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Consent for Participation and Treatment

Effective as of August 18, 2025

Livara Health Medical Group, P.C. (“Livara Health”) offers a variety of online programs, including Medical Consultations and Online Exercise and Education Programs. By participating in any of these offerings, I provide my consent as follows:

Consent for Medical Consultations

Depending on my clinical needs, I may be eligible for consultation and treatment by licensed clinical providers, who are typically medical doctors, physical assistants or other advanced practice professionals, or physical therapists (collectively, “Medical Providers”). I understand that my consultation by a Medical Provider (the “Medical Consultation”) will be provided in accordance with recognized medical standards and clinical practice guidelines, but acknowledge that medicine is not an exact science and results are not guaranteed. I understand that I have the right to discuss the purposes and risks associated with all recommended treatment procedures and activities with my Medical Provider.

I further understand that my Medical Provider’s advice, recommendations, and/or decisions may be based on factors not within the Medical Provider’s control, including incomplete or inaccurate information provided by me. I understand that my Medical Provider relies on information provided by me, and that I must provide information about my medical history, condition(s), and current or previous medical care that is complete and accurate to the best of my ability.

In the event of an emergency, I understand that I should immediately call “911” and request emergency care assistance rather than contact a Livara Health Medical Provider.

If eligible, I consent for Medical Consultations according to these terms.

Consent to Online Exercise and Education Program

Depending on my clinical needs, I may be eligible for participation in an online fitness education and training program (the “Online Exercise and Education Program”). I acknowledge that as part of the Online Exercise and Education Program, I may be engaging in physical exercises and using exercise equipment and, as with all such physical activity, there is an inherent risk of injury or complication to any pre-existing condition. I am voluntarily participating in these activities, and I knowingly and freely assume all risks of injury, loss or damage on account of these activities. I further agree that I am responsible for the condition and proper use of my personal exercise equipment and Livara Health is not liable for any injuries or damages related to equipment malfunctions or misuse. I understand that it is my responsibility to follow up on any issues identified in any self-assessments, including by following up with a medical provider as necessary.

I agree that I am responsible to ensure a safe and private environment for my participation in the Online Exercise and Education Program. I acknowledge that the services provided in the Online Exercise and Education Program will be provided over the internet and other electronic means, and that these online services (the “Online Services”) are subject to the disclosures and risks regarding the limitations of Online Services below.

If eligible, I consent to the Online Exercise and Education Program according to these terms.

Consent to Medically Supervised Education and Exercise Program

Depending on my clinical needs, I may be placed in an Online Exercise and Education Program track that is supervised by Medical Providers. I understand that these Medical Providers may offer medical advice and supervision as necessary to administer my customized, supervised Online Exercise and Education Program and Home Exercise Program (the “Supervised Exercise and Education Program”). If I am placed in a Supervised Exercise and Education Program, I acknowledge and agree that my day-to-day interactions in the Online Exercise and Education Program and training may be handled by non-licensed specialists engaged by Livara Health (collectively, “Coaches”), who may be athletic trainers, dieticians, mindfulness coordinators, health coaches, and other non-licensed support staff. Online Services in the Supervised Exercise and Education Program will include online chats, video calls, and virtual evaluations.

I acknowledge that the Coaches will not offer independent medical advice. I further understand that my Coach’s advice, recommendations, and/or decisions may be based on factors not within the Coach’s control, including incomplete or inaccurate information provided by me. I understand that my Coach relies on information provided by me, and that I must provide any information I have received regarding any physical limitations I may have.

I understand that the Coach will consult with a Medical Provider in the event of any medical issues. In the event of any urgent medical questions, I agree to contact a licensed medical professional rather than Livara Health or any of its Coaches. I further understand that in the event of an emergency, I should immediately call “911” and request emergency care assistance rather than contact Livara Health or any of its Coaches.

If eligible, I consent to the Supervised Exercise and Education Program according to these terms.

Consent for Online Services & Telehealth

I understand I will receive education and training through Online Services, which may involve a combination of live and pre-recorded instruction. I acknowledge that in a Supervised Exercise and Education Program or when receiving a Medical Consultation via telehealth, the Coach or Medical Provider interacting with me may not have the benefit of information that would be obtained through in-person evaluations, education, or training. Accordingly, my Coach or Medical Provider may not be fully aware of facts or other information that may affect the Coach’s opinion regarding a potential training recommendation for me or Medical Provider’s opinion regarding a potential clinical recommendation. I also understand that my Coach and/or the Medical Provider may determine in his/her sole discretion that my condition is not suitable for training using Online Services, and that I may need to seek in-person training or education from an alternative source.

