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 in response to legal, business, or other reasons.

Telehealth Consent

Telehealth is the type of care that allows patients to access health services using audio-video interface such as videoconferencing and asynchronous messaging platforms.

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

Expected Benefits

• Improved access to weight management healthcare by enabling patients to receive services across distances.
• More efficient healthcare including medical evaluation and management.
• Obtaining expertise of a distant specialist or licensed clinician.
• 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 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.
• Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment or technology.
• 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, allergic reactions, or other clinical errors.

By Consenting to These Forms, You Understand the Following:

• The laws that protect privacy and confidentiality of medical information also apply to telehealth, and no information obtained in the use of telehealth which identifies you will be disclosed to researchers or other entities without your consent.
• You have the right to withhold or withdraw your consent to the use of telehealth in the course of your care at any time, without affecting your right to future care or treatment.
• You 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.
• A variety of alternative methods of healthcare may be available to you, and you may choose one or more of these at any time.
• It is in your best interest to inform your provider of any other healthcare providers involved in your medical care.
• You may expect the anticipated benefits from the use of telehealth in your care, but no results can be guaranteed or assured.

Client Consent to the Use of Telehealth

By using our services, you acknowledge that you have read and understand the information provided above regarding telehealth. Your continued use of the services constitutes your understanding and acceptance of the above terms and you hereby authorize the use of telehealth in the course of your diagnosis and treatment.

HIPAA Consent

The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. A more complete text is available in our Notice of Privacy Practices.

Our Policies

• 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, and health insurance payers as necessary and appropriate for your care.
• It is our policy to communicate appointment reminders and service updates by telephone, email, SMS/text, U.S. mail, or as requested by you.
• We utilize 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.
• Your confidential information will not be used for the purposes of marketing or advertising products, goods, or services.
• We agree to provide patients with access to their records in accordance with state and federal laws.

Your continued use of the services constitutes your understanding and acceptance of the above HIPAA Information Form terms. This consent shall remain in force from this time forward.

Financial Consent

You understand and accept that in order to render services, a payment method may be kept on file and that any remaining balances for services rendered shall be paid in full. You authorize OralTrim to submit on your behalf the release of any medical records or other information necessary to process your consultation. Fee schedules and receipts for all professional services are available upon request.

All programs are auto-renewing and you consent to be automatically charged for any program you are a part of unless you explicitly request cancellation. To cancel, contact support@oraltrim.com.

Contact

If you have any questions about this Medical Consent, please contact us at support@oraltrim.com.