Wasef Health - Telehealth Informed Consent

Effective Date: May 6, 2026

BY CHECKING A BOX, CLICKING “I AGREE,” ELECTRONICALLY SIGNING, OR OTHERWISE AFFIRMATIVELY ACCEPTING THIS CONSENT, YOU ACKNOWLEDGE THAT YOU HAVE READ, UNDERSTAND, AND AGREE TO BE BOUND BY THIS CONSENT. IF YOU DO NOT AGREE, DO NOT PROCEED WITH A TELEHEALTH VISIT WITH WASEF HEALTH. YOU GRANT AGENCY AUTHORITY TO ANY PARTY WHO ACCEPTS THIS CONSENT ON YOUR BEHALF AND AGREE TO BE BOUND AS IF YOU HAD PERSONALLY ACCEPTED IT.

1. Introduction

This Telehealth Informed Consent (“Consent”) describes how you, the patient, will receive medical care from licensed healthcare providers affiliated with Wasef Health, P.C., a New Jersey professional corporation, together with its affiliated professional entities Wasef Health CA, P.C. (California), Wasef Health KS, P.A. (Kansas), Wasef Health PR, P.C. (Puerto Rico), and Wasef Health TX, P.A. (Texas) (collectively, “Wasef Health,” “we,” “us,” or “our”) using telehealth technology. Please read this document carefully. By acknowledging this Consent, you confirm that you understand and agree to receive telehealth services for your care.

2. Wasef Health’s Professional Entities

Wasef Health operates as a multi-jurisdiction professional medical group. Your care is provided by the Wasef Health entity that is licensed to practice medicine in the state or territory where you are physically located at the time of your visit. The entities that collectively form Wasef Health are listed below:

Your Provider will hold an active license in the jurisdiction where you are physically located at the time of your visit. 

You acknowledge that, in some cases, your Provider may be a nurse practitioner, physician assistant, or other licensed clinician rather than a physician, in each case practicing within the scope of their license and applicable supervisory or collaborative arrangements.

3. What Is Telehealth?

Telehealth is the delivery of healthcare services using electronic communication technologies. Telehealth may include:

• Live two-way audio and video consultations

• Store-and-forward transmission of medical information (for example, photos, medical history, questionnaires, or laboratory results)

• Asynchronous (non-real-time) messaging and review of your health information

Telehealth services may be provided by physicians, nurse practitioners, physician assistants, or other licensed clinicians (“Providers”) affiliated with Wasef Health.

You acknowledge that the delivery of healthcare via telehealth is an evolving field and that the technology used in your care may differ from, or include uses not specifically described in, this Consent. No specific results or benefits from telehealth are guaranteed.

4. Services Delivered Through Partner Platforms; Consent to Technologies   [REVISED]

Wasef Health partners with third-party platforms and technology vendors, including OpenLoop Health, Inc. and its affiliates and subsidiaries (collectively, “OpenLoop”), and other platform partners (collectively with OpenLoop, “Platform Partners”), to deliver telehealth services. Platform Partners may provide the patient intake, video infrastructure, electronic health record, prescription routing, payment processing, AI-assisted clinical documentation, and patient communication tools used in your care. Clinical decisions are made solely by your Wasef Health Provider.

By acknowledging this Consent, you specifically consent to the following technologies that may be used in connection with your care:

Artificial Intelligence (AI). AI technologies may be used during and after your visit for purposes including transcription, analysis of medical information, clinical decision support, quality assurance, generation of clinical documentation or summaries, and improvement of the Services. AI tools are intended to support, not replace, your Provider’s clinical judgment, and your Provider will review AI-assisted outputs before relying on them. AI systems may process, analyze, and store voice, image, and medical information from your visit, in accordance with applicable law and our Notice of Privacy Practices. You may ask your Provider what AI technologies are being used in your care and may request that AI not be used in certain aspects of your treatment, where feasible.

