Patient Resources

I understand that my health care provider wishes me to engage in a telehealth consultation.

My health care provider explained to me how the video conferencing technology that will be used to affect such a consultation will not be the same as a direct client/health care provider visit due to the fact that I will not be in the same room as my provider.

I understand that a telehealth consultation has potential benefits including easier access to care and the convenience of meeting from a location of my choosing.

I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my health care provider or I can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.

I understand that a telehealth consultation by nature cannot capture a patient's full clinical picture in every scenario. For example, there are physical findings that cannot be assessed (e.g., prostate exam). As such, some clinical conditions cannot be fully assessed.

I have had a direct conversation with my provider, during which I had the opportunity to ask questions in regard to this procedure. My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language in which I understand.

By acknowledging this form, I certify:

• — That I have read or had this form read and/or had this form explained to me.
• — That I fully understand its contents including the risks and benefits of the procedure(s).
• — That I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.
• — That I am physically located in Illinois at the time of this consultation.

Introduction

At Expert Urology Consulting, I am committed to providing you with the best possible care. To help me manage my practice efficiently and enhance my services, I use technology, including certain artificial intelligence (AI) tools. This document explains how I use these tools and asks for your consent to use them as part of your treatment. Your privacy, confidentiality, and the quality of your treatment remain my highest priorities.

How I Use AI Tools

AI tools are used strictly for administrative and supplementary support tasks under my direct supervision. These tools do not provide medical care, make independent clinical decisions, or interact with you directly. The specific purposes for which I may use AI now and in the future include:

• — Assisting in drafting and organizing session notes
• — Managing appointment scheduling and/or sending reminders
• — Processing billing and insurance claims
• — Analyzing data to identify treatment trends and track progress, which is always reviewed by me
• — Analyzing business information and generating reports or trends to help me manage my business
• — Helping to identify and organize external resources or referrals for your use

How I DO NOT Use AI Tools

To be clear, I do not use AI to:

• — Make independent medical decisions or diagnoses
• — Communicate with you directly to provide medical advice
• — Generate treatment recommendations without my direct review, approval, and input
• — Detect or interpret your emotions or mental state

Consent for Session Transcription

All sessions will be recorded and transcribed using AI technology to ensure accurate documentation of your care. The AI transcription tool will be used for all appointments to assist with note-taking and maintain comprehensive medical records.

Your Rights and Confidentiality

Confidentiality:

All information, including any data processed by an AI tool, is treated as part of your confidential health record and is protected by the same privacy and security standards as all other aspects of your care, including HIPAA.

• — SimplePractice and its Note Taker tool are HIPAA-compliant and HITRUST certified.
• — All audio-recordings of sessions through Note Taker are immediately deleted as soon as a transcript is created, generally within minutes of a session ending.
• — Transcripts that are created through Note Taker are only retained for the shorter of 7 days or when the progress note is signed and locked. After that, they are permanently deleted.
• — During the time that transcripts are available in Note Taker, they always remain confidential and secure, and are only available for my use to verify the accuracy of the progress note. They are not used for any other purpose.

Right to Revoke Consent:

Your consent is voluntary. You have the right to withdraw this consent at any time by notifying me in writing. Revoking your consent will not affect your ability to receive medical services.

Patient Acknowledgment and Consent

By signing, you confirm that:

• — You have read and understood this form.
• — You have had the opportunity to ask questions about the use of AI tools in your treatment.
• — You voluntarily agree to the use of AI tools for the purposes described above.

Appointments and Cancellations

Please remember to cancel or reschedule 24 hours in advance. You will be responsible for the entire fee if you need to cancel or reschedule within 24 hours. If Dr. Wille needs to reschedule your appointment at any time, you will not be charged. If your appointment needs to be canceled because of our office's doing, you will receive a full refund. If you are late for a session, you may lose some of that session time. The standard meeting time for new patient appointments is 30 minutes. The standard meeting time for follow-up patient appointments is 15 minutes.

A $35 service charge will be charged for any checks returned for any reason for special handling.

Telephone Accessibility

If you need to contact me by phone, please call the office. You may leave a message on that voicemail. EUC does not employ any other staff to answer the phone. I am often not immediately available; however, I will attempt to return your call within 24 hours. If a true emergency situation arises, please call 911 or any local emergency room.

