Telehealth Consent & Authorization to Use and Disclose Medical Information

Effective Date: June 3, 2025

By clicking “I Agree,” checking a related box to signify your acceptance, or otherwise affirmatively accepting this Consent, you confirm that you have read, understand, and agree to the terms outlined in this document. If you do not agree, do not use our telehealth services or submit any personal information.

1. Authorization to Use and Disclose Medical Information

By accepting this Consent, you authorize Restoration Health & Wellness, LLC, including its medical providers, clinical team, staff, and pharmacy partners, to collect, use, and disclose your medical and personal information—including protected health information (“PHI”)—for the purposes of:

• Providing medical care and health services, including diagnosis, treatment, and prescription management

• Communicating with you regarding appointments, treatment plans, follow-ups, and general health education

• Coordinating prescription fulfillment with licensed U.S. pharmacies

• Managing payment processing and billing services

• Complying with regulatory, legal, and insurance requirements

Your health information may include—but is not limited to—your medical history, treatment records, lab results, and communications with your provider. This information may also include sensitive health data, including information related to mental health, substance use, reproductive health, and communicable diseases.

You understand that while HIPAA and related privacy laws protect your data, any information disclosed to third parties may be subject to re-disclosure and may not remain protected.

2. Pharmacy Information and Consent to Fulfill Prescriptions

If a licensed provider at Restoration Health & Wellness determines that a prescription is medically appropriate for you, it may be fulfilled through a licensed U.S. pharmacy.

We currently partner with:

Compounding Pharmacy of America
5710 Kingston Pike, Suite A
Knoxville, TN 37919
Phone: (865) 243-2488
Website: www.compoundingrxusa.com

By agreeing to this Consent, you authorize Restoration Health & Wellness to transmit your prescription and health information to this pharmacy, or another licensed pharmacy, to fulfill and ship your medication. You may request to have your prescription transferred to a pharmacy of your choice at any time by contacting our support team.

3. Consent to Telehealth Services

You consent to receive healthcare services via telehealth, which may include video, audio, messaging, electronic transmission of medical records, and the use of remote monitoring technologies. These services may be provided by physicians, nurse practitioners, physician assistants, or licensed mental health professionals.

Telehealth may be used for diagnosis, treatment, care planning, and health education.

You understand that:

• Telehealth does not replace in-person care in all cases

• You may decline or discontinue telehealth services at any time

• You are responsible for disclosing all relevant health history and symptoms to your provider

• Providers may be limited in their ability to examine or assess certain conditions remotely

• There is no guarantee of treatment outcome or cure

4. Data Protection & Privacy

Restoration Health & Wellness uses encrypted, HIPAA-compliant platforms to safeguard your data. We maintain administrative, physical, and technical security measures to protect your information from unauthorized access or disclosure.

Electronic communications may include appointment reminders, follow-up instructions, and health-related updates via email, phone, or patient portal.

You have the right to:

• Request a copy of your health records

• Correct or update your personal information

• Revoke this consent at any time by submitting a written request to info@restorationhealthwellness.com

Revocation will not affect any use or disclosure already made in reliance on this consent.

5. Acknowledgments

By consenting, you acknowledge that:

• You are at least 18 years of age

• You understand and agree to receive services via telehealth

• You understand that your provider may use their professional judgment in determining whether telehealth is appropriate

• You have been informed of the potential risks and limitations of telehealth

• You understand that you may contact a different provider or pharmacy if you choose

• You are responsible for the full cost of services provided by Restoration Health & Wellness, which are not submitted to Medicare or insurance

6. Emergencies and Crisis Situations

Telehealth is not suitable for emergencies. If you are experiencing a medical or mental health crisis, please:

• Call 911, or

• Call the 988 Suicide & Crisis Lifeline

7. Expiration

This consent remains in effect for one year from the date of your acceptance or until you submit written revocation.

Questions or Contact

For questions about this consent or your rights, contact:

Restoration Health & Wellness
info@restorationhealthwellness.com
 (850) 332-4484