Recordings. Your telehealth visit may be recorded (audio and/or video) for purposes including quality assurance, Provider training, clinical documentation, and care coordination. You will be notified at the beginning of any recorded session. Recordings will be retained in accordance with applicable law and Wasef Health’s and Platform Partners’ retention policies.

Ambient Listening. Ambient listening technologies — which may include third-party vendors engaged by Wasef Health or a Platform Partner — may be used during your visit to capture relevant clinical information. You may ask your Provider to disable ambient listening for any portion of your visit.

Evolving and Beta Technology. Some technology used to deliver care, including the platforms and AI tools described above, may be in active development or beta testing. Such technology may contain bugs or errors, may produce erroneous results, may become temporarily unavailable, and may cause records, transmissions, or data to be corrupted or lost.

You agree to hold harmless Wasef Health and OpenLoop, and each of their respective affiliates, employees, contractors, agents, directors, members, managers, shareholders, officers, representatives, assigns, predecessors, and successors, for delays in evaluation, for information lost or corrupted due to technical failures, and for any issue arising from the use of AI technologies, recordings, or ambient listening systems, in each case to the fullest extent permitted by law.

5. Expected Benefits

• Improved access to healthcare, including from remote or underserved locations

• Shorter wait times and greater scheduling flexibility

• Reduced travel, time away from work, and exposure to other illnesses

• Continuity of care coordination, where clinically appropriate

6. Potential Risks and Limitations

Although telehealth offers many benefits, there are certain risks and limitations you should understand:

Incomplete physical examination. Your Provider will not be able to perform a hands-on physical exam, which may limit the ability to diagnose or treat certain conditions.

Technology failures. Delays, disconnections, poor image or audio quality, or outages may occur and could affect the quality of your visit.

Data transmission. Despite reasonable safeguards, there is a small risk that electronic transmissions could be intercepted or accessed without authorization.

Information you provide. The quality of care depends on the accuracy and completeness of the information you share. Omitting information may affect diagnosis, treatment, or safety.

Clinical limitations. Some conditions cannot be safely managed via telehealth and may require in-person evaluation, laboratory testing, or imaging. Your Provider may decline to treat, request further workup, or refer you to in-person care if telehealth is not appropriate.

Prescribing limitations. Your Provider may decline to prescribe certain medications via telehealth, including controlled substances, based on clinical judgment and applicable law.

AI and automated tools. AI tools may misinterpret spoken or written information, produce inaccurate transcriptions, summaries, or recommendations, or contribute to delays. AI tools support but do not replace your Provider’s clinical judgment.

7. Alternatives to Telehealth

You have the right to receive care in person from a qualified provider. You may decline telehealth at any time and pursue in-person care. Declining telehealth will not affect your ability to seek other medical services.

8. Privacy of the Visit   [NEW SECTION]

To protect the confidentiality of your health information, you agree to take part in your telehealth visit from a private location. Your Provider will also be in a private location. If any other individual is present during the visit (for example, to assist with technology, translation, or training), you will be informed of the individual’s presence and role and will be given the opportunity to consent before the visit continues. If you do not wish to consent, the visit will be discontinued or rescheduled, and your care will not be affected.

9. When a Telehealth Visit Is Not Appropriate   [NEW SECTION]

Your Provider may determine that a telehealth visit is not appropriate for you due to your particular health concern, your clinical history, or other factors. In such a case: (i) you will receive a notification that telehealth is not appropriate for the issue you submitted; (ii) your request will not proceed to a clinical visit with the Provider; (iii) the Provider will not receive any clinical information that you submitted beyond what is necessary to communicate the determination; and (iv) you will need to seek any needed care through another channel, such as an in-person visit. Wasef Health and your Provider make no guarantee that you will be diagnosed, treated, or prescribed any medication as a result of using telehealth services.

