GENERAL CONSENT AND POLICIES

 
INFORMED CONSENT TO TREAT
 
I hereby give my consent for Health Refined (henceforth referred to as "the practice") to treat me for my presenting complaint. 
I understand and I am informed that, as with all healthcare treatments, results are not guaranteed and there is no promise of cure. 
I have had the opportunity to discuss with my provider the nature and purpose of treatments and procedures. I am aware that all existing methods of diagnosis and treatment pose some level of risk. 

I do not expect the provider to be able to anticipate and explain all risks and complications, and I wish to rely on the provider to exercise judgment during the course of the treatment which the provider feels at the time, based upon the facts then known, is in my best interests.
 
I will immediately inform the provider if I experience any gastrointestinal upset (nausea, gas, stomac hache, vomiting or similar condition), allergic reactions (hives, rashes, tingling of the tongue, headache or similar condition), or any unanticipated or unpleasant effects associated with treatment or supplements prescribed/recommended. I understand that if an emergency medical condition arises, I am expected to call 9-1-1.
 Practice and Patient Relationship
We love having you as a patient, but we do reserve the right to refuse service at any time, to anyone and for any reason


LABORATORY TESTS
 
I understand that Dr. Marianne Go-Wheeler or any other medical provider at Health Refined  (henceforth referred to as "the practitioner") / the practice may recommend blood, saliva, stool, urine, hair, or skin testing within their scope of practice. In addition to conventional testing,  specific tests may be ordered through specialized laboratories to assess structural and/or functional deficiencies, and may not always be diagnostic, but can provide critical information to help improve my health outcomes. I agree with the use of such tests and will always have the opportunity to discuss their applicability and limitations with my provider, prior to sample collection. I agree to pay the laboratory any fees due for sample collection and processing.

TELEHEALTH CONSENT
 
I consent to voluntarily engaging in a telemedicine consultation with the practice. I understand that the video conferencing technology will not be the same as a direct patient/health care provider visit:
Telehealth consultation has potential benefits, including easier access to care, decreasing costs, and allowing visits to be performed from the comfort of my home. It also has potential risks including interruptions, unauthorized access, and technical difficulties. 

I understand that my healthcare provider or I can discontinue the telehealth consult/visit if it is felt that the video conferencing connections are not adequate for the situation.
 
If there is another individual present during the telehealth consultation, I will be informed of their presence and I will also disclose if there is another individual with myself. It is agreed that these individuals will maintain confidentiality of the information obtained. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history/physical examination that are personally sensitive to me; (2) ask non-medical personnel to leave the telemedicine examination room: and or (3) terminate the consultation at any time.
  
I understand that telemedicine has limitations in regard to the physical examination. I understand that the physical exam portion of the care provided through the practice will be limited to inspection via video conferencing and some parts of the exam such as physical tests, examination of certain body parts, and vital signs may be conducted by individuals at my location at the direction of the consulting health care provider or not done at all.
 
Telemedicine services offered through the practice are not an Emergency Service and in the event of an emergency or urgent medical issue, I will use a phone to call 911, go to the emergency department, or go to an urgent care.
 
To maintain my privacy, I will not share telemedicine login information or video conferencing links with anyone unauthorized to attend the appointment.

TELEPHONE CONSULTATION CONSENT
 
I understand that the practitioner / the practice may allow telephone consultations - verbal conversation only / no video.  I understand that these consultations have considerable limitations, including but not limited to no physical exam or visual assessment. I understand that my provider, during the telephone consultation, may determine that adequate care and treatment will not be possible with the limited assessment via telephone consultation. I agree to follow through with them on any required in-person office visits or video telehealth visits. I consent to receive instructions via phone/telemedicine platform and take full responsibility to follow through with specific instructions as required for my treatment. I have had the opportunity to discuss the limitations with my provider.
  
EMAIL USE CONSENT
 
The preferred method of communication is via HIPAA-compliant Patient Portal. However, the practitioner / the practice provides patients with the opportunity to communicate by email. Transmitting confidential health information by email, however, has a number of risks: E-mail can be immediately broadcast worldwide and be received by many intended and unintended recipients; recipients can forward e-mail messages to other recipients without the original sender(s) permission or knowledge; users can easily copy information.
 
