Medical Consent

Telehealth Consent

Telehealth is a type of care that allows clients to access health services using audio-video interfaces 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 safeguards to maintain data integrity against intentional or unintentional corruption.

Expected Benefits

• Improved access to healthcare by enabling a client to receive services across distances and between programs.
• More efficient medical evaluation and management.
• Obtaining expertise from distant specialists when needed.
• 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. These risks may include, but are not limited to:

• In rare cases, information transmitted may not be sufficient to allow for appropriate medical decision-making.
• Delays in medical evaluation and treatment could occur due to equipment deficiencies or failures.
• In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information.
• In rare cases, lack of access to complete medical records may result in adverse drug interactions, allergic reactions, or other judgment errors.

By consenting to these forms, I understand the following:

• The laws that protect privacy and confidentiality of medical information also apply to telehealth.
• I have the right to withhold or withdraw consent to telehealth at any time, without affecting my right to future care or treatment.
• I have the right to inspect information obtained and documented during telehealth interactions and may receive copies for a reasonable fee where applicable.
• A variety of alternative methods of healthcare may be available, and I may choose one or more of those methods at any time.
• It is in my best interest to inform my physician or clinical staff of any other healthcare providers involved in my medical care.
• No results can be guaranteed or assured from the use of telehealth in my care.

Client Consent to the Use of Telehealth

I have read and understand the information provided above regarding telehealth, have discussed it with my physician or clinical staff as 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 healthcare. I understand that my continued use of the services constitutes my understanding and acceptance of these terms and authorizes the use of telehealth in the course of my diagnosis and treatment.

HIPAA Consent

The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. This page provides a simplified version of those protections. More complete information may be available through the office.

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 exchange of information necessary to provide services to you. HIPAA provides certain rights and protections to you as the patient, and we balance those rights with our goal of providing quality care and service.

We have adopted the following policies:

• Patient information will be kept confidential except as necessary to provide services or handle administrative matters related to care.
• Information may be shared with other healthcare providers, laboratories, or health insurance payers as necessary and appropriate for your care.
• Appointment reminders and service communications may be sent by phone, email, U.S. mail, or other convenient methods.
• We may use vendors in the conduct of business, and those vendors may have access to PHI but must agree to follow applicable confidentiality obligations.
• Government agencies or insurance payers may inspect office documents or records containing PHI during the normal performance of their duties.
• Your confidential information will not be used for marketing or advertising products, goods, or services.
• Patients will be provided access to records in accordance with applicable state and federal law.
• We may change, add, delete, or modify these provisions to better serve the needs of both the practice and the patient.
• You may request restrictions on the use of your PHI, though we are not always required to alter internal policies to match every request.

My continued use of the services constitutes my understanding and acceptance of the above HIPAA-related terms and any subsequent changes in office policy. I understand that this consent remains in force going forward.

Financial Consent

I understand and accept that, in order to render services, a credit card may be kept on file and any remaining balances for services rendered shall be paid in full.

I authorize Vitara, LLC to process charges on my behalf and to use or release medical records or other information necessary to process my consultation order when appropriate. Fee schedules and receipts for professional services are available upon request.

I authorize Vitara, LLC to make invoice adjustments and debit my account for orders placed, goods received, or services rendered that are not fully covered by third-party vouchers or credits.

I authorize Vitara, LLC to charge my credit card account for any unpaid balances due.

All programs are auto-renewing, and I consent to be automatically charged for any program in which I participate unless I explicitly request cancellation before payment is processed. There are no refunds or exchanges unless otherwise stated. I certify that I am an authorized user of the credit card provided and that I will not dispute valid charges with my credit card company.

Shipping Authorization

All prescription medications are dispensed according to applicable state and federal law with the approval of the pharmacist in charge and in compliance with relevant medical and pharmacy board requirements.

The customer requesting shipping disclaims and agrees to hold harmless Vitara, LLC for 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 Vitara, LLC to ship medication to me at the address provided in my intake form or any other address I provide to the company, subject to the conditions listed above.