Informed Consent to Telehealth Treatment

Part I: Informed Consent to Treatment via Telehealth

Nature of Telehealth Services

Kosius Group, LLC and Dr. Shivani Anumolu ("Practice") provide medical consultations and related services through synchronous audio-video telehealth technology. By scheduling and participating in a telehealth visit, you consent to delivery of medical services through electronic means.

Consent to Evaluation and Treatment

You voluntarily consent to evaluation, diagnosis, and treatment recommended by the Practice's licensed providers through telehealth. You understand that you will interact through secure, HIPAA-compliant video and/or audio technology; a provider may be a physician, nurse practitioner, or physician assistant licensed in the applicable state; you may withhold or withdraw consent; a provider may determine telehealth is inappropriate and refer you for in-person care; and consent does not guarantee a particular outcome or prescription.

Electronic Communications and Patient Portal

You consent to video conferencing, secure messaging, and email through the Practice's EHR and scheduling platform. Communications may include PHI and will be maintained under HIPAA and applicable law. After an initial visit, follow-up or refill requests may be submitted through the portal. The provider will determine whether a live consultation is needed and which fee applies.

Prescription Policy

• Prescriptions are based entirely on clinical judgment and are not guaranteed.
• The Practice does not prescribe controlled substances through telehealth except where all applicable federal and state requirements are met.
• Prescriptions are transmitted electronically to a pharmacy you select.
• A prescription will not be transmitted until the associated visit balance is paid in full.

Emergency Situations

Telehealth is not an emergency service. In a medical emergency, call 911 or go to the nearest emergency room immediately.

Age and Patient Location

Telehealth services are generally available to patients age 18 or older. Where services are provided to a minor, a parent or legal guardian must provide legally valid consent and sign applicable forms. You attest that you are physically located in Georgia at the time of every visit and understand a visit cannot proceed if you are outside Georgia.

Visit Type and Scope of Care

The Practice offers single-issue visits addressing one discrete concern and multi-issue visits addressing multiple concerns or greater complexity. The treating provider determines the applicable visit type and fee based on clinical scope and complexity.

Part II: Acknowledgment of Telehealth Limitations

Technology and Clinical Limitations

• Physical examination: A provider cannot conduct a complete physical examination and must rely on history, visual observation, and information you provide.
• Technical failures: Internet, equipment, video, or audio problems may require rescheduling or use of a telephone where appropriate.
• Diagnostic limitations: Tests, imaging, and procedures may require referral for in-person care.
• Jurisdiction: Services are limited to locations where Practice providers are licensed.
• Privacy: Platforms use safeguards, but no electronic communication is risk-free. Participate from a private location.
• Pharmacy and insurance: Pharmacy acceptance and insurance coverage vary. You are responsible for confirming coverage.

Conditions Not Appropriate for Telehealth

Telehealth is not appropriate for conditions such as acute chest pain or shortness of breath, suspected stroke or neurological emergency, severe abdominal pain, major trauma, suicidal or homicidal ideation, or other situations requiring physical assessment or emergency intervention. The provider determines whether a condition is suitable for telehealth.

Symptom Intake and Follow-Up Care

You may be asked to complete a symptom and history intake before a visit. The intake is not a diagnosis. Telehealth may not substitute for continuity with a primary care provider. You remain responsible for obtaining recommended in-person follow-up, specialist care, testing, or imaging.

Pharmacy and Compounded Medications

The Practice may use partner or compounding pharmacies where clinically appropriate. Compounded medications, including compounded GLP-1 receptor agonists such as semaglutide and tirzepatide, are not FDA-approved drug products or generic equivalents of FDA-approved medication and are not subject to the same pre-market review. You may ask questions and discuss risks, benefits, and alternatives with your provider.

Telehealth Does Not Replace Primary Care

Kosius does not serve as your primary care physician or provide continuous, comprehensive primary care. You are encouraged to maintain an ongoing relationship with a primary care provider.

Patient Acknowledgment

By completing the Practice's formal consent process, you acknowledge that you have read and understood the informed-consent and telehealth-limitations information, voluntarily consent to telehealth services, and have had an opportunity to ask questions. Required acknowledgment and signatures are completed through the secure patient-intake platform.