It is the policy of the practitioner / practice that all e-mail messages sent or received which concern the diagnosis or treatment of a patient will be a part of the patient’s protected personal health information. The practice cannot guarantee the security and confidentiality of e-mail or internet communication.
 
Patients may consent to the use of email for confidential medical information after having been informed of the above risks with the following conditions: All e-mails to or from patients concerning diagnosis and/or treatment will be made part of the protected personal health information. As a part of the protected personal health information, other individuals, insurance coordinators and, upon written authorization, other healthcare providers and insurers will have access to e-mail messages contained in protected personal health information.
 
The practitioner / practice will endeavor to read e-mail promptly. However, the practice can provide no assurance that the email will be read immediately. Therefore, e-mail must never be used in a medical emergency.
 
Because some medical information is so sensitive that unauthorized disclosure can be damaging, e-mail should not be used for communications concerning diagnosis or treatment of any sexually transmittable or communicable diseases such as syphilis, gonorrhea, and the like; behavioral health, mental health; or alcohol and drug abuse.
 
The practitioner / practice cannot guarantee that electronic communications will be private. The practitioner / practice is not liable for improper disclosure of confidential information not caused by its employee’s gross negligence or wanton misconduct and is not liable for breaches of confidentiality caused by the patient.

I understand that my consent to the use of e-mail may be withdrawn at any time, whether it be by e-mail or written communication to the practitioner / practice. I have read this form carefully and understand the risks and responsibility associated with the use of e-mail. I agree to assume all risks associated with the use of e-mail

APPOINTMENT REMINDERS CONSENT
 
The practitioner / practice may need to use my name, address, phone number, and my clinical records to contact me with appointment reminders/text message, information about treatment alternatives or other health related information that may be of interest to me. If this contact is made by phone and I am not available, a message will be left on my answering machine or with the person answering the phone.
 
By signing this form, I am giving the practice the authorization to contact me with these reminders and information and to leave a message on my answering machine or with individuals at my home or place of employment.

Electronic Communication

E-mail and text communication provides for a fast and easy way to communicate with your healthcare provider for those issues that are non-emergent, non-urgent or non-critical. It is not a replacement for the interpersonal contact that is the very basis of the patient-healthcare provider relationship; rather it can support and strengthen an already established relationship.
The following summarizes the information you need to determine whether you wish to supplement your healthcare experience at our practice by electronically communicating with staff members.

General Considerations

  • E-mail communication will be considered and treated with the same degree of privacy and confidentiality as written medical records.

  • Standard e-mail services, such as Gmail, AOL, Yahoo, and Hotmail are not secure. This means that the e-mail messages are not encrypted and can be intercepted and read by unauthorized individuals.

  • Transmitting e-mail that contains protected health information through an e-mail system that is not encrypted does not meet the security guidelines as required by the Health Information Protection and Accountability Act (HIPAA).

  • Your E-mail address will not be used for external marketing purposes without your permission. You may receive a group mailing from the practice, however, the recipients e-mail addresses will be hidden.

Provider Responsibilities

  • The Provider will attempt to electronically confirm your e-mail address by requesting a return response to all email messages.

  • Your provider may route your e-mail messages to other members of the staff for informational purposes or for expediting a response. This will be done through our secure portal to protect your information. 

  • Designated staff may receive and read your e-mail.

  • The provider will make every attempt to respond to your email message within 1 business days. If you do not receive a response from the provider within 1 business days, please contact the office at (951)-290- 8810

  • Copies of e-mails sent and received from and to you will be incorporated into your medical record. You are advised to retain all electronic correspondence for your own files.

Patient Responsibilities

  • E-mail messages should not be used for emergencies or time sensitive situations. In event of a medical emergency, you should contact 911. For emergent or time sensitive situations, you should contact your healthcare provider through the office at (951)-290- 8810.

  • E-mail messages should be concise. Please arrange for an office appointment if the issue is too complex or sensitive to discuss via e-mail. Additionally, the provider may request you schedule an appointment based on the contents of your email and the specific concern you have. 

  • Please key in your full name and the topic, i.e., medication question, in the subject line. This will serve to identify you as the sender of the e-mail.

  • Please acknowledge that you received and read the provider’s message by return e-mail to the provider

 CONSENT AND AUTHORIZATION FOR ELECTRONIC COMMUNICATION (E-MAIL AND TEXT)

I have read and understood the above description of the risks and responsibilities associated with electronic communication with my healthcare provider.

