Telehealth Policy

Informed Consent Regarding the Use of Telehealth to Deliver Care:

By signing this Consent, you acknowledge that you have read, accept, and agree to be bound by this Consent and that this acceptance constitutes a legal signature. You also affirm that you will provide accurate and complete information to the best of your knowledge.

Purpose:

The purpose of this Consent form (“Consent”) is to provide you with information about telehealth and to obtain your informed consent to the use of telehealth in the delivery of healthcare services to you. Practice-engaged providers, including physicians and other providers employed by or otherwise engaged to provide services for or on behalf of a Practice are referred to collectively herein as “Providers.”

Nature of Telehealth Services:

Telemedicine is the use of electronic communications to enable health care providers at different locations to share individual patient medical information for the purpose of improving patient care. The information may be used to determine eligibility for a prescription and, where indicated, to provide such prescription.

Telehealth services offered by Weight Loss Shots may include a patient consultation, evaluation, diagnosis, treatment recommendation, prescription, and/or a referral, as determined clinically appropriate by the Practice and Provider (the “Services”).

Possible Benefits of Telehealth

Improved access to medical care, more efficient medical evaluation and management, possibility of selecting a time that is convenient to you, and/ or possibility to choose a location that is convenient for you.

Possible Risks of Telehealth

There are potential risks associated with the use of telehealth. These risks include, but may not be limited to: Information transmitted may not be sufficient to allow for appropriate medical decision-making by the provider, provider may not be able to provide medical treatment for your particular conditions, regulatory requirements may limit your Provider’s ability to provide treatment options, delays in medical evaluation and treatment could occur due to deficiencies or failures in technology equipment or Provider availability, and/or security protocols could fail, resulting in privacy breaches of personal medical information.

Service Limitations:

Telehealth Providers are unable to have direct, physical contact with the patient. As a result, some clinical needs may not be appropriate for a telehealth visit and your Provider will make that determination. Your Provider’s determination regarding the appropriateness of telehealth care is their sole and absolute discretion and may not be appealed.

Providers do not address medical emergencies. If you believe you are experiencing a medical emergency, you should dial 9-1-1 and/or go to the nearest emergency room. After receiving emergency healthcare treatment, you should visit your local primary care provider.

If you are not experiencing an emergency or do not require immediate or urgent care, you can communicate with our team via text, call, or email.

Our Providers are not a replacement for your local primary care provider. Responsibility for your overall medical care should remain with your local primary care provider. We strongly encourage you to locate one if you do not already have one.

Confidentiality:

We prioritize your privacy and maintain the confidentiality of your medical information in accordance with our Privacy Policy and applicable law. However, please note that the security of electronic communication cannot be guaranteed, and there are risks associated with the transmission of data.

Patient Agreements:

As a patient utilizing telehealth services and by signing or otherwise acknowledging agreement to this Telehealth Consent, you agree as follows:

-You have read and understand the information provided above regarding the benefits and risks of telehealth.

-You give your informed consent to the use of telehealth by Providers hereunder.

-If you are experiencing a medical emergency, you will dial 9-1-1 immediately, you will not seek emergency or urgent care or treatment from Weight Loss Shots.

-There is no guarantee that you will be treated by a Provider. Your Provider reserves the right to deny care for potential misuse of the Services or for any other reason. If, in the professional judgment of your Provider, the provision of the Services is not medically or ethically appropriate, you may be denied treatment. There is no guarantee that you will be issued a prescription, and the decision of whether a prescription is appropriate will be made in the professional judgment of your Provider.

-You understand that no results from telehealth services can be guaranteed or assured.

-You understand that the laws that protect privacy and the confidentiality of medical information also apply to telehealth.

-You understand that all medical reports resulting from the telehealth visit are part of your medical record.

-You hereby release and hold harmless Weight Loss Shots and each Provider from damage or loss arising from or in connection with the loss or misappropriation of data or information arising out of the telehealth service.

-There is a risk of technical failures during the telehealth visit beyond the control of your Providers.

