Telehealth Informed Consent and Disclosure
I understand that Peak Plastic Surgery, LLC has arranged a telehealth consultation for me with a duly licensed healthcare provider (the “Provider”) utilizing its telehealth platform. There are two primary methods for such telehealth consultations:
I may be able to conduct an asynchronous telehealth consultation, in which I will provide the requisite personal health information to my Provider in a digital format. Based on that health information, my Provider may be able to diagnose and prescribe treatment upon review of the information that I have provided. I acknowledge, however, that I may not be a good candidate for asynchronous consultations and that either the Provider or Peak Plastic Surgery may require that I engage in a live, interactive video consultation with the Provider prior to beginning any treatment.
If required to conduct—or if I choose to conduct—an interactive video consultation with my Provider, I will be able to consult with the Provider about my health and wellness concerns in real time via a live video connection through the Peak Plastic Surgery platform.Peak Plastic Surgery has explained to me how telehealth will be used to conduct such consultations and how else we will use telehealth to connect with the Provider while working together, utilizing the telehealth platform.
I confirm that the identity and location information I provide through the Peak Plastic Surgery telehealth platform is accurate and up-to-date. I understand that this information is essential for the proper administration of my telehealth consultation.
I understand there are potential risks with this technology:
The video connection may not work, or it may stop working during the consultation.The video picture or information transmitted may not be clear enough to be useful for the consultation. My personal health information may be misreported or inaccurately stored, making asynchronous or live video consultations difficult, inaccurate, or impossible. I acknowledge, however, that I have an obligation to accurately and truthfully present my personal health information to Peak Plastic Surgery and the Provider, and that any treatment provided based on inaccurate information will be my sole responsibility and liability.
I acknowledge that it is my responsibility to share all medical information exclusively through the HIPAA-compliant channels designated by Peak Plastic Surgery. I understand that any information I choose to share through other channels may not be protected under HIPAA, and Peak Plastic Surgery cannot guarantee the security or confidentiality of such information.
The benefits of a telehealth consultation are:
I do not need to travel to the consult location.I can meet with a Provider quickly and efficiently.I have access to a specialist Provider through this consultation.
I also understand that other individuals may need to use the telehealth platform and that they will take all reasonable and necessary steps to maintain the confidentiality of the information I provide. Peak Plastic Surgery and all involved healthcare providers will take all reasonable and necessary steps to ensure the confidentiality of the information provided during the telehealth consultation.
A member of my Provider team assessed my medical condition and made a clinical treatment determination, taking into account the information I provided. If I forgot to provide or incorrectly provided certain information related to my health, there is a possibility that the Provider may misdiagnose or fail to diagnose conditions that I may have, which could affect their recommendation for treatment. If I need to clarify or update any information about my health, I must message my Provider team through the Peak Plastic Surgery platform as soon as possible.
I understand that my telehealth consultation will be recorded as part of my medical record. I consent to this recording and acknowledge that it will be used in accordance with Peak Plastic Surgery's privacy policies and relevant laws.
The treatments that I may be prescribed are not 100% effective for all patients. Any such treatment may not work or may only partially resolve the condition for which I am seeking treatment. Likewise, treatments may result in adverse side effects, varying in severity from mild to severe. If I do not see any signs of improvement or if I am experiencing new or worsening symptoms, I will message a Provider through the Peak Plastic Surgery platform or contact my regular healthcare provider. If it is an emergency, I understand that I should call 911 or seek immediate help in person at my nearest hospital or healthcare provider.I understand that the prescribed medication is compounded by a local state-approved 503A pharmacy and contains added vitamin B12. This differs from FDA-approved brand-name drugs like Wegovy™, Saxenda®, Mounjaro™, Zepbound™, Ozempic®, and others. The vitamin B12 in the compounded formula is included to help with energy levels, manage gastrointestinal side effects, support metabolism and fat metabolism, improve sleep, promote red blood cell production, and boost the immune system. My provider has reviewed my health history with me, and I have been given the opportunity to ask questions.
I acknowledge that there is a risk that the Provider may misdiagnose or fail to diagnose conditions that I may have, which could affect the recommendation for treatment. The healthcare Providers providing treatment through the Peak Plastic Surgery platform use evidence-based guidelines as well as clinical decision-making to try to minimize these risks.