I acknowledge that commonly used e-mail and cell phone services are not secure and fall outside of the security requirements set forth by the Health Insurance Portability and Accountability Act for the transmission of protected health information.

I have been given the opportunity to discuss electronic communication with my healthcare provider and have had all my questions answered.

In consideration of my desire to use electronic communication as supplement to in-person office visits with my provider, I hereby consent to electronic communication via non-secure e-mail services.
I understand that I may revoke my consent to communicate electronically at any time by notifying HEALTH REFINED in writing, but if I do, the revocation will not have any effect on actions my healthcare provider has already taken in reliance on my consent.

I agree to release my provider and the practice from any and all liability that may occur due to electronic communication over a non-secure network.

I further agree to be held accountable for the patient responsibilities as outlined above.

By signing this consent, I am acknowledging that I have read this consent in it's entirety and agree to receiving electronic communication via e-mail and/or text.
 .
 

FINANCIAL POLICIES 

FEES AND PAYMENTS:
The practice does NOT file for insurance reimbursement. All services are paid for by the patient at the time of service. You may pay cash, credit card, HSA card, or Flexible Spending Card. We will provide you with a superbill with all the necessary codes, so that you may file for reimbursement with your insurance company if needed.
  
 All outstanding balances must be paid in full prior to the next office visit or receiving supplements.

Cancellation, Rescheduling, and No Shows:
When an appointment is scheduled, that time is specifically allocated to you. We understand changes may be necessary, so we kindly request a 48-hour notice for any cancellations or appointment rescheduling. Cancellation or rescheduling requests need to be made Monday to Friday between 9am to 5pm. 
 Failure to provide adequate notice will result in a cancellation fee equivalent to 50% of the visit cost or a $50 late cancellation fee depending on which option is more. No shows will be charged the full cost of the visit and will be required to prepay for all future visits. . If the visit was part of a bundle, the bundle will be applied to the missed visit. 

Refund and Non-refundable Deposit
All payment for services are final; we do not offer refunds or credits on service rendered. Due to increasing no show appointments, most of our service appointments require a deposit, this is non-refundable, and only applies to the service originally booked and is non-transferrable if the appointment is altered with less than  48 hour notice. All sales are final. 

Changes to the Financial Policy:
Health Refined reserves the right to update this financial policy at any time. Clients
will not always be notified of any changes; however, the updated policy will be made available at our establishment.

Packages, Discounts and Promotions:
Periodically, Health Refined may offer discounts and promotions. These are subject to specific terms and conditions and cannot be combined with other offers unless stated
otherwise. All packages must be paid in full at the time of the first service.

Gift Cards
Health Refined offers gift cards for purchase, which can be used for any of our
services. Gift cards have no expiration date and are non-refundable.

PHONE CALLS - Phone calls requiring 10 minutes or more of the provider's time will be charged as a minimum visit ($50/15 minutes).
 
RETURNED CHECK- There is a $20.00 fee for any check returned by the bank.
  
PAST DUE ACCOUNTS- If your account becomes past due, we will take necessary steps to collect this debt. At the time of your initial office visit, a copy of your credit card will be taken. If your account becomes past due over 15 days, that credit card will be charged. If the credit card declines or there are any other problems, your account will be referred to our collection agency. You will be charged for this service in addition to your current account balance. If payment is not received, your credit report will be blemished. If we have to refer the collection of the balance to a lawyer, you agree to pay all of the lawyer's fees which we incur, plus all court costs.
  
COPIES - The cost for copies of lab work, chart notes, imaging, and invoices will be 50 cents per page, EXCEPT if requested at the time of the visit. Lab work, chart notes, imaging, and invoices pertinent to the visit will be provided free of charge on the day of the visit. Most documents will also be available to you for free  on the patient portal.
 
SPECIAL LETTERS, FORMS, and DOCUMENTS - Completing special insurance forms, workplace documentation, writing letters of medical necessity, etc. require significant provider time and will be charged an administrative fee of $25 per document/letter. Fees must be paid in advance. Some documentation may require extensive time / complexity and may justify a higher fee. If so, this fee will be disclosed to you prior to preparing the documents. 

