Telehealth Consent

You have asked Revitalize Rx to arrange for a licensed provider ("Clinician”) to review the health information you provided to Revitalize Rx through its online Telehealth platform (the “Service”) to determine what, if any, Revitalize Rx services are medically appropriate for you (the “Provider Consultation”). The purpose of this consent form (“Consent”) is to provide you with information about Telehealth and to obtain your informed consent for Revitalize Rx and the Medical Providers to use Telehealth to provide you with health care services through the Service.

In this Consent, the words “you” and “yours” means the person using the Service, or in the case of a minor between the ages of 13 and 18 years-old (or a higher age of majority under applicable state law) means both the parent or guardian who provides consent to use the Service by minor and the minor for whom consent is being provided.

Please carefully read all of the information below. By clicking “I Agree” below, by carrying through with the Medical Consultation, or by signifying your acceptance of any other component of the Service means you understand and agree to all of the following:

Telehealth means the use of electronic communication systems and information technology to provide health care services when the patient and the health care provider are not in the same physical location. Telehealth may be used for diagnosis, treatment, prescribing, patient education, and follow-up care, and can be done through phone, electronic transmission of medical records and health information, or by electronic communication between the patient and the provider by audio, visual, audiovisual, or other data transmission, including messaging services or email.

The use of telehealth may have some or all of the following benefits for you: increase your access to health care services; increase the efficiency of health care services, allow you to access health care services at times and places that are convenient for you.

The use of Telehealth may also present some or all of the following risks to you: the inability of your health care provider to perform an in-person exam may limit the quality, accuracy or effectiveness of the health care services you receive, and may limit or negatively impact your health care provider’s ability to diagnose your condition and provide you with the care that you need; you may be required to seek alternative sources of medical care; the technology used for telehealth, including the Service, may have errors or bugs that negatively impact the quality and timeliness of health care services provided, the accurate or timely transmission of health care information, the accuracy or completeness of information used to provide health care services, render the technology, including the Service inoperable or unavailable, or cause the loss of health information and/or personal data.

The use of telehealth also involves the risk of possible failures of technology, equipment, electronic systems or security systems and protocols that could result in a loss of your health information or a breach of privacy and unintended disclosure to unauthorized individuals or entities, which may also negatively impact the care you receive by Telehealth.

The health care services you receive through use of the Service will be provided to you using telehealth. By starting or continuing to use the Service or by requesting or receiving a Medical Provider Consultation, you consent to the use of telehealth to provide you with health care services.

You understand that at any time a Medical Provider using their independent medical judgement may determine that it is not medically appropriate to provide health care services to you using telehealth or the Service. You agree to discontinue using the Service immediately if the Provider makes such a determination.

You may withdraw your consent to use Telehealth for the provision of health care services at any time by providing Revitalize Rx with written notice. Your withdrawal of consent is immediately effective upon Revitalize Rx’s receipt of your written notice but will not impact health care services provided using Telehealth prior to Revitalize Rx’s receipt of your notice of withdrawal of consent. Your withdrawal of consent shall not impact any other terms of this Consent, and you must continue to follow the Consent. You understand that withdrawal of consent for Telehealth means that Revitalize Rx and the providers will no longer be able to provide you with health care services using the Service or otherwise, as neither the Provider nor Revitalize Rx provides in-person health care services.

The Service is not designed to provide you with emergency medical or mental health services.

IF YOU HAVE A MEDICAL EMERGENCY, YOU SHOULD DIAL 911.

IF YOU ARE HAVING A MENTAL HEALTH EMERGENCY OR ARE THINKING ABOUT SUICIDE, YOU SHOULD DIAL THE SUICIDE AND CRISIS LIFELINE AT 988.

Revitalize Rx and its Providers use software and network security systems and protocols to safeguard the security and privacy of your health information. Revitalize Rx and its Providers will not release your protected health information to third parties without your consent, except as permitted or required by law. You may receive phone, email, or other electronic communication from Revitalize Rx or a Provider that may contain your protected health information. You acknowledge that Revitalize Rx and the Provider cannot and do not guarantee the security and privacy of the technology or services or equipment you use to receive such communications.

