Ultimate Body Weight Medical Consent

WE ARE NOT A REPLACEMENT FOR EMERGENCY MEDICAL SERVICES. IF YOU HAVE A MEDICAL EMERGENCY SEEK EMERGENCY MEDICAL CARE IMMEDIATELY IN-PERSON OR DIAL 911 OR YOUR LOCAL EMERGENCY NUMBER.

We may change these terms at any time, as required by law. This may include changing, adding, or removing terms. We may do this in response to legal, business, competitive environment or other reasons not listed here.

Telehealth Consent

Telehealth is the type of care that allows clients to access behavioral health services using audio-video interface such as videoconferencing.

Electronic systems used will incorporate network and software security protocols to protect the confidentiality of client identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

Expected Benefits:

• Improved access to behavioral health care by enabling a client to receive services across distances and between programs.
• More efficient behavioral health care including psychiatric evaluation and management.
• Obtaining expertise of a distant specialist.
• Maintaining connections with established providers in other areas.

Possible Risks:

As with any medical procedure, there are potential risks associated with the use of telehealth for behavioral health treatment. These risks include, but may not be limited to:

• In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision making by the physician or other clinical staff.
• Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment.
• In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information.
• In rare cases, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgmental errors.

By consenting to these forms, I understand the following:

1. I understand that the laws that protect privacy and the confidentiality of medical information also apply to telehealth, and that no information obtained in the use of telehealth which identifies me will be disclosed to researchers or other entities without my consent.
2. I understand that I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time, without affecting my right to future care or treatment.
3. I understand that I have the right to inspect all information obtained and documented in the course of a telehealth interaction, and may receive copies of this information for a reasonable fee.
4. I understand that a variety of alternative methods of behavioral health care may be available to me, and that I may choose one or more of these at any time.
5. I understand that it is in my best interest to inform my psychiatrist or other clinical staff of any other healthcare providers involved in my medical/psychiatric care.
6. I understand that I may expect the anticipated benefits from the use of telehealth in my care, but that no results can be guaranteed or assured.

Client Consent to the Use of Tele-health

I have read and understand the information provided above regarding telehealth, have discussed it with my psychiatrist or other clinical staff as may be designated, and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of telehealth in my behavioral health care. I have been offered a copy of this form for my personal records.

My continued use of the services constitutes my understanding and acceptance of the above terms and I hereby authorize the use tele-health in the course of my diagnosis and treatment.

HIPAA Consent

The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. Implementation of HIPAA requirements officially began on April 14, 2003. This form is a “friendly” version. A more complete text is available in the office and online.

What this is all about: Specifically, there are rules and restrictions on who may see or be notified of your Protected Health Information (PHI). These restrictions do not include the normal interchange of information necessary to provide you with office services. HIPAA provides certain rights and protections to you as the patient. We balance these needs with our goal of providing you with quality professional service and care. Additional information is available from the U.S. Department of Health and Human Services. www.hhs.gov

We have adopted the following policies: 

1. Patient information will be kept confidential except as is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately. This specifically includes the sharing of information with other healthcare providers, laboratories, health insurance payers as is necessary and appropriate for your care. Patient files may be stored in open file racks and will not contain any coding which identifies a patient’s condition or information which is not already a matter of public record. The normal course of providing care means that such records may be left, at least temporarily, in administrative areas such as the reception office, examination room, etc. Those records will not be available to persons other than office staff and third-party providers. You agree to the normal procedures utilized within the office for the handling of charts, patient records, PHI and other documents or information.
2. It is the policy of this office to remind patients of their appointments. We may do this by telephone, e-mail, U.S mail, or by any means convenient for the practice and/or as requested by you. We may send you other communications informing you of policy or procedure changes that you might find valuable or informative.
3. The practice utilizes a number of vendors in the conduct of business. These vendors may have access to PHI but must agree to abide by the confidentiality rules of HIPAA.
4. You understand and agree to inspections of the office and review of documents which may include PHI by government agencies or insurance payers in normal performance of their duties.
5. You agree to bring any concerns or complaints regarding privacy to the attention of the office manager or the doctor.
6. Your confidential information will not be used for the purposes of marketing or advertising of products, goods or services.
7. We agree to provide patients with access to their records in accordance with state and federal laws.
8. We may change, add, delete or modify any of these provisions to better serve the needs of the both the practice and the patient.
9. You have the right to request restrictions in the use of your protected health information and to request change in certain policies used within the office concerning your PHI. However, we are not obligated to alter internal policies to conform to your request.

My continued use of the services constitutes my understanding and acceptance of the above terms set forth in the HIPAA INFORMATION FORM and any subsequent changes in office policy. I understand that this consent shall remain in force from this time forward.

Financial Consent

I understand and accept the terms in order to render services that a credit card must be kept on file and that any remaining balances for services rendered shall be paid in full. I authorize Ultimate Body Weight, to submit on my behalf and the release of any medical records or other information necessary to process my consultation order. Fee schedules and receipts for all professional services are available upon request.

I authorize Ultimate Body Weight, to make invoice changes and debit my account for orders placed, goods received, and/or services rendered not fully covered by third party vouchers or credits. I authorize Ultimate Body Weight, to charge my credit card account upon any unpaid balances due. All programs are auto-renewing and I consent to be automatically charged for any program I am a part of unless I explicitly request to cancel before my payment is processed. There are no refunds or exchanges. I certify that I am an authorized user of this credit card and that I will not dispute the payments with my credit card company.

Shipping Authorization

All prescription medications provided by Ultimate Body Weight are provided by a licensed and accredited pharmacy according to state and federal law with the approval of the pharmacist in charge and in compliance with all laws applicable from the relevant Medical Boards and State Boards of Pharmacy. The customer requesting shipping disclaims and agrees to holds harmless Ultimate Body Weight for any delays or errors during the shipping process. Medication is considered dispensed and the order completed when it is signed out for shipping, not when it arrives via delivery.

My continued use of the services constitutes my understanding and acceptance of the above terms and I give permission for Ultimate Body Weight to ship medication to me at the address provided in my intake form or any other address given by me to the company, and agree to all of the conditions listed above.