Telehealth Consent

AUTHORIZATION TO USE AND DISCLOSE MY MEDICAL INFORMATION AND CONSENT TO TELEHEALTH
OPEN PAYMENTS NOTICE

Last updated: December 7, 2025

BY CLICKING “I AGREE,” CHECKING A RELATED BOX TO SIGNIFY YOUR ACCEPTANCE, USING ANY OTHER ACCEPTANCE PROTOCOL PRESENTED THROUGH THE SERVICE, OR OTHERWISE AFFIRMATIVELY ACCEPTING THIS CONSENT, YOU ACKNOWLEDGE THAT YOU HAVE READ, ACCEPTED, AND AGREED TO BE BOUND BY THIS CONSENT. IF YOU DO NOT AGREE TO THIS CONSENT, DO NOT CREATE AN ACCOUNT OR USE THE SERVICE. YOU HEREBY GRANT AGENCY AUTHORITY TO ANY PARTY WHO CLICKS ON THE “I AGREE” BUTTON OR OTHERWISE INDICATES ACCEPTANCE TO THIS CONSENT ON YOUR BEHALF.

IF YOU ARE EXPERIENCING A LIFE-THREATENING SITUATION, SUCH AS CONTEMPLATING SUICIDE, CALL 911 OR THE 988 SUICIDE & CRISIS LIFELINE AT 988.

AUTHORIZATION TO USE AND DISCLOSE MY MEDICAL INFORMATION

By signing this Authorization, I am authorizing VITL.life (“VITL Healthcare”), and all of its respective affiliates and subsidiaries (“Receiving Entities”) to use and disclose my Medical Information, including my Protected Health Information (collectively “Personal Information”), for the following purposes:

• Provide me with information related to my condition and provide disease management support;

• Provide me with information about offers and services from pharmaceutical manufacturers and other third parties that may be of interest to me;

• Provide pharmaceutical manufacturers and their affiliates and agents with information about me to allow them to administer applicable pharmaceutical manufacturers’ patient support services program, including but not limited to understanding health care providers utilizing services to enhance delivery of educational materials, assessing inventory and dispensing data to improve forecasting models for future supply, and which may support my pharmacy experience and treatment journey. Such services may include: copayment assistance programs, reimbursement assistance programs, drug coverage verification, nurse educator services, adherence programs, and/or

• Provide me with promotional and informational materials relating to pharmaceutical manufacturers’ products and services.

To permit the proper administration of the pharmaceutical manufacturers and their agents for a product when you are obtaining the pharmaceutical manufacturer’s product from VITL Healthcare.

INFORMED CONSENT REGARDING USE OF TELEHEALTH

PURPOSE
The purpose of this consent form (“Consent”) is to provide you with information about telehealth and to obtain your informed consent to the use of telehealth in the delivery of healthcare services to you by physicians, physician assistants, nurse practitioners, and other licensed professionals (“Providers”) using the online platforms owned and operated by VITL Healthcare (the “Service”).

LIFE-THREATENING AND EMERGENCY SITUATIONS

If you are experiencing a life-threatening situation, such as contemplating suicide, call 911 or the 988 Suicide & Crisis Lifeline at 988.

If the situation is an emergency, call 911. Providers may not respond promptly to communications submitted through the Service.

DATA PRIVACY AND PROTECTION

The electronic systems used in the Service will incorporate network and software security protocols to protect the privacy and security of your information. Personal information that identifies you or contains protected health information will not be disclosed to any third party without your consent, except as authorized by law for treatment, payment, or administrative purposes.

OPEN PAYMENTS NOTICE

For informational purposes only, a link to the federal Centers for Medicare & Medicaid Services Open Payments webpage is provided here: https://openpaymentsdata.cms.gov.

GOVERNING LAW

This Consent shall be governed by and construed under the laws of the State of Texas, without regard to its conflict of law provisions.