10. Confidentiality and Privacy

Your health information is protected under the Health Insurance Portability and Accountability Act (“HIPAA”) and applicable state and territorial laws. How we collect, use, and disclose your protected health information (“PHI”) is described in our Notice of Privacy Practices (“NOPP”), available at https://wasef-health.com and upon request. By acknowledging this Consent, you acknowledge that:

• Your visit and related clinical information may be stored electronically in a HIPAA-compliant system operated by Wasef Health or its technology and platform partners (including, where applicable, OpenLoop Health).

• Your clinical information may be shared with other licensed providers within Wasef Health, with pharmacies for prescription fulfillment, and with other parties as permitted or required by law.

• Audio, video, or photo content captured during your visit may be stored in your medical record to support continuity of care.

If you were referred to Wasef Health through a third-party partner (for example, a wellness program, marketplace, employer-sponsored program, or referring brand) (each, a “Referral Partner”), you authorize Wasef Health and OpenLoop to disclose to the Referral Partner limited information — including your name, dates of service, and prescription order dates, as applicable — for administrative purposes and not for treatment or payment. Such disclosure does not constitute a sale of your personal information under any applicable state privacy law. You may revoke this authorization at any time in writing at contact@wasef-health.com.

11. Authorization to Use and Disclose Protected Health Information

In addition to the confidentiality provisions above, you authorize Wasef Health and your Provider to use and disclose your protected health information (“PHI”), including your entire medical record relevant to your care, for the purpose of providing telehealth treatment, coordinating your care, and operating Wasef Health’s healthcare practice. You acknowledge and agree that:

• If the person or entity receiving your PHI under this authorization is not a healthcare provider or health plan covered by HIPAA, the information disclosed may be re-disclosed to other individuals or institutions and would no longer be protected by HIPAA.

• You may refuse to provide this authorization. Your refusal will not affect your ability to obtain treatment from Wasef Health, your eligibility for benefits, or any payment for services already provided, except where this authorization is requested for research-related treatment, enrollment in a health plan, or where the sole purpose of providing care is to give your information to a third party.

• You may inspect or copy the PHI to be used or disclosed under this authorization, subject to applicable law. For PHI created in connection with a clinical trial, your right to access may be suspended until the trial is completed.

• You may revoke this authorization at any time by sending written notice to the Privacy Officer at the address in the Contact Information section below or by emailing contact@wasef-health.com. Your revocation will not apply to actions taken in reliance on this authorization before the date Wasef Health received your revocation notice.

12. Authorization to Import and Access Prior Records

You authorize Wasef Health and your Provider to import, access, and review your medical records and medication history, including prescription records obtained through pharmacy data networks (such as Surescripts) and state Prescription Drug Monitoring Programs (PDMPs), for the purpose of providing safe and appropriate care. You may withdraw this authorization at any time in writing at contact@wasef-health.com, except that withdrawal will not affect records already obtained.

13. Not for Emergencies

Telehealth is not intended for medical emergencies. If you are experiencing a medical emergency, call 911 or go to the nearest emergency department immediately. Examples of emergencies include chest pain, difficulty breathing, severe bleeding, signs of stroke, suicidal thoughts, or any condition you believe is life-threatening.

14. Honest and Complete Information

You agree to provide accurate, current, and complete information about your medical history, medications, allergies, symptoms, and any other information requested by your Provider. Providing false or incomplete information may result in unsafe care, denial of services, or termination of the provider-patient relationship.

15. Prescribing

Prescribing decisions are made by your Provider based on clinical judgment and applicable federal, state, and territorial laws. Your Provider may:

• Decline to prescribe a requested medication

• Require additional information, laboratory testing, or in-person evaluation before prescribing

• Decline to prescribe controlled substances via telehealth where not permitted or clinically appropriate

• Check state Prescription Drug Monitoring Programs (PDMPs) as permitted or required

16. Pharmacy and Laboratory Choice

Wasef Health may make available certain pharmacy or laboratory services in connection with your care. You have the right to use any licensed pharmacy or laboratory of your choice, and may instruct your Provider to route prescriptions or laboratory orders accordingly. Your choice will not affect the availability or quality of your care from Wasef Health.