Neither Revitalize Rx nor the Physician makes any guarantee that you will receive a prescription for a Revitalize Rx product as a result of using the Service or receiving a Medical Consultation Consultation.

Neither Revitalize Rx nor the Provider guarantees any specific result if you use the Service or a Revitalize Rx product.

You agree to provide accurate and complete information about yourself and your health when using the Service or communicating with a Provider. There are risks to your health and well-being if you give incorrect or incomplete information. You certify that all of the information you provide to Revitalize Rx and the Provider is true, accurate, and complete.
You understand that the information you provide to the Provider when using the Service or communicating with the Provider might be the only information used by the Provider to provide you with health care services. The Provider will not have access to your health information held by other medical professionals.
The fees you have paid or will pay to Revitalize Rx cover the cost of using the Service, receiving a Medical Consultation, and any Revitalize Rx products prescribed by the Provider. Revitalize Rx and the Provider will not bill your medical insurance company or any other third-party payor for your use of the Service, the Medical Consultation, or medication.

You are responsible for arranging and paying for any follow-up care you receive after the Medical Consultation or while or after using the Service.

If the Provider prescribes a product for you, the Provider will send the prescription to a Revitalize Rx affiliated pharmacy for dispensing. Revitalize Rx and the pharmacy will work together to deliver the prescribed products to you at the address you have provided to Revitalize Rx. Please ensure you have provided Revitalize Rx with an address where you may safely and securely receive delivery of medication.

By clicking “I Agree” or utilizing the Service, you are consenting to the Provider's and Revitalize Rx's sharing of your protected health information with certain third parties, including the pharmacy, as more fully described in Revitalize Rx’s Notice of Privacy Practices, available on the Revitalize Rx website.

Copies of your medical record associated with your use of the Service are available in accordance with applicable law by request to Revitalize Rx.

If you have a concern or complaint about the pharmacy that fills your prescription for the prescribed medication, please contact the pharmacy licensing board in your state.

Revitalize Rx follows and is governed by these notices. On your becoming a patient of the practice, you acknowledge receipt of these notices and accept that they will govern your medical treatment by Revitalize Rx. You acknowledge that you accept the practices and policies mentioned below:

Arizona

I am aware that any medical records generated by a telemedicine consultation will become a component of my medical file. (A.R.S. § 12-2291.)

Connecticut

I am aware that my telehealth encounter records may be shared with my primary care physician and that I have the right to withdraw my permission at any time. 19a-906 of the Connecticut General Statutes.

Florida

Florida’s Consumer Bill of Rights for Weight Loss

The rights of customers looking for expert weight-loss services are outlined in Florida Statute 501.0575. Please review the following rights:

A. Warning: Serious health issues could result from rapid weight reduction. Rapid weight loss after the second week of involvement in a weight loss program is defined as weight loss of more than 1 12 to 2 pounds per week or weight loss of more than 1% of body weight per week.

B. Before beginning any weight-loss program, speak with your personal doctor.

C. Long-term weight loss can only be aided by permanent lifestyle changes, like choosing wholesome foods and upping physical exercise.

D. On request, this provider’s credentials are accessible.

You are entitled to:

Inquire about the program’s dietary provisions, psychological support, and instructional aspects as well as any health risks.
Get a detailed statement detailing the cost of the weight reduction program, including any additional items, services, supplements, checkups, or lab tests.
Be aware of the program’s real or projected duration.
In accordance with Section 468.505(1)(I) of the Florida Statutes, be aware of the name, address, and credentials of the physician, dietician, or nutritionist who has examined and authorized the weight-loss program.

Please attentively read the following information before signing the patient’s informed consent to use appetite suppressants. Please sign the following page to acknowledge your comprehension and agreement.

I. Alternatives and procedures:

A. I have read and comprehend each of the following statements, and I am aware that there is a lack of scientific evidence pertaining to the possible risk of long-term use of combination weight-management programs that include GLP-1 medications. B. I am aware that it is my responsibility to closely adhere to my doctor’s instructions and to report any medical issues as soon as possible, regardless of whether I believe they may be connected to my weight management program. I further declare that I am not pregnant right now and that I will notify my doctor right away if I become pregnant. C. I am aware that there are additional strategies and programs that can help me lose weight and keep it off. If I adhered to a healthy diet and exercise regimen, I could achieve success without taking a GLP-1 agonist.