Electronic Communication

As a patient of Expert Urology Consulting, you will have access to the patient portal. Electronic communication is preferred and has a much faster return speed. It is through this portal that we can message securely. I cannot ensure the confidentiality of any form of communication through other electronic media like including text messages. If you prefer to communicate via email for issues regarding scheduling or cancellations, I will do so. Please allow 1 business day for a response to electronic communication, although response time is often much faster. While I may try to return messages in a timely manner, I cannot guarantee immediate response. This method should not be used to communicate in an emergency. Services by electronic means, including but not limited to telephone communication, the Internet, facsimile machines, and e-mail is considered telemedicine. If you and your physician chose to use information technology for your treatment, you need to understand that:

• — You retain the option to withhold or withdraw consent at any time without affecting the right to future care or treatment or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled.
• — All existing confidentiality protections are equally applicable.
• — Your access to all medical information transmitted during a telemedicine consultation is guaranteed, and copies of this information are available for a reasonable fee.
• — Dissemination of any of your identifiable images or information from the telemedicine interaction to researchers or other entities shall not occur without your consent.
• — There are potential risks, consequences, and benefits of telemedicine. Potential benefits include, but are not limited to improved communication capabilities, providing convenient access to up-to-date information, consultations, support, reduced costs, improved quality, change in the conditions of practice, improved access to treatment, better continuity of care, and reduction of lost work time and travel costs. Effective treatment is often facilitated when the healthcare provider gathers within a session or a series of sessions, a multitude of observations, information, and experiences about the client. The provider may make assessments, diagnosis, and interventions based not only on direct verbal or auditory communications, written reports, and third person consultations, but also from direct visual and olfactory observations, information, and experiences. When using information technology in services, potential risks include, but are not limited to the provider's inability to make visual and olfactory observations of clinically or therapeutically potentially relevant issues such as: your physical condition including deformities, apparent height and weight, body type, gait and motor coordination, posture, any noteworthy mannerism or gestures, physical or medical conditions including bruises or injuries, basic grooming and hygiene including appropriateness of dress, eye contact (including any changes in the previously listed issues), sex, chronological and apparent age, ethnicity, facial and body language, and congruence of language and facial or bodily expression. Potential consequences thus include the provider not being aware of what they would consider important information, that you may not recognize as significant to present verbally to the provider.
• — You must be located in the State of Illinois at the time of your appointment.

Treatment Decision Making and Laboratory Review

Treatment decision making and laboratory review cannot be done over the portal. Please schedule an appointment with Dr. Wille to review any laboratory results or to discuss treatment decision-making.

Minors

If you are a minor, your parents may be legally entitled to some information about your treatment. I will discuss with you and your parents what information is appropriate for them to receive and which issues are more appropriately kept confidential.

Termination

Ending relationships can be difficult. Therefore, it is important to have a termination process in order to achieve some closure. The appropriate length of the termination depends on the length and intensity of the treatment. I may terminate treatment after appropriate discussion with you and a termination process if I determine that the treatment is not being effectively used or if you are in default on payment. I will not terminate the therapeutic relationship without first discussing and exploring the reasons and purpose of terminating. If treatment is terminated for any reason or you request another provider, I will provide you with a list of qualified Urologists to treat you. You may also choose someone on your own or from another referral source. Should you fail to schedule an appointment for three consecutive weeks, unless other arrangements have been made in advance, for legal and ethical reasons, I must consider the professional relationship discontinued.

No In-Person Modalities

This practice does not service any in-person clinic, hospital, or emergency room. Should you need this type of care, EXPERT UROLOGY CONSULTING will not be able to manage your clinical needs and you will need to be under the care of the providers who are credentialed and staff those entities.

Financial and Insurance Billing Policy

1. Direct Pay Patients

• — Payment is required in full at the time of booking in order to confirm your appointment.
• — If Dr. Wille needs to reschedule your appointment, you will not be charged.
• — If your appointment is canceled by our office, you will receive a full refund.
• — If you arrive late to your session, you may receive less session time as a result.
• — A $35 service charge will be applied to any returned checks requiring special handling.

2. Insurance Coverage

You are responsible for knowing the details of your insurance plan, including:

• — Whether our services are covered
• — If a referral is required
• — What your copay, deductible, or coinsurance obligations may be.

3. No-Show and Late Cancellation Fees

• — We require at least 24 hours' notice to cancel or reschedule your appointment.
• — Missed appointments or late cancellations will be charged the full visit fee, which is not covered by insurance.

4. Card on File Policy

• — A valid credit or debit card is required to be kept on file.
• — Your card may be charged for copays, deductibles, coinsurance, no-show fees, or any outstanding balance after insurance processing.