to my PHI
My confidentiality may not be guaranteed if others are present
If I include any third party on an electronic exchange with PRSCA, I am granting permission for PRSCA to communicate my PHI with such third party
PRSCA and/or the Professional will not initiate inclusion of any third party
PRSCA and/or the Professional is not responsible for any breach of confidentiality made by any person I invite or add as a third party

Privacy and Security

I understand:

Virtual care may involve electronic communication of my PHI to other medical professionals who may be located in other areas, including out of state
Laws protecting privacy and confidentiality of PHI also apply to virtual care
No PHI obtained in receiving virtual care which identifies me will be disclosed to researchers or other entities without my consent

⚠️ I acknowledge that the security and privacy of electronic communications cannot be guaranteed.

I have read and understand:

PRSCA Terms of Service
PRSCA Health Privacy Notice
Notice of Privacy Practices

My Rights

I understand that I have the right to:

Inspect all PHI obtained and recorded in the course of a virtual care interaction
Receive copies of this PHI for a reasonable fee
Withhold or withdraw my consent to receive virtual care at any time, without affecting my right to future care or treatment

Liability and Certification

Liability Disclaimer

Neither PRSCA nor any third party is liable for any professional or other advice I obtain from a Professional via the virtual care session or for any information obtained through the Service.

I acknowledge:

My reliance on any Professional or information provided during the virtual care session is solely at my own risk
I assume full responsibility for all risk associated therewith

Location Certification

I hereby certify I am physically located in the state I have entered as my current location for the virtual care.

I acknowledge:

My ability to access and use the Site is conditioned upon the truthfulness of this certification
The Professionals I access through the Site are relying upon this certification
In the event my certification is inaccurate, I agree to indemnify PRSCA and the Professionals I interact with from any resulting damages, costs, or claims

Electronic Signature

I agree that my electronic agreement to these Terms is equivalent to the signature of a patient to this Informed Consent.

A copy of this Informed Consent form is available by printing this document or by request.

Authorization

By checking the open box and clicking "SUBMIT," I hereby authorize PRSCA and any Professional performing Services through the Site to:

1. Virtual Care

Provide care to me virtually in the course of my engagement and treatment, as applicable.

2. Recording and AI Analysis

To record, photograph, transcribe, summarize, and analyze my visits ("Recorded Data") utilizing artificial intelligence (AI) to enhance my care by allowing PRSCA and its Professionals to be more fully present with me by not needing to take notes during my visits.

Regarding Recorded Data:

Will not be published without my express consent
May be shared with my primary care physician or other healthcare provider I list and provide to PRSCA
After de-identification (names, email addresses, and other identifying information removed), PRSCA's contracted AI platform provider may use the de-identified data to improve its services and offerings

Final Authorization Statement

I authorize PRSCA and any PRSCA Professional to provide care to me virtually and I consent to such virtual care being recorded as described in this Informed Consent.

If I have questions or wish to withdraw my consent, I may do so at any time by emailing:

📧 [email protected]