II. Risks of Proposed Treatment:

I am aware that there are several side effects when taking any drug, and that taking GLP-1 medications has been linked to gastrointestinal symptoms, particularly nausea, vomiting, and diarrhea. Reactions at the injection site, headaches, and nasopharyngitis are additional frequent adverse effects. If I am taking another medication known to lower blood sugar at the same time, such as sulfonylureas or insulin, hypoglycemia (low blood sugar levels) may be a danger. I am aware that taking GLP-1 medicines is not advised if I have had pancreatitis, multiple endocrine neoplasia, medullary thyroid cancer, or either of these conditions in the past.

III. Risks of Being Overweight or Obese:

I am aware that being overweight or obese entails several risks, including a propensity for high blood pressure, diabetes, heart disease, hip, knee, and foot arthritis, as well as some malignancies. I am aware that these risks could be minimal if I am not extremely overweight, but that they rise with any weight gain.

IV. No Promises:

I am aware that my efforts and adherence to the program will be a big part of its success. I am aware that despite my efforts, there are no assurances or guarantees that this program will be effective. I also realize that if I want to succeed, I will have to maintain a healthy weight throughout my existence.

Title XXXIII governs regulation of trade, commerce, investments, and solicitations.

Consumer Protection Act, Chapter 501

Weight-Loss Consumer Bill of Rights, Section 501.0575.

(1) The following clauses make up the weight-loss consumer bill of rights:

RAPID WEIGHT LOSS IS WEIGHT LOSS OF MORE THAN 11/2 POUNDS TO 2 POUNDS PER WEEK OR WEIGHT LOSS OF MORE THAN 1% OF BODY WEIGHT PER WEEK AFTER THE SECOND WEEK OF PARTICIPATION IN A WEIGHT-LOSS PROGRAM. (A) WARNING: RAPID WEIGHT LOSS MAY CAUSE SERIOUS HEALTH PROBLEMS.

(B) BEFORE STARTING ANY WEIGHT-LOSS PROGRAM, SPEAK WITH YOUR PERSONAL PHYSICIAN.

(C) ONLY LONG-TERM WEIGHT LOSS IS PROMOTED BY PERMANENT LIFESTYLE CHANGES, LIKE SELECTING HEALTHY FOODS AND INCREASING PHYSICAL ACTIVITY.

(D) THIS PROVIDER’S QUALIFICATIONS ARE AVAILABLE UPON REQUEST.

(E) You are entitled to:

ASK QUESTIONS ABOUT THE POTENTIAL HEALTH RISKS OF THIS PROGRAM, AS WELL AS ABOUT THE NUTRITIONAL CONTENTS, PSYCHOLOGICAL SUPPORT, AND EDUCATORY ELEMENTS.
GET AN ITEMIZED STATEMENT OF THE WEIGHT-LOSS PROGRAM’S ACTUAL OR ESTIMATED COST, INCLUDING ADDITIONAL GOODS AND SERVICES, SUPPLEMENTS, EXAMS, AND LABORATORY TESTS.
KNOW THE PROGRAM’S ACTUAL OR ESTIMATED DURATION.
KNOW THE NAME, ADDRESS, AND SKILLS OF THE NUTRITIONIST OR DIETITIAN WHO HAS REVIEWED AND APPROVED THE WEIGHT-LOSS PROGRAM IN ACCORDANCE WITH S. Florida Statutes, section 468.505(1)(j).

(2) The weight-loss consumer bill of rights copies that must be displayed in accordance with s. 501.0573(6) must be displayed on one side of a sign in at least 24-point bold font. according to s., the palm-sized copies will be disseminated. 501.0573(5) must be visible and in boldface. The Weight-Loss Consumer Bill of Rights must be created and printed in the proper quantities by each weight-loss provider.

History.—s. 4, Ch. 93-274; s. 45, Ch. 2000-154

Iowa

I have been told to go to the medical board’s website if I want to file an official complaint about a provider.