CREDIT CARD AUTHORIZATION

Health Refined  has implemented a credit card on file policy. We kindly request our patients’ guardian/guarantor for a credit card which may be used later to pay any balance that may be due on your bill. I authorize the practice to process the credit card on file for any balance due on my account past 15 days and for any payments authorized by me.
  You may call our office if you have a question about your balance. We will send you a receipt for the charge. This “Card-on-File” program simplifies payment for you and eases the administrative burden on your provider’s office. It reduces paperwork and ultimately helps lower the cost of healthcare. This in no way compromises your ability to dispute a charge. If you have any questions about the card-on-file payment method, please do not hesitate to let us know. By signing below, I authorize Health Refined to keep my signature and my credit card information securely on-file in my account. I authorize Health Refined to charge my credit card for any outstanding balances when due. I understand that a receipt showing what was paid for will be sent to me within 30 days if my card on file is charged and I know that I am responsible for letting the clinic know if anything has changed concerning my credit card information.

 SUPPLEMENT DISCLAIMER

 
Many supplements, vitamins, medical grade foods, nutritional powders, botanicals, and homeopathic remedies have not been evaluated by the US Food & Drug Administration (FDA) and these products are not intended to diagnose, treat, cure, or prevent any disease. 
 
NO REFUNDS, CREDITS, OR EXCHANGES are allowed on any supplement(s), herbs, homeopathic remedy/remedies, vitamins, and nutritional supplements. Once these items have been purchased or left the office, they cannot be brought back under any circumstance.  
  
All services and supplementation must be PAID IN FULL at the time of service. A remaining balance is not allowed.

  • Supplements will not be held, picked up or shipped without prior payment.

  • Special orders need to be paid for at the time of order. Once paid for, there will be no credits, refunds, exchanges, or modifications allowed. 

Supplements may be bought directly from our trusted online dispensary (FullScript) or you can choose to purchase them at a dispensary of your choice. The cost of supplements is not included in the visit fee. 
 
Please inform the practitioner if you are vegetarian and require vegetarian supplementation. Remember, there are NO refunds, exchanges or credits given. All sales are FINAL.

PATIENT CONSENT & ACKNOWLEDGMENT

Health Refined provides specialized, service-specific medical care and does not function as a primary care provider. Our services are designed to address specific concerns such as aesthetics Weight loss and wellness treatments, and we do not offer comprehensive medical management, routine screenings, or urgent care services.

Primary Care Provider Requirement:

By signing this form, you acknowledge and agree to the following:

  1. You must have a designated primary care physician (PCP) for general healthcare, routine medical evaluations, and any urgent or chronic medical conditions.

  2. Health Refined does not replace your primary care provider and does not manage general health concerns, chronic illnesses, or emergency medical needs.

  3. If a medical issue arises beyond the scope of our specialized services, you will be directed to follow up with your primary care provider.

  4. It is your responsibility to maintain regular care with a primary care physician for your overall health and wellness.


PRIVACY POLICY / HIPPA COMPLIANCE

We are required by law to make the following information available to you.  We have paper copies in the office if you need another copy. 
Notice of Privacy Practices

 As Required by the Privacy Regulations Promulgated Pursuant to the Health Insurance Portability and Accountability Act of 1996 (HIPAA). 

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO YOUR IDENTIFIABLE HEALTH INFORMATION. PLEASE REVIEW THIS NOTICE CAREFULLY.

A. Our Commitment to your privacy: Our organization is dedicated to maintaining the privacy of your identifiable health information. In conducting our business, we will create records regarding you and the treatment and services we provide to you. We are required by law to maintain the confidentiality of health information that identifies you. We also are required by law to provide you with this notice of our legal duties and privacy practices concerning your identifiable health information. By law, we must follow the terms of the notice of privacy practices that we have in effect at the time. To summarize, this notice provides you with the following important information: *How we may use and disclose your identifiable health information *Your privacy rights in your identifiable health information *Our obligations concerning the use and disclosure of your identifiable health information The terms of this notice apply to all records containing your identifiable health information that are created or retained by our practice. We reserve the right to revise or amend our notice of privacy practices. Any revision or amendment to this notice will be effective for all of your records our practice has created or maintained in the past, and for any of your records we may create or maintain in the future. Our organization will post a copy of our current notice in our offices in a prominent location, and you may request a copy of our most current notice during any office visit
B. If you have any questions about this notice, please contact: 
Compliance officer, 
Health Refined