The Provider who recommended or may recommend this treatment for me did so with my consent and because the potential benefits outweigh the risks in their estimation, based on their clinical judgment, training, and experience. I should evaluate this information and any input from my in-person healthcare team, and any other relevant information to decide if this treatment plan is appropriate for me. I understand that I am free to not follow the treatment recommendations I received from the Provider through the Peak Plastic Surgery platform.
I can request a copy of my health records anytime. Peak Plastic Surgery strongly recommends that I update my in-person healthcare team about any new medicines that I am taking or other changes in my health. I can also ask questions anytime by messaging a Provider through the Peak Plastic Surgery platform, who can help me share any information about my health with my in-person healthcare team.
If I begin treatment through Peak Plastic Surgery at the direction of my Provider, I acknowledge and agree that I must follow the prescribed treatment plan from my Provider team and Peak Plastic Surgery. All prescription medication must be taken and used only as prescribed. If I do not follow my treatment plan precisely as prescribed and directed by the Provider team and/or Peak Plastic Surgery, Peak Plastic Surgery cannot and will not be liable for my care and may terminate my current and future treatment plan(s).
By signing below, I acknowledge that I have had the opportunity to ask questions regarding the telehealth consultation process, potential risks, and benefits, and that my questions have been answered to my satisfaction. I hereby consent to participate in telehealth consultations under the conditions described in this document.
Financial Agreement
Thank you for choosing Peak Plastic Surgery.
Please read and sign the agreement below. It outlines billing, scheduling, and cancellation procedures. If you have any questions, please ask for clarification.Payment Policies
Payment Policies
Consultation Appointments: All consultation appointments are free of charge.
Payment for Medications: Clients will pay Peak Plastic Surgery directly for the cost of medications. Payment is due at the time of service or prior to the prescription being processed.
I hereby authorize payment of medical benefits directly to Peak Plastic Surgery, LLC and affiliates such as W Enterprises, LLC for all services rendered where applicable.Out-of-pocket payments for medications or additional services can be made via credit/debit card and are due on the date of your appointment or service.
Prescription Disclaimer
Prescriptions for medications are at the sole discretion of the provider and cannot be guaranteed.
Provider Rights
Peak Plastic Surgery, LLC reserves the right to modify, pause, or cancel a treatment plan, program, or service at any time for any individual.
Default Payments
If I default on my account, I understand I will be responsible for finance and/or legal fees in addition to the total account balance.
Additional Notes
All sales and orders are final and not eligible for refunds or other reimbursements.
By signing below, I agree to the above financial and cancellation policies. I understand that in the event of default payment, I will be responsible for the balance, interest accrued, and any collection costs or legal fees incurred to collect on this account. I also understand that insurance will not be accepted by Peak Plastic Surgery, LLC for its services.I have read, understand, and accept the information and conditions specified in this agreement.
HIPAA Agreement
This notice outlines your protected health information, how it may be used, and what your rights are. Please review carefully and ask any questions prior to signing. Questions about this notice can be directed to Peak Plastic Surgery, LLC.
We, Peak Plastic Surgery, LLC, understand that protected health information about you and your health is personal. We are committed to protecting health information about you. This Notice applies to all records of your care generated by Peak Plastic Surgery, LLC, whether made by Peak Plastic Surgery, LLC personnel or your personal doctor or other healthcare provider. This Notice will tell you about the ways in which we may use and disclose protected health information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of protected health information. The law requires us to:
Make sure that protected health information that identifies you is kept private.
Notify you about how we protect protected health information about you.
Explain how, when, and why we use and disclose protected health information.
Follow the terms of the Notice that is currently in effect.
We are required to follow the procedures in this Notice. We reserve the right to change the terms of this Notice and to make new notice provisions effective for all protected health information that we maintain by:
Posting the revised Notice in our office.
Making copies of the revised Notice available upon request.
Posting the revised Notice on our website.
HOW WE MAY USE AND DISCLOSE PROTECTED HEALTH INFORMATION ABOUT YOU
The following categories describe different ways that we use and disclose protected health information without your written authorization.
We may use protected health information about you to provide you with, coordinate, or manage your medical treatment or services. We may disclose protected health information about you to doctors, nurses, technicians, medical students, or other personnel who are involved in taking care of you. Peak Plastic Surgery, LLC staff may also share protected health information about you in order to coordinate the different things you need, such as prescriptions, lab work, and x-rays. We may also disclose protected health information about you to people outside Peak Plastic Surgery, LLC’s office who may be involved in your medical care. We may use and disclose protected health information to contact you as a reminder that you have an appointment for treatment or medical care at Peak Plastic Surgery, LLC. We may use and disclose protected health information to tell you about or recommend possible treatment options or alternatives or health-related benefits or services.