17. Financial Responsibility

You are responsible for any fees associated with your telehealth visit and any prescribed medications, laboratory testing, or follow-up services, unless otherwise covered by the platform through which you are receiving care. Fees will be disclosed prior to service.

Wasef Health offers services on a cash-pay basis and does not bill insurance. Wasef Health does not guarantee that any amounts you pay are eligible for reimbursement by insurance, HSA, FSA, or any other plan, and you are solely responsible for confirming any reimbursement eligibility with your plan. Services performed by outside providers (for example, laboratories, pathology, radiology, or pharmacies) may be billed separately by those entities.

18. Right to Withdraw Consent

You may withdraw this Consent at any time by notifying Wasef Health in writing at contact@wasef-health.com or at the mailing address below. Withdrawal will not affect the lawfulness of care provided prior to withdrawal.

19. Provider-Patient Relationship

A provider-patient relationship is established between you and your Wasef Health Provider through your telehealth visit. This Consent applies to your current visit and to future telehealth visits with Wasef Health providers unless and until withdrawn.

20. Laboratory and Diagnostic Tests

Certain services may involve at-home or third-party laboratory or diagnostic tests. Neither Wasef Health, OpenLoop, nor any Provider can guarantee the accuracy or reliability of any such test. False negative, false positive, or inconclusive results may occur and could affect your Provider’s ability to diagnose or treat your condition.

21. Communications

By providing your contact information, you authorize Wasef Health and OpenLoop, and their respective service providers, to contact you by phone call, SMS/text message, or email for purposes including appointment reminders, clinical follow-up, prescription notifications, patient feedback requests, and general health and wellness information. You acknowledge and agree that:

• These communications may be generated in part by automated systems or artificial intelligence (AI).

• Standard messaging and data rates may apply.

• This authorization remains in effect until you revoke it.

• You may opt out at any time by following the opt-out instructions in each message or by contacting contact@wasef-health.com.

• The transmission of protected health information (PHI) by SMS, email, or similar methods carries a risk of unauthorized access. You accept that risk in exchange for the convenience of these communications.

22. Third-Party Beneficiary

You acknowledge and agree that OpenLoop Health, Inc. and its affiliates (including any successor platform vendor) are intended third-party beneficiaries of this Consent and have the right to enforce its terms directly against you, including the technology consents, hold-harmless provisions, communications consents, and authorizations set forth above. No other person or entity is an intended third-party beneficiary of this Consent.

23. Treatment-Specific Acknowledgments 

The following acknowledgments apply only if you receive the corresponding treatment from your Wasef Health Provider. They supplement, and do not replace, the general consents above.

23.1   Compounded Medications

If your Provider prescribes a compounded medication for you, you acknowledge:

• The U.S. Food and Drug Administration (“FDA”) does not approve or review compounded medications for safety, effectiveness, or quality.

• Compounding pharmacies are licensed pharmacies that must adhere to applicable state and federal regulations and quality-control standards in preparing the medications they dispense.

• Information about your specific compounded medication, including risks, side effects, and storage instructions, will be provided by your Provider or the dispensing pharmacy. You agree to read this information carefully and contact your Provider with any questions before starting the medication.

• You may experience adverse reactions, including allergic reactions, that have not been observed in FDA-approved formulations of similar drugs. You agree to notify your Provider of any side effect or unexpected response.

23.2   Weight-Loss Treatment, Including GLP-1 Medications

If your Provider prescribes a weight-loss medication, including a GLP-1 medication (for example, semaglutide or tirzepatide), you acknowledge:

• WARNING: RAPID WEIGHT LOSS MAY CAUSE SERIOUS HEALTH PROBLEMS. Rapid weight loss is generally defined as more than 1½ to 2 pounds per week, or more than 1% of body weight per week after the second week of participating in a weight-loss program.