I AGREE TO RELEASE AND HOLD HARMLESS WEIGHT LOSS SHOTS, PROVIDERS, EMPLOYEES, CONTRACTORS, AGENTS, DIRECTORS, MEMBERS, MANAGERS, SHAREHOLDERS, OFFICERS, REPRESENTATIVES, PARENTS, PRE- DECESSORS, AND SUCCESSORS FROM AND AGAINST CLAIMS RELATING TO DAMAGE OR LOSS ARISING IN CONNECTION WITH TELEHEALTH SERVICES, INCLUDING FOR DELAYS IN EVALUATION AND FOR INFORMATION LOST DUE TO SUCH TECHNICAL FAILURES.

Other State-Specific Consents

The following apply to patients accessing Weight Loss Shots Platforms and Services for the purposes of participating in telehealth services as required by the listed states:

Alaska: I understand that my primary care provider may obtain a copy of the records of my telehealth services. I have been informed that to register a formal complaint about a provider, I should visit the medical board’s website here: https://www.commerce.alaska.gov/web/cbpl/ComplaintFAQs.aspx

Connecticut: I understand that my primary care provider may obtain a copy of the records of my telehealth services.

Florida: I can view my rights under Florida’s Patient Bill of Rights and Responsibilities, by visiting the Florida Agency for Health Care Administration: https://www.flsenate.gov/laws/statutes/2011/381.026. To view my rights under Florida’s Weight-Loss Consumer Bill of Rights, I should click here: https://www.flsenate.gov/Laws/Statutes/2015/501.0575

Iowa: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website here: https://dial.iowa.gov/about-dial/boards/medicine

Idaho: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website here: https://apps-dopl.idaho.gov/IBOMPortal/LINKS/discipline/IDBOM_complaint_form.pdf

Indiana: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website here: https://www.in.gov/pla/file-a-complaint/

Kansas: I understand that if I have a primary care provider or other treating physician, the Provider providing telehealth services must send records to such primary care or other treating physician of the treatment and services rendered to me during the telehealth encounter within three days of when I provide consent to the Provider providing telemedicine services to send such records.

Kentucky: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website here: https://kbml.ky.gov/grievances/Pages/default.aspx

Maine: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website here: https://www.maine.gov/md/complaint/file-complaint or the Maine Board of Osteopathic Licensure’s website here: https://www.maine.gov/osteo/contact

New Hampshire: I understand that my primary care provider or treating provider may obtain a copy of my records of my telehealth services.

Ohio: I understand that my primary care provider may obtain a copy of my records of my telehealth services.

Oklahoma: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website here: https://www.okmedicalboard.org/complaint or the Oklahoma Board of Osteopathic Examiners’ website here: https://osboe.us.thentiacloud.net/webs/osboe/register/#/complaint-form

Rhode Island: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website here: https://health.ri.gov/complaints

South Carolina: I understand that my medical records may be distributed only with my consent and in accordance with applicable laws and regulations to other treating health care practitioners.

Texas- I have been informed of the following notice:

NOTICE CONCERNING COMPLAINTS -Complaints about physicians, as well as other licensees and registrants of the Texas Medical Board, including physician assistants, acupuncturists, and surgical assistants may be reported 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, Assistance in filing a complaint is available by calling the following telephone number: 1-800-201-9353, For more information, please visit www.tmb.state.tx.us.

AVISO SOBRE LAS QUEJAS- Las quejas sobre médicos, asi como sobre otros profesionales acreditados e inscritos del Consejo Médico de Tejas, incluyendo asistentes de médicos, practicantes de acupuntura y asistentes de cirugia, se pueden presentar en la siguiente dirección para ser investigadas: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018, Si necesita ayuda para presentar una queja, llame al: 1-800-201-9353, Para obtener más información, visite nuestro sitio web en www.tmb.state.tx.us.

Vermont: I understand that I have the right to receive a consult with a distant-site provider and will receive one upon request immediately or within a reasonable time after the results of the initial consult. I understand that receiving telemedicine services via Weight Loss Shots does not preclude me from receiving real-time telemedicine or face-to-face services with the distant provider at a future date. (VT Stat. Ann. § 9361).

I have been informed that if I want to register a formal complaint about a provider, I should visit the Vermont Board of Medical Practice website here: https://www.healthvermont.gov/systems/board-medical-practice/file-complaint or the Vermont Board of Osteopathic Examiners here: https://sos.vermont.gov/opr/complaints-conduct-discipline/