Telehealth Informed Consent

FUTURE NOW RX NOTICE OF PRIVACY PRACTICES

Telehealth Services Provided by Life and Destiny Health

Last Updated: January 2026

IMPORTANT NOTICE – NO EMERGENCY SERVICES

Telehealth providers do not provide emergency medical services.

If you are experiencing a medical emergency, call 911 or go to the nearest emergency room immediately.

1. PARTIES AND STRUCTURE

   Future Now Rx is a healthcare technology and administrative services platform. Clinical services are provided by Life and Destiny Health and its affiliated licensed healthcare professionals (collectively, the “Practice”).

   Future Now Rx does not practice medicine or provide clinical care. All medical decisions are made solely by licensed healthcare providers contracted with or employed by the Practice.

   This Telehealth Informed Consent applies to services delivered through telehealth technologies made available via the Future Now Rx platform (the “Platform”).

2. NATURE OF TELEHEALTH SERVICES

   Telehealth involves the delivery of healthcare services using electronic communications, including but not limited to:

   • Live video conferencing
   • Telephone consultations
   • Secure messaging or asynchronous communication
   • Electronic transmission of medical information

   The Provider will not be physically present with you during the visit.

3. RISKS AND LIMITATIONS

   By consenting to telehealth services, you acknowledge and understand:

   • Technical failures, delays, or interruptions may occur.
   • Electronic systems may be vulnerable to unauthorized access despite reasonable safeguards.
   • The Provider may not have access to your complete medical history.
   • A physical examination may be limited or unavailable.
   • Telehealth may not be appropriate for all medical conditions.

   You understand that no specific outcome or result is guaranteed.

   If the Provider determines that telehealth is not appropriate for your condition, you may be advised to seek in-person care.

4. VOLUNTARY PARTICIPATION

   Participation in telehealth services is voluntary.

   You may withdraw your consent at any time without affecting your right to future care.

   You may choose to seek care from an in-person provider at any time.

5. PROVIDER CREDENTIALS

   Your healthcare provider may be a:

   • Physician (MD/DO)
   • Nurse Practitioner (NP)
   • Physician Assistant (PA)
   • Other licensed healthcare professional authorized under applicable state law

   All Providers are licensed in the state where you are located at the time of service, as required by law.

6. PRESCRIPTIONS

   A telehealth consultation does not guarantee that a prescription will be issued.

   Any prescribing decision is made solely in the independent professional judgment of the Provider and in accordance with applicable laws and medical standards of care.

   You may select the pharmacy of your choice.

7. PATIENT RESPONSIBILITIES

   You agree that:

   • All information you provide is accurate, complete, and truthful.
   • You will participate in the telehealth visit in a private setting.
   • You will notify your Provider of your physical location at the time of service.
   • You will inform your Provider of any emergency contact information if required.

8. PRIVACY AND USE OF HEALTH INFORMATION

   Your protected health information (“PHI”) will be used and disclosed in accordance with:

   • Applicable federal and state law
   • HIPAA (Health Insurance Portability and Accountability Act)
   • The Practice’s Notice of Privacy Practices

   You authorize the Practice to use and disclose your PHI for treatment, payment, and healthcare operations.

   If information is disclosed to entities not covered by HIPAA, it may no longer be protected by federal privacy laws.

   You may revoke this authorization in writing, subject to applicable legal limitations.

9. BILLING AND FINANCIAL RESPONSIBILITY

   By accepting this consent, you:

   • Authorize the Practice to bill your insurance, if applicable
   • Assign benefits directly to the Practice
   • Agree to be financially responsible for any unpaid balances

   Services provided by external laboratories, pharmacies, or diagnostic facilities may be billed separately.

10. SPECIAL SERVICES CONSENT

    Where applicable, additional consent applies to:

    Compounded Medications

    Compounded medications are not reviewed or approved by the FDA for safety or effectiveness. They are prepared by licensed compounding pharmacies in accordance with applicable regulatory standards.

    Teletherapy Services

    Teletherapy is not appropriate for crisis or emergency situations. If you are experiencing suicidal thoughts or are in crisis, call 988 or 911 immediately.

    HIV Testing

    HIV testing is voluntary. Results may be reported to public health authorities as required by law.

    Genetic Testing

    Genetic testing carries potential medical, psychological, and privacy implications. Specific risks and benefits will be explained prior to testing.

11. LIMITATION OF LIABILITY

    To the extent permitted by law, you agree that Future Now Rx, as a non-clinical administrative platform, is not responsible for clinical decisions, diagnoses, treatment recommendations, or outcomes. Clinical responsibility rests solely with the licensed Provider and the Practice.

    Nothing in this agreement waives rights that cannot legally be waived under applicable law.

12. CONSENT

    By clicking “I Agree” or “Accept,” you acknowledge that:

    • You have read and understand this Telehealth Informed Consent.
    • You have had the opportunity to ask questions.
    • You voluntarily consent to receive telehealth services from Life and Destiny Health through the Future Now Rx platform.
    • The information you provided is true and accurate.