Address


C. We may use and disclose your health information in the following ways: The following categories describe the different ways in which we may use and disclose your identifiable health information: 
1. Treatment. Our organization may use your identifiable health information to treat you. For example, we may perform a follow-up interview and we may use the results to help us modify your treatment plan. Many of the people who work for our organization may use or disclose your identifiable health information in order to treat you or to assist others in your treatment. Additionally, we may disclose your identifiable health information to others who may assist in your care, such as your physician, therapists, spouse, children or parents. 
2. Payment.Our organization may use and disclose your identifiable health information in order to bill and collect payment for the services and items you may receive from us. For example, we may contact your health insurer to certify that you are eligible for benefits (and for what range of benefits), and we may provide your insurer with details regarding your treatment to determine if your insurer will cover, or pay for, your treatment. We also may use and disclose your identifiable health information to obtain payment from third parties who may be responsible for such costs, such as family members. Also, we may use your identifiable health information to bill you directly for services and items. 
3. Health Care Operations.Our organization may use and disclose your identifiable health information to operate our business. As examples of the ways in which we may use and disclose your information for our operations, our organization may use your health information to evaluate the quality of care you received from us or to conduct cost-management and business planning activities of our practice. 
4. Appointment Reminders. Our organization may use and disclose your identifiable health information to inform you of health-related benefits or services that may be of interest to you.
 5. Health-Related Benefits and Services. Our organization may use and disclose your identifiable health information to inform you of health-related benefits or services that may be of interest to you. 
6. Release of Information to Family/Friends. Our organization may release your identifiable health information to a friend or family member who is helping you pay for your health care of who assists in taking care of you. 
7. Disclosure Required By Law. Our organization will use and disclose your identifiable health information when we are required to do so by federal, state or local law. 
D. Use and disclosure of your identifiable health in certain special circumstances. The following categories describe unique scenarios in which we may use or disclose your identifiable health information:
 1. Public Health Risks. Our organization may disclose your identifiable health information to public health authorities who are authorized by law to collect information for the purpose of: 
a. Maintaining vital records, such as births and deaths
 b. Reporting child abuse or neglect 
c. Preventing or controlling disease, injury or disability 
d. Notifying a person regarding potential exposure to a communicable disease 
e. Notifying a person regarding a potential risk for spreading or contracting a disease or condition 
f. Reporting reactions to drugs or problems with products or devices
 g. Notifying individuals if a product or device they may be using has been recalled
 h. Notifying appropriate government agency (ies) and authority (ies) regarding the potential abuse or neglect of an adult patient (including domestic violence); however, we will only disclose this information if the patient agrees or we are required or authorized by law to disclose this information. 
i. Notifying your employer under limited circumstances related primarily to workplace injury or illness or medical surveillance. 
2. Health Oversight Activities. Our organization may disclose your identifiable health information to a health oversight agency for activities authorized by law. Oversight activities can include, for example, investigations, inspections, audits, surveys, licensure, and disciplinary actions; civil, administrative, and criminal procedure or actions; or other activities necessary for the government to monitor government programs, compliance with civil rights laws, and the health care system in general. 
3. Lawsuits and Similar Proceedings. Our organization may use and disclose your identifiable health information in response to a court or administrative order if you are involved in a lawsuit or similar proceeding. We also may disclose your identifiable health information in response to a discovery request, subpoena, or other lawful process by another party involved in the dispute, but only if we have made an effort to inform you of the request or to obtain an order protecting the information the party has requested.
4. Law Enforcement. We may release identifiable health information if asked to do so by a law enforcement official: 
a. Regarding a crime victim in certain situations, if we are unable to obtain the person’s agreement
 b. Concerning a death we believe might have resulted from criminal conduct 
c. Regarding criminal conduct at our offices 
d. In response to a warrant, summons, court order, subpoena, or similar legal process 
e. To identify/locate a suspect, material witness, fugitive or missing person 
f. In an emergency, to report a crime (including the location or victim (s) of the crime, or the description, identity or location of the perpetrator) 
5. Serious Threats to Health or Safety. Our organization may use and disclose your identifiable health information when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. Under these circumstances, we will only make disclosures to a person or organization able to help prevent the threat. 
