First Name *

Last Name *

What Insurance do you have? *

Client's ID [OR] Policy number on insurance card *

Date of birth: Example 03/20/1958 *

Street Address *

City *

State *

Country

Postal code *

Patient's contact information (required):

Email *

Phone *

(please specify) *

Mobile (able to receive text/SMS)

Landline

I Consent to Receive SMS Notifications, Alerts & Occasional Marketing Communication from company. Message frequency varies. Message & data rates may apply. Text HELP to (XXX) XXX-XXXX for assistance. You can reply STOP to unsubscribe at any time.

I, the undersigned, hereby give my consent to enroll in the Non-Face-to-Face Encounter Program highly recommended and provided by my physician and their clinical staff using the Universal Patient Link platform. I understand that these services are not meant as a form of medical treatment or to replace any required treatment, but rather to monitor and coordinate care. In the event of any medical need, please call the provider directly, and in case of medical emergency call 911 right away.

1. Communication channels: I authorize that correspondences may be sent to me through various communication channels, including but not limited to phone calls, text messages, emails, or in-app notifications. These channels are used to provide necessary information concerning my health.

Types of Correspondences: Correspondences may include, but are not limited to, the following: • CarePoints: questionnaires or checkpoints related to my symptoms, medication adherence, overall well-being, and other relevant health aspects. • Vitals: requests to provide and report vital readings such as blood pressure, heart rate, blood glucose levels, weight, or other measurements specific to my health condition. • General health updates: information and educational materials related to my health condition, treatment plan, medication management, or preventive care.

I consent to receive services from the provider listed above and/or any associates they may designate to assist in providing the services under their direction and supervision, including Non-Face-to-Face services for which provider uses the software and support tools of Universal Medication Management Inc. dba Universal Patient Link ("UPL").

2. Privacy and Confidentiality: I understand that my privacy and confidentiality will be respected and upheld in all correspondences. All personal health information shared through these channels will be handled in accordance with applicable laws and regulations governing patient privacy and data protection (HIPAA).

3. I acknowledge my responsibility to actively participate in the Non-Face-to-Face Encounter Program by providing accurate and timely responses to CarePoints, reporting vitals as requested, and promptly engaging with correspondences related to my health.

4. My provider has explained to me the availability and the elements of the services that are relevant for my condition(s).

5. I understand that I have the right to stop services at any time (effective at the end of a calendar month) with this provider. I may revoke this agreement verbally by calling the office or in writing.

By signing below, I confirm that I have read, understood, and agree to the terms outlined in this consent form. I acknowledge that my enrollment in the Non-Face-to-Face Encounter Program and my active participation in the receipt of correspondences are essential for the effective management of my health.

Patient's name (printed): *

Date of signing

Patient's Signature: *

Clear