Electronic Records, Signatures and Communications Consent

Electronic Records, Signatures and Communications Consent

Effective date: [EFFECTIVE DATE] | Last updated: [LAST UPDATED] | Version [VERSION]

In short

• Our service is online. Your forms, notices, receipts and messages come to you in the portal and by email.
• You can ask for a paper copy of any document. [VERIFY: paper copy fee and timing]
• You can take back this consent at any time. If you do, you will not be able to keep using our online service.
• Texts and calls are optional. You can say no, or reply STOP at any time, and still get care by portal and email.
• Email and text are not fully private. Do not use them for emergencies, passwords or card numbers.
• Your typed name or a click counts as your signature, the same as ink.

Part A. Electronic records and signatures

1. Who this consent is with

This consent is with WellPeps, a Wyoming corporation (“WellPeps,” “we,” “us”), and with [PRACTICE NAME] (the “Practice”), the independent medical practice whose licensed clinicians provide your care. When this form says “we,” it means WellPeps and the Practice unless it says otherwise. The Practice relies on this consent for its own records and messages. WellPeps does not provide medical care.

2. What records this covers

This consent covers all records we give or make available to you in connection with your WellPeps account and the care you request, for as long as you have an account. It is not just for one order. It includes:

• our terms, policies and notices, including the Notice of Privacy Practices and our Privacy Policy;
• consent and acknowledgment forms, including those about telehealth, compounded medicines, lab testing and medication safety;
• information about your treatment and your medicines, and lab information, that the Practice or the pharmacy gives you electronically;
• messages from your clinician;
• order confirmations, shipping and delivery updates;
• receipts, invoices, renewal reminders, price-change notices, payment-failure notices and cancellation confirmations;
• account and security notices; and
• any other notice the law lets us give you electronically.

3. Your right to paper copies

You have the right to get any of these records on paper. To ask, send a portal message or email [SUPPORT EMAIL]. Tell us which document you want and the mailing address to use. We will mail it within [10 business days] at no charge. [VERIFY: paper copy fee and timing] You can also save or print any record from the portal at any time. If you ask for a copy of your medical record, the Practice follows the Notice of Privacy Practices, which explains any cost-based fee the law allows.

4. Your right to withdraw consent, and what happens if you do

You may withdraw this consent at any time and for any reason. To withdraw, send a portal message or email [SUPPORT EMAIL] and say that you withdraw your consent to electronic records and signatures. We will confirm in writing. There is no fee for withdrawing.

If you withdraw:

• Records you received, and documents you signed, before you withdrew stay valid.
• Our service is online only. Intake, consents, ordering, payment and messages with your clinician all happen online. If you withdraw, we cannot start new orders or keep providing the service, and your clinician may not be able to continue your treatment. [VERIFY: paper or phone alternative]
• If you have an active plan, we will help you cancel under the Refund, Cancellation and Auto-Renewal Policy. The Practice can tell you how to continue or stop your medicine appropriately.
• We may send required notices to you by mail at the address on your account.

5. Keeping your contact information current

To get records electronically you must keep your email address up to date, and your mobile number if you choose texts. You can change them in your portal profile or by emailing [SUPPORT EMAIL] from the address on your account. We may rely on the most recent contact details you gave us. If an email bounces or a message cannot be delivered, we may not be able to get time-sensitive information to you, such as a safety notice or a lab result.

6. What you need to use electronic records

To receive, view and keep these records you need:

• a computer, smartphone or tablet with an internet connection;
• a current version of a major web browser, such as Chrome, Safari, Edge or Firefox, with JavaScript and cookies turned on [VERIFY: supported browsers and devices];
• software that opens PDF files (most devices include it);
• an email address you can open, and a way to save or print documents; and
• for texts only: a mobile phone number that can receive text messages.

If these requirements change in a way that could keep you from reading your records, we will tell you before the change takes effect, and you may withdraw your consent without a fee.

7. Showing that you can open electronic records

Before you agree, please open the sample document at [SAMPLE DOCUMENT LINK]. If you can open and read it on the device you are using, check box 2 below. If you cannot, do not check the box. Email [SUPPORT EMAIL] for help. [VERIFY: E-SIGN consent mechanics]

8. Electronic signatures

When we ask you to sign, you may sign by typing your name, checking a box or clicking a button that says you agree. Your electronic signature has the same legal effect as your handwritten signature. When you sign, we record the date and time, the version of the document and your IP address. You agree that:

• you will not claim that a signature or record is invalid only because it is electronic;
• you are responsible for keeping your sign-in details private, and anyone who uses your account can sign as you, so do not share it;
• you are old enough to sign for yourself (18 or older; 19 in Alabama and Nebraska; 21 in Mississippi); and
• you are signing for yourself. Another person cannot sign for you.