6. Military. Our organization may disclose your identifiable health information if you are a member of US or foreign military forces (including veterans) and if required by the appropriate military command authorities. 
7. National Security. Our organization may disclose your identifiable health information to federal officials for intelligence and national security activities authorized by law. We also may disclose your identifiable health information to federal officials in order to protect the President, other officials or foreign heads of state, or to conduct investigations.
 8. Workers’ Compensation. Our organization may release our identifiable health information for workers’ compensation and similar programs. 
E. Your rights regarding your identifiable health information.You have the following rights regarding the identifiable health information that we maintain about you. 
1. Confidential Communication. You have the right to request that our organization communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home rather than work. In order to request a type of confidential communication, you must make a written request to Compliance Officer, Star Wellness MD 652 Pat Booker Rd , Universal City, TX, 78148, specifying the requested method of contact or the location where you wish to be contacted. Our organization will accommodate reasonable requests. You do not need to give a reason for your request. 
2. Requesting Restrictions. You have the right to request a restriction in our use or disclosure of your identifiable health information for the treatment, payment or health care operations. Additionally, you have the right to request that we limit our disclosure of your identifiable health information to individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you. In order to request a restriction in our use of disclosure of your identifiable health information, you must make your request in writing to Compliance Officer, Address..... Your request must describe in a clear and concise fashion: (a) the information you wish restricted; (b) whether you are requesting to limit our practice’s use, disclosure or both; and (c) to whom you want the limits to apply. 
3. Inspection and Copies. You have the right to inspect and obtain a copy of the identifiable health information that may be used to make decisions about you, including patient medical records and billing records, but not including psychotherapy notes. You must submit your request in writing to Compliance Officer, Address...in order to inspect and/or obtain a copy of your identifiable health information. Our practice may deny your request to inspect and/or copy in certain limited circumstances; however, you may request a review of our denial. Reviews will be conducted by another licensed healthcare professional chosen by us. 
4. Amendment. You may ask us to amend your health information if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by or for our organization. To request an amendment, your request must be made in writing and submitted to Compliance Officer, Address. You must provide us with a reason that supports your request for the amendment. Our organization will deny your request if you fail to submit your request (and the reason supporting your request) in writing. Also, we may deny your request if you ask us to amend information that is:
 (a) accurate and complete; (b) not part of the identifiable health information kept by or for the organization; (c) not part of the identifiable health information which you would be permitted to inspect and copy; or (d) not created by our organization, unless the individual or entity that created the information is not available to amend the information. 
5. Accounting of Disclosures. All of our patients have the right to request an “accounting of disclosures.” An “accounting of disclosures” is a list of certain disclosures our organization has made of your identifiable health information. In order to obtain an accounting of disclosures, you must submit your request in writing to Compliance Officer, Address. All requests for an “accounting of disclosures” must state a time period which may not be longer than six years and may not include dates before October 1, 2006. 
6. 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. To obtain a paper copy of this notice, contact Compliance Officer,Address.
 7. Right to file a complaint. If you believe your privacy rights have bene violated, you may file a complaint with our organization or with the Secretary of the Department of Health and Human Services. To file a complaint with our organization, Compliance Officer,Address. All complaints must be in writing. You will not be penalized for filing a complaint. 
8. Right to Provide an authorization for other uses and disclosures. Our organization will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your identifiable health information may be revoked at any time in writing. After you revoke your authorization, we will not longer use or disclose your identifiable health information for the reasons described in the authorization. Please note that we are required to retain records of your care. 
By signing this form, I certify: 

  • I have read this form or had this form explained/read to me

  • I have read or had the Consents for Treatment explained/read to me. I understand its contents, including the risks and benefits of treatment, telemedicine, email use, and voicemail/text appointment reminders.

  • I give my consent for treatment and accept all associated risks.

  • I have read or had this Financial Policy explained/read to me. I understand its contents and agree with and accept the terms and requirements.

  • I have read or had this Privacy Policy / HIPPA Compliance Policy explained/read to me. I understand its contents and agree with and accept the terms and requirements.

  • I have read or had the Patient’s Rights and Responsibilities explained/read to me. I understand its contents and agree with and accept the terms and requirements.

  • I have had the opportunity to ask questions and have had them answered to my satisfaction.