Kansas

I am aware that if I have a primary care physician or another treating physician, I have the right to request that the person providing telemedicine services send a report of the treatment and services provided to me during the telemedicine encounter to my primary care or other treating physician within three business days (see Kan. Stat. Ann. 40-2,212(2)(d)(2)).(A). I am aware that this website, http://www.ksbha.org/complaints.shtml, contains information on the complaint procedure.

Maryland

I am aware that one key distinction between telehealth and in-person service delivery for audiologists, speech language pathologists, and hearing aid dispensers is the inability to have direct, physical interaction with the patient. It is not necessary for the provider of telehealth services to fully understand or be aware of the knowledge, experiences, and credentials of the consultant giving data and information to them. The provider’s ability to deliver high-quality services may be impacted by the content of transmitted data. It might not be feasible to alter the environment or test conditions while providing telehealth services. Telehealth services cannot be given exclusively via email. 10.41.06.04 of the Maryland Code). I have been told to go to the medical board’s website if I want to file an official complaint about a provider.

Nebraska

If I am a Medicaid recipient, I have the choice to decline the telehealth consultation at any time without jeopardizing my ability to receive future care or treatment or running the risk of having any program benefits to which I would otherwise be eligible being lost or withdrawn. The telehealth consultation shall be subject to all currently in effect secrecy safeguards. As permitted by legislation for access to my medical records, I shall have access to all medical information resulting from the telehealth consultation. Without my written permission, no images or data from the telehealth consultation that could be used to identify the patient will be shared with researchers or other organizations. I am aware that I have the option to ask for an in-person consultation right away following the telehealth consultation, and that I will be told if one is not offered. (Neb. Rev. Stat. Ann. 71-8505; 471 Neb. Admin. Code 1-006.05). (“Informed Consent & Use of Telehealth Technology | Right way”) I have been told to go to this website if I want to file an official complaint about a provider.

New Jersey

I am aware that I have the right to ask for a copy of my medical records, and that they may be sent to other healthcare providers at my request or immediately to my primary care doctor or the health care provider on file. 45:1-62 of the New Jersey Revised Statutes.

Texas

I am aware that my primary care physician may receive a copy of my medical information. 111.005 of the Texas Occupations Code. I have been made aware of the upcoming notice:

NOTICE REGARDING COMPLAINTS: You can report complaints about doctors, as well as other licensees and registrants of the Texas Medical Board, such as physician assistants, acupuncturists, and surgical assistants, for investigation at the following address: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018; 1-800-201-9353; for more information, please check our website at www.tmb.state.tx.us; assistance with filing a complaint is available.

ADVICE REGARDING QUESTIONS- Concerns regarding physicians, along with those regarding other licensed and registered members of the Texas Medical Council, such as physician assistants, acupuncturists, and surgical assistants, may be brought to the following address to be investigated: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018; If you need assistance to file a complaint, call 1-800-201-9353; for more information, go to our website at www.tmb.state.tx.us.

Utah

I am aware of the following: (i) any additional fees for telehealth services, if any, and the method of payment for those additional fees, if those fees are charged separately from any fees for in-person services provided in conjunction with the telehealth services; (ii) the recipients and purposes for which my health information may be disclosed; and (iii) any consents governing the release of my patient-identifiable information to third parties. I am aware that the telehealth services adhere to all applicable laws and regulations and satisfy industry security and privacy standards (see Section 26-60-102(8)(b)).(ii). I understand there could be privacy risks despite the security precautions in place, and I promise to hold the provider harmless if information is lost due to technical issues. I now have the website address and contact details for the telehealth business. To the extent that it was possible, I was allowed to choose my service provider. I had the option to choose my preferred drugstore. I have the following rights: a (i) access, complete, and amend my patient-provided personal health information; b (ii) get in touch with my doctor for further treatment; c (iii) request a transfer of my medical record containing the telemedicine services to another provider; and d (iv) obtain upon request an electronic or paper copy of my medical record containing the telemedicine services, including the informed consent given. (Utah Admin. Code r. 156-1-603).

Please email Patients Medical at info@revitalizerx.com if you have any questions, comments, or issues about these notices.