I further understand that there are potential risks to the technology used for Online Services, including interruptions, unauthorized access, loss of information and delays in evaluation and training arising from technical difficulties and the potential inability of my Coach or Medical Provider to provide appropriate education and training via an online session. I understand that I can stop an online session at any time, for any reason, or stop using online sessions for fitness education and training. I understand that Livara Health can discontinue the Online Services if it is felt that the use of Online Services is not adequate for my situation. I understand that my Coach or Medical Provider may determine in his or her sole discretion that my condition is not suitable for online services, and that I may need to seek care from an alternative source.

I am also aware that in addition to my Coach or Medical Provider, other Livara Health staff members may be present during my online session. In addition, I may provide permission to record the session. I understand that I will be informed of the presence of any Livara Health staff members during the session, and will have the right to consent to their presence as part of the session. The authorized staff will at all times maintain the privacy and confidentiality of the information obtained pursuant to the online session.

Consent to Artificial Intelligence Processing

Livara Health may use artificial intelligence (“AI”) technologies to process your health information for purposes of treatment, payment, and healthcare operations. This may include AI-enabled recording and transcription during your visits with your consent to create documentation of your care, AI-powered medical scribes to assist healthcare providers in real-time documentation, AI systems for medical coding and billing processes, and other AI capabilities to analyze your health information, assist with clinical decision-making, identify patterns in your health data, and improve the quality and efficiency of your care. All AI processing of your health information is subject to the same privacy protections, security measures, and compliance requirements as other uses of your information described in this consent and in our Notice of Privacy Practices. You have the right to request that your health information not be processed using certain AI technologies, though this may impact how we deliver certain services.

Notice of Privacy Practices

I acknowledge that a copy of Livara Health’s Notice of Privacy Practices has been made available to me. Additional copies are available to me upon request.

Terms of Use

I acknowledge that a copy of Livara Health’s Terms of Use has been made available to me, and that I consent to the terms therein.

Release of Billing Information and Assignment of Insurance Benefits

Some of the services I receive may be billed to insurance. Where applicable, I request that payment of authorized insurance benefits be made on my behalf to Livara Health for any services furnished to me. I authorize any holder of medical information about me to be released to insurance companies, as well as any information necessary to pay any claim associated with my treatment.

Eligibility Guarantee

I agree that I must be eligible with my health insurance plan at the time of the appointment for insurance coverage to apply where applicable. I understand and agree that Livara Health will not take responsibility for the refusal of an insurance company to pay for training or other services due to lack of insurance benefits. If I am unable to provide any required insurance coverage at the time of the appointment, my appointment may be cancelled; if not, I will assume full financial responsibility for all charges incurred. In addition, should insurance eligibility status terminate retroactively, I will be financially responsible for any services provided that were billed to insurance.

Patient Health Plan Change

I agree to promptly inform Livara Health if my health plan changes to ensure I am not accruing additional expenses.

Common Interest

Kamshad Raiszadeh, MD holds an ownership interest in Livara Health. As a patient, I understand that I have the right to choose another program or specialist if I seek spine rehabilitation, physical therapy, or medical care. If I choose another option for training or for clinical advice, I understand that I should contact my insurance company for assistance.

Patient Acknowledgement

I acknowledge that I have been informed regarding the Online Exercise and Education Program, Supervised Exercise and Education Program, and Medical Consultation, including the possible benefits, risks, and limitations of each. I acknowledge that I have been given the opportunity to ask questions regarding the Online Exercise and Education Program and Medical Consultation, and my questions have been answered to my satisfaction. I certify that I have the legal capacity to execute this consent. I also certify that I have carefully read and consent to this Consent for Participation and Treatment. I agree that Livara Health shall not be liable for any injury, loss, or damage to personal property associated with my participation in the Online Exercise and Education Program, Supervised Exercise and Education Program, and/or Medical Consultation.

I have carefully read and acknowledged the terms and conditions stated in the Livara Health Privacy Policy at livarahealth.com/privacy-policy-2 and in the Livara Terms of Use Agreement at livarahealth.com/terms-of-use/.

I understand that I may withdraw my consent to training and/or treatment at any time, except to the extent that Livara Health has already acted based on my consent, by providing Livara Health with written notice at support@livarahealth.com. Unless revoked earlier, this consent will remain valid for the duration of one (1) year (or shorter period if required by applicable state law), and will expire one (1) year from the date of my acknowledgement.

Notice of Privacy Practices

Livara Health Medical Group, P.C. (“Livara Health”) is dedicated to maintaining the privacy of your protected health information (“PHI”) consistent with the Health Insurance Portability and Accountability Act (“HIPAA”) and other applicable privacy laws. As part of our commitment to your privacy, we have established policies to ensure that your PHI is handled properly and in accordance with federal and state laws.