• You should consult your personal physician before starting any weight-loss program or using any weight-loss medication. Long-term weight management is the safest and most effective goal of any weight-loss program. Permanent lifestyle changes — such as nutritious eating, calorie awareness, and increased physical activity — promote durable weight loss.

• You have the right to ask questions about the potential health risks of the recommended program and any prescribed medication, including the program’s nutritional, psychological-support, and educational components, and to receive an estimated price of the program (including any extra products, services, supplements, examinations, and laboratory tests) and the estimated duration of the program.

• Qualifications of your Provider, and (where applicable) of any dietitian or nutritionist who has reviewed the weight-loss program, are available upon request.

• Weight-loss medications may cause significant side effects, including but not limited to nausea, vomiting, diarrhea, constipation, abdominal pain, pancreatitis, gallbladder disease, kidney problems, hypoglycemia, allergic reactions, and (in animal studies of GLP-1 receptor agonists) thyroid C-cell tumors. You agree to notify your Provider promptly of any side effect or concerning symptom.

• Compounded GLP-1 medications, where prescribed, are not FDA-approved and are subject to the additional disclosures in Section 23.1 above.

23.3   Genetic Testing

If your Provider offers or orders genetic testing as part of your care, you acknowledge:

• Genetic testing can be complex. The specifics of any test, including the type of biological specimen collected and what the test can and cannot detect, vary by condition.

• There are both potential benefits and potential risks to genetic testing, including the possibility of false positive, false negative, or inconclusive results, and the possibility that test results reveal information about other family members.

• Your Provider will explain the specifics of any test offered to you, and you will have the opportunity to obtain professional genetic counseling before completing testing.

• Genetic information is subject to special protections under federal and state law, including the federal Genetic Information Nondiscrimination Act (“GINA”), which restricts the use of genetic information by employers and most health insurers.

23.4   Peptide Therapy

If your Provider offers or prescribes peptide therapy, you acknowledge:

• Peptides are short chains of amino acids that act as signaling agents in the body. Peptide therapy is intended to support, reduce, or control dysfunctions associated with hormonal balance, oxidative stress, and other physiological processes.

• Peptide therapy may be viewed by parts of the mainstream medical community as new or controversial, and the FDA has not approved compounded peptides for any particular indication.

• Common side effects include reactions at the injection site (such as pain, redness, or swelling) and facial flushing. A small percentage of patients report dizziness, headache, heart palpitations, or hyperactivity. Allergic reactions can occur in sensitive individuals. Side effects generally resolve when the peptide is discontinued.

• Most peptides should not be used in patients with cancer. Other contraindications may apply to your individual case and should be discussed with your Provider.

• Your insurance is likely to consider this treatment “experimental” or “investigational” and to deny reimbursement. Wasef Health is a cash-pay practice and does not bill insurance for peptide therapy.

• You agree to inform your Provider of all known allergies, current medications and supplements, and any past reaction to injections. You acknowledge that satisfactory results from peptide therapy cannot be guaranteed.

24. State-Specific and Territorial Disclosures

Certain states and territories impose additional telehealth consent or disclosure requirements. The following disclosures apply if you are physically located in the listed jurisdiction at the time of your telehealth visit. Where any state or territorial requirement conflicts with the general provisions of this Consent, the state or territorial requirement controls for visits in that jurisdiction.

24.1   California

If you are a California patient:

• Your medical records may be distributed only with your consent and in accordance with applicable laws and regulations to other treating health-care practitioners.

• Open Payments Notice. The federal Centers for Medicare and Medicaid Services (“CMS”) Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. The federal Physician Payments Sunshine Act requires that detailed information about payments and other transfers of value worth over ten dollars ($10) from manufacturers of drugs, medical devices, and biologics to physicians and teaching hospitals be made publicly available. The database is available at https://openpaymentsdata.cms.gov.