9. How we deliver records

We deliver records by posting them in your portal and emailing you that they are there, by email with a document or a link, or, if you choose texts, by text message with a link. A record is delivered when we post or send it. Some records, such as the Notice of Privacy Practices, are also on our website. Please check your portal and email regularly.

10. Notices we may also send another way

The law requires some notices to be given in other ways. Urgent safety notices, such as a medication recall, may also be sent by phone or by mail. This consent does not limit our right to use those other ways. [VERIFY: E-SIGN exceptions and state e-signature rules]

11. Changes to this consent

We may update this consent. If a change is important, we will tell you and ask you to agree again. If you do not agree to an important change, you may withdraw your consent as described in section 4.

12. Records of your consent

We keep a record of your consent: your name, the date and time, your IP address, the version you saw and how you agreed. We keep these records for at least [7] years, or longer if the law requires. You can ask for a copy of your consent record by emailing [SUPPORT EMAIL]. Your medical records are kept by the Practice.

Part B. Communications: portal, email, text and calls

13. What we will contact you about

We will contact you about your care, your orders and your account. We call these “care and service messages.” They include:

• your health assessment and the status of your review, and requests from your clinician for more information;
• visit scheduling and reminders;
• messages from your clinician and notices that you have a new message;
• prescription, pharmacy, shipping and delivery updates;
• lab orders and notices that results are ready;
• receipts, billing, failed-payment notices, renewal reminders, price-change notices and cancellation confirmations;
• account and security notices, and answers from our support team; and
• required legal, privacy and safety notices, including medication recalls.

This form is not about marketing. See section 15 for marketing texts. Unsubscribing from marketing emails never stops care and service messages.

14. How we contact you

• Portal messages. The portal is our main and most private way to reach you. Using the portal and email for care and service messages is part of using our online service.
• Email. We email the address you gave us. Please check spam and junk folders.
• Text messages. Only if you check the optional text box below. See sections 15 and 16.
• Calls. If you agree in box 4, a clinician of the Practice or a WellPeps team member may call you about your care, a visit or an urgent result. Calls may come from a number you do not know, so please answer or check your voicemail and portal. [VERIFY: automated or prerecorded calls]

15. Text messages: your consent and what to expect

If you check box 4, you give your express consent for WellPeps, and the Practice through the WellPeps platform, to send care and service text messages to the mobile number you give, using an automated system. The Text Messaging Terms call this Program A. These messages are about your account, visits, orders, refills and billing, for example reminders, notices that you have a new message, shipping updates and billing notices.

• Your choice. Consent is optional. You do not have to agree to texts to buy anything from us or to get care. If you say no, we will use the portal and email. [COUNSEL: text consent optional and care not conditioned on it]
• How often. Message frequency varies with what is happening on your account.
• Cost. Message and data rates may apply. Carriers are not responsible for delayed or undelivered messages.
• Who texts you. Texts come from [SMS SENDER NUMBER].
• Your number. We do not share your mobile number or your text consent with third parties for their marketing. [VERIFY: mobile data sharing statement]
• Not marketing. We do not send marketing text messages. If we ever do, we will ask you separately and the Text Messaging Terms will apply. Agreeing to care and service texts does not sign you up for marketing texts, and you never have to agree to marketing messages to buy anything or get care. [VERIFY: TCPA consent language and revocation rules]

16. How to stop texts, and what it means for your care

Reply STOP to any text. You can also reply QUIT, END, CANCEL or UNSUBSCRIBE, send a portal message, email [SUPPORT EMAIL] or tell us in any other reasonable way. We will stop as soon as we can, and within the time the law requires. You may get one last text to confirm. Reply HELP, or email [SUPPORT EMAIL], for help. If you get a new phone number, tell us so that texts do not go to someone else.

If you stop texts, your care does not stop. We will use the portal and email instead. You may miss time-sensitive alerts, so check your portal and email regularly. A clinician of the Practice may still call you personally about an urgent care matter. Stopping texts does not stop portal messages and emails about your care and orders. You need at least one working way for the Practice to reach you, so keep your email and portal access current.