Uses and Disclosures of Protected Health Information

Your PHI may be used and disclosed for treatment, payment, healthcare operations, and other purposes permitted or required by law. Your PHI may be shared with our partners or “Business Associates” for these uses and disclosures. Not every use or disclosure will be listed; however, all of the ways we are permitted to use and disclose information will fall into one of the categories below:

  • Treatment: We will use and disclose your PHI to provide, coordinate, or manage your healthcare and any related services. This includes coordination or management of your healthcare with Livara and other third parties, consultations between healthcare providers, or referrals to other providers for treatment.
  • Payment: Your PHI may be used, as needed, to obtain payment for the services we provide.
  • Healthcare Operations: We may use or disclose your PHI in order to support the business activities of our practice. These activities include, but are not limited to, quality assessment, employee review, training, licensing, quality improvement, and conducting or arranging for other business activities.
  • AI Processing and Technology: We may use artificial intelligence (“AI”) technologies to process your PHI for purposes of treatment, payment, and healthcare operations stated above. This may include AI recording and transcription during scheduling and during your visits with your consent to create documentation of your care, perform medical coding and billing processes, analyze your health information, assist with clinical decision-making, identify patterns in your health data, and improve the quality and efficiency of your care. All AI processing of your PHI is subject to the same privacy protections, security measures, and compliance requirements as other uses and disclosures of your information described in this notice.
  • Other Legal Purposes: We may also need to disclose your PHI for other recognized legal purposes including, without limitation, providing help with public health and safety issues, doing research, responding to legal actions, and complying with the law.

Your Rights

You have the following rights regarding the PHI we maintain about you:

  • Right to Inspect and Copy: You have the right to inspect and copy PHI that may be used to make decisions about your care. This includes medical and billing records.
  • Right to Amend: If you feel that the PHI we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for our practice.
  • Right to an Accounting of Disclosures: You have the right to request an accounting of certain disclosures we have made of your PHI. This right applies to disclosures for purposes other than treatment, payment, or healthcare operations as described in this Notice of Privacy Practices.
  • Right to Request Restrictions: You have the right to request a restriction or limitation on the PHI we use or disclose for treatment, payment, or healthcare operations. You also have the right to request a limit on the PHI we disclose about you to someone who is involved in your care or the payment for your care.
  • Right to Request Confidential Communications: You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at a certain phone number or that we do not send texts or leave voicemails.
  • Right to a Paper Copy of This Notice: You are entitled to receive a paper copy of our Notice of Privacy Practices. You may ask us to give you a copy of this notice at any time.
  • Right to Be Notified of a Breach: You have the right to be notified in the event that we (or one of our Business Associates) discover a breach of unsecured PHI.
  • Right to Decline or Opt Out of Recording: You have the right to request that your visit and other oral communications not be recorded.
  • Right to Opt Out of AI Processing: You have the right to request that your PHI not be processed using certain AI technologies. Please note that opting out of AI processing may impact how we deliver certain services.

Additional State Privacy Rights

In addition to your rights under HIPAA, you may have additional rights under state law regarding your medical information.

Telehealth Specific Provisions

For services provided via telehealth, we apply the same privacy practices as for in-person visits. Your PHI may be used or disclosed in accordance with federal and state laws applicable to telehealth services.

Consent for Electronic Communications & Voicemails

You consent to receive appointment reminders and other healthcare communications via text message, email, and/or voicemail. You acknowledge that certain electronic communications may not be encrypted and could potentially be intercepted, altered, forwarded, or read by others, accessed through unsecured networks, or sent to the wrong recipient. You understand that electronic communications and voicemails to Livara Health are not monitored outside of normal business hours and that messages containing your health information may become part of your medical record. Despite these risks, you consent to receive electronic communications and voicemails from Livara Health. By consenting to electronic communications and voicemails, you agree to hold Livara Health harmless for any unauthorized access, use, or disclosure of your protected health information sent via these methods.

You agree to provide accurate contact information, including your mobile phone number and email address, to facilitate these communications. You may opt-out of receiving appointment reminders and other healthcare communications at any time by contacting our office or following opt-out instructions in the messages. Standard text messaging rates may apply based on your mobile carrier’s plan.

Complaints

If you believe your privacy rights have been violated, please let us know by contacting legal@livarahealth.com. You may also file a complaint with us or with the Secretary of the Department of Health and Human Services.

Contact Information

For further information about the matters covered by this notice, please contact our Privacy Department at legal@livarahealth.com.

Changes to This Notice

We reserve the right to change the terms of this notice and will inform you of any changes.