Consent to Arrange Telehealth Appointment & Obtain Letter of Medical Necessity (Consent)

1. ABOUT THIS CONSENT

Pursuant to Internal Revenue Service (IRS) rules, certain healthcare services and products (Service/Product) are only eligible for reimbursement through your Health Savings Account or Flexible Spending Account(HSA/FSA) when your doctor or other licensed health care provider certifies such product or service is medically necessary. In connection with this certification, which is referred to as a Letter of Medical Necessity (LMN), your provider must indicate your (or your spouse’s or dependent’s) specific diagnosis, the specific treatment necessary, and how this treatment will ameliorate or alleviate your medical condition.

2. REASON FOR THIS CONSENT

Sika Health, Inc. (Sika), through its medical practice affiliates, is able to facilitate the LMN process for you, and you have elected to utilize Sika’s services to try to obtain an LMN to support the purchase of aService/Product using your HSA/FSA funds.

3. ABOUT THE LMN PROCESS

In connection with the LMN process, Sika will collect certainpersonal and health information (Personal Information) from you and may securely share that information with a licensed healthcare provider (Provider)on your behalf to secure an appointment for a telehealth visit (Visit). The purpose of the Visit will be for you to meet with the Provider to review the medical necessity of the Product you wish to purchase.  During that Visit, the Provider will request details of your medical history and diagnosis. In connection with the Visit, you will need access to a mobile device to participate in the telehealth appointment.

Following the telehealth appointment and where appropriate and determined by the healthcare provider, an LMN will be provided.  Sika will also confirm whether the product orservice you wish to purchase is reimbursable through your HSA/FSA.  Sika may also store the LMN on its platform on your behalf in accordance with the retention policy set forth in its PrivacyPolicy.

It is important that you understand that the Visit is not intended to be used to identify emergencies or to treat emergent, serious, or life-threatening conditions, or any conditions at all. If you or someone you know is suffering from an emergent or life-threatening condition, call 9-1-1immediately where that service is available or go to the nearest open clinic or emergency room.  

4. PERSONAL INFORMATION NEEDED

In order to facilitate the LMN process, Sika willneeds to collect certain Personal Information from you via the screens that follow this consent form. Accordingly,  please provide the following PEersonal Information:

5. AFFIRMATIVE CONSENT

By signing below, I acknowledge and agree that:

  • I am providing my Personal Information to Sika, at my request, for Sika to facilitate the LMN process on my behalf through its affiliated Providers, to assist me in purchasing the specified Service/Product using my HSA/FSA funds.
  • I ATTEST THAT I AM PURCHASING THE SPECIFIED SERVICE/PRODUCT FOR A VALID AUTHORIZED REASON AND NOT FOR GENERAL HEALTH OR COSMETIC PURPOSES.
  • In connection with the LMN process, I hereby authorize Sika to share my Personal Information with its affiliated Providers.
  • I understand that upon execution of this Consent and disclosure to Sika of my Personal Information, that my Personal Information will immediately be transmitted to affiliated Providers of Sika via secure portal in connection with the LMN process. Accordingly, although I may withdraw my consent to share my PersonalInformation with Sika on a go forward basis by notifying Sika atsupport@sikahealth.com; I understand that this initial consent cannot be revoked.
  • I understand Sika will connect me with an independent licensed Provider for the purpose of engaging in a Visit to review the medical necessity of my healthcare related product or service and determine whether an LMN can be issued.
  • I understand that Sika’s obligation and responsibility in connection with the LMN process is to facilitate the process on my behalf; Sika does not and cannot guarantee that an LMN will be issued. The determination as to whether an LMN supporting the purchase of the Service/Product using my HSA/FSA funds lies solely with the Provider.  
  • If after a Visit is complete a Provider determines if is appropriate to issue an LMN supporting the purchase of the Product using my HSA/FSA funds, I understand that the LMN will be transmitted to Sika and I hereby expressly authorize Sika to provide the LMN to me via email at the address provided above.
  • I understand that I have the option to withdraw my decision to participate in Visit with a Provider at any point prior to theVisit.
  •  I understand that I am responsible for ensuring privacy at my location prior to and during the Visit.  
  • I understand that I am responsible for information security on my device, including but not limited to, my computer, tablet, or phone.
  • I understand that it is my obligation to ensure that any virtual assistant artificial intelligence devices, including but not limited to Alexa or Echo, will be disabled or will not be in the location where information can be heard.
  • I agree that I will not record either through audio or video any of the session unlessI provide advance notification and receive agreement.
  • I understand there are potential risks to using telehealth technology, including but not limited to interruptions, unauthorized access, and technical difficulties. I understand some of these technological challenges include issues with software, hardware, and internet connection which may result in interruption.
  • I understand that Sika is not responsible for any technological problems over which Sika has no control.  I further understand that Sika does not guarantee that technology will be available or work as expected.
  • I understand that my Provider or I may discontinue the Visit if it is determined by either me or the Provider that the communications connections or security protections are not adequate for the situation.
  • To maintain confidentiality, I will not share my Visit appointment link or information with anyone not authorized to attend the session.
  • I ATTEST THAT I HAVE READ AND UNDERSTAND THIS CONSENT, AS WELL AS SIKA’S TERMS OF SERVICE, SIKA’S PRIVACY POLICY, AND THE PRIVACY POLICY FORANY SIKA AFFILIATE PROVIDING THE LMN SERVICES, WHICH SUCH PRIVACY POLICY IS REFERENCED AND LINKED IN SIKA’S PRIVACY POLICY.  

6. CONSENT

By checking the box on the screen from which this consent is accessible, I expressly give my permission for Sika to collect and share my Personal Information with its affiliated Providers in connection with the LMN process. I acknowledge that I have read, understand, agree, certify, and/or authorize the information above on my own behalf. This consent shall remain in effect unless it is revoked in writing to support@sikahealth.com.

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