• Formal Complaints. To register a formal complaint about a Provider, you may visit the Medical Board of California at https://www.mbc.ca.gov/Consumers/file-a-complaint/ or, for physician assistants, the Physician Assistant Board at https://www.pab.ca.gov/consumers/complaints.shtml.

24.2   Kansas

If you are a Kansas patient and have a primary care provider or other treating physician, the Wasef Health Provider rendering telemedicine services must, with your consent, send a report of the treatment and services rendered during the telemedicine encounter to such primary care or treating provider within three (3) days of your providing consent. You may provide or withhold this consent during your visit or by contacting contact@wasef-health.com.

24.3   New Jersey

If you are a New Jersey patient:

• You have the right to request a copy of your medical information.

• Your medical information may be forwarded directly to your primary care provider or healthcare provider of record or, upon your request, to other healthcare providers.

• If you do not have a primary care provider or other healthcare provider of record, your Wasef Health Provider may advise you to contact a primary care provider and, upon your request, may assist you in locating a primary care provider or other in-person medical assistance, to the extent possible, located within reasonable proximity to you.

24.4   Texas

If you are a Texas patient, with your consent your medical records may be sent to your primary care physician within seventy-two (72) hours after receiving services from Wasef Health.

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 1-800-201-9353. For more information, please visit 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.

24.5   Puerto Rico (DRAFT — PR-counsel review required)

Reviewer note: This section is a working draft based on Puerto Rico Law 168-2018 (Telemedicine Act) and related guidance. It should be confirmed by Puerto Rico-licensed counsel before use, including assessment of Spanish-language presentation requirements. Patients located in Puerto Rico should be presented this Consent in Spanish where required by applicable law or regulation.

If you are physically located in the Commonwealth of Puerto Rico at the time of your telehealth visit, you acknowledge:

• Your Wasef Health Provider holds an active license issued by the Puerto Rico Board of Medical Licensure and Discipline (“Junta de Licenciamiento y Disciplina Médica”) and is authorized to provide telemedicine services in Puerto Rico.

• You have been informed of the scope and limitations of telemedicine, including the inability to perform a hands-on physical examination, and you voluntarily consent to receive medical services through telemedicine technologies.

• You have the right to receive a copy of your medical record, to request that your medical record be transferred to another licensed healthcare provider in Puerto Rico, and to request a Spanish-language version of this Consent and other patient-facing materials.

• Complaints regarding the conduct of your Provider may be filed with the Puerto Rico Board of Medical Licensure and Discipline. Information on filing a complaint is available through the Department of Health of Puerto Rico (Departamento de Salud de Puerto Rico).

• Your protected health information will be handled in accordance with HIPAA, the Puerto Rico Health Insurance Portability Act, and other applicable Puerto Rico privacy laws. Disclosure of PHI to Platform Partners and Referral Partners is governed by Sections 4, 10, and 11 of this Consent.

25. Patient Acknowledgment and Consent

By acknowledging this Consent (electronically, by checkbox, by signature, or by proceeding with a telehealth visit), you confirm that:

• You have read and understand this document.

• You have had the opportunity to ask questions and receive answers to your satisfaction.

• You are voluntarily consenting to receive telehealth services from Wasef Health.

• You are physically located in the United States or in a United States territory where Wasef Health is licensed to provide care, at the time of your visit.

• You are 18 years of age or older, or you are the parent or legal guardian of a minor patient and are providing consent on their behalf.

• You have read and acknowledged the state- or territory-specific disclosures applicable to the jurisdiction in which you are physically located.

• If applicable, you have read and acknowledged the treatment-specific addenda in Section 23 corresponding to the care you are receiving.

Contact Information

Simone Wasef, Privacy Officer

Wasef Health, P.C.

5260 78th Avenue N, Box 1697, Pinellas Park, FL 33780

Email: contact@wasef-health.com

Phone: (941) 845-6153