17. Risks of email and text, and what not to send

Email and text messages are not fully secure. They can be intercepted, read by other people who use your phone or email account, forwarded, delayed, lost or stored by your phone carrier or email provider. A message that shows on a lock screen can be seen by others. By checking box 5 you tell us you understand these risks and choose to receive care and service messages this way. If you prefer portal messages only, tell us at [SUPPORT EMAIL].

To protect your privacy we keep email and text content short. They usually say only that you have a new message, an order update or a reminder, and ask you to sign in to the portal for details. We do not put a diagnosis, a medicine name or a lab value in a text. [VERIFY: content of text and email messages]

Please do not send these by email or text:

• anything urgent or an emergency (call 911);
• passwords, PINs or one-time codes (we will never ask you for them);
• full payment card numbers or bank details;
• Social Security numbers or photos of identity documents (upload them in the portal only when asked); or
• details of your health history or symptoms (use portal messages).

Watch for scams. We will never ask you to pay by gift card, cryptocurrency or wire. Our real messages come from the addresses and numbers we list at [PORTAL URL]. [VERIFY: official sender addresses and numbers]

18. Secure messaging in the portal

For anything about your health, use secure messaging in the portal at [PORTAL URL]. It is built for private messages with your clinician. The portal uses security safeguards designed to protect your information. [VERIFY: portal message security statement] Messages you send to your clinician become part of your medical record.

Portal messages are for non-urgent questions. Your clinician may take [1 to 2 business days] to answer, and a reply cannot be guaranteed. [MEDICAL DIRECTOR: confirm portal response time] In an emergency, call 911. Messages to WellPeps support are for orders, billing and your account. Our support team cannot give medical advice, so send clinical questions to your clinician.

19. Recording, chat and AI note-taking

We want you to know when your words are recorded or analyzed by software. Nothing in this consent lets anyone record you without telling you first.

• Support. WellPeps support is by email. If we add phone support and record calls, we will tell you at the start of the call and let you continue or end it. [VERIFY: call, video and chat recording practices]
• Visits with your clinician. If a video visit is recorded or an AI note-taking tool is used, you will be told before it starts and asked to agree. You may say no and still have your visit.
• Chat tools. Our website and portal may include chat or AI tools. The AI Use Disclosure explains what they do, what they do not do and whether a chat is saved.
• State rules. Some states require every person on a call or recording to agree. We follow the stricter rule where it applies.

20. Companies that send messages for us

Our technology platform and our email and text delivery companies send messages for us and for the Practice. They may use your contact details only to deliver those messages, under agreements with us. See our Privacy Policy and the Notice of Privacy Practices for how your information is handled.

21. How long your choices last

Your consent in Part A lasts until you withdraw it. Your consent to texts and calls lasts until you reply STOP or tell us you want to stop. You can change your choices at any time in your portal profile or by emailing [SUPPORT EMAIL]. We keep records of your choices as described in section 12.

22. Contact us

Acknowledgment

Please read this consent (version [VERSION], dated [EFFECTIVE DATE]) before checking each box. This is not a consent to treatment. You will be asked to read and sign other forms next.

☐ Box 1 (required). I have read this Electronic Records, Signatures and Communications Consent. I agree to receive records, notices, consent forms and messages about my care and orders electronically, and to sign electronically. I know I can ask for paper copies and can withdraw this consent as described in Part A.

☐ Box 2 (required). I opened the sample document and I can read it on the device I am using. I have the equipment and software described in section 6.

☐ Box 3 (required). I agree that WellPeps and the Practice may contact me about my care, orders, payments and account by portal message and by email at the address I give below. I will keep my contact information up to date.

☐ Box 4 (optional). Yes, send me text messages. I agree that WellPeps, and the Practice through the WellPeps platform, may text me at the mobile number I give below about my account, visits, orders, refills and billing, and to tell me when I have a new portal message, and may call me about my care, including by using an automated system. Texts will not include health details. These are not marketing messages. Message frequency varies. Message and data rates may apply. Reply STOP to cancel and HELP for help. I do not have to agree to get care or to buy anything. If I leave this box unchecked, I will get email and portal notices instead.

☐ Box 5 (required). I understand that email and text messages are not fully secure. I will not send emergencies, passwords or card numbers by email or text. I can choose to use only the secure portal for health questions.

Electronic signature

By typing my name, I agree that my electronic signature is the legal equivalent of my handwritten signature. This consent does not by itself create a clinician-patient relationship and is not a consent to treatment.

Technical and drafting notes

Build notes

From: Acknowledgment