We may use and disclose protected health information about you so that the treatment and services you receive at Peak Plastic Surgery, LLC may be billed to and payment may be collected from you, an insurance company, or a third party. For example, we may need to give your health plan information about services you received at Peak Plastic Surgery, LLC so your health plan will pay us or reimburse you for the service. We may also tell your health plan about the services you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.
We may use and disclose protected health information about you for Peak Plastic Surgery, LLC health care operations, such as our quality assessment and improvement activities, case management, coordination of care, business planning, customer services, and other activities. These uses and disclosures are necessary to run the facility, reduce health care costs, and make sure that all of our patients receive quality care. We may also combine protected health information about many Peak Plastic Surgery, LLC patients to decide what additional services Peak Plastic Surgery, LLC should offer, what services are not needed, and whether certain new treatments are effective. We may also disclose information to doctors, nurses, technicians, medical students, and other Peak Plastic Surgery, LLC personnel for review and learning purposes. We may also combine the protected health information we have with protected health information from other healthcare facilities to compare how we are doing and see where we can make improvements in the care and services we offer. We may remove information that identifies you from this set of protected health information so others may use it to study healthcare and healthcare delivery without learning who the specific patients are. We may also contact you as part of a fundraising effort.Subject to applicable state law, in some limited situations, the law allows or requires us to use or disclose your health information for purposes beyond treatment, payment, and operations. However, some of the disclosures set forth below may never occur at our facilities.
We will disclose protected health information about you when required to do so by federal, state, or local law.
We may disclose your protected health information (PHI) to researchers when their research has been approved by an institutional review board or privacy board that has reviewed the research proposal and established protocols to ensure the privacy of your information.
We may disclose protected health information about you to a government authority if we reasonably believe you are a victim of abuse, neglect, or domestic violence. We will only disclose this type of information to the extent required by law, if you agree to the disclosure, or if the disclosure is allowed by law and we believe it is necessary to prevent or lessen a serious and imminent threat to you or another person.
If you are involved in a lawsuit or dispute, we may disclose your information in response to a court or administrative order. We may also disclose health information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made, either by us or the requesting party, to tell you about the request or to obtain an order protecting the information requested.
We may disclose information to business associates who perform services on our behalf (such as billing companies); however, we require them to appropriately safeguard your information.
As required by law, we may disclose your protected health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.
We may use and disclose protected health information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.
We may disclose health information to a health oversight agency for activities authorized by law. These activities include audits, investigations, and inspections, which may be necessary for licensure and for the government to monitor the healthcare system, government programs, and compliance with civil rights laws.
We may release protected health information as required by law or in response to an order or warrant of a court, a subpoena, or an administrative request. We may also disclose protected health information in response to a request related to identification or location of an individual, victims of crime, decedents, or a crime on the premises.
If you are an organ donor, we may release protected health information to organizations that handle organ procurement or organ, eye, or tissue transplantation or to an organ donation bank to facilitate organ or tissue donation and transplantation.
If you are a member of the armed forces, we may release protected health information about you if it relates to military and veterans' activities. We may also release your protected health information for national security and intelligence purposes, protective services for the President, and medical suitability or determinations of the Department of State.
We may release protected health information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also disclose protected health information to funeral directors consistent with applicable law to enable them to carry out their duties.
If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release protected health information about you to the correctional institution or law enforcement official as necessary for your or another person’s health and safety.
We may disclose information as necessary to comply with laws relating to worker’s compensation or other similar programs established by law.
We may disclose to the FDA, or persons under the jurisdiction of the FDA, protected health information relative to adverse events with respect to drugs, foods, supplements, products and product defects, or post marketing surveillance information to enable product recalls, repairs, or replacement.
Unless you object, or request that only a limited amount or type of information be shared, we may use or disclose protected health information about you in the following circumstances:
We may share with a family member, relative, friend, or other person identified by you protected health information directly relevant to that person’s involvement in your care or payment for your care. We may also share information to notify these individuals of your location, general condition, or death.
We may share information with a public or private agency (such as the American Red Cross) for disaster relief purposes. Even if you object, we may still share this information if necessary for the emergency circumstances.
If you would like to object to the use and disclosure of protected health information in these circumstances, please call or write to our contact person listed on page 1 of this Notice.
You have the following rights regarding protected health information we maintain about you:
You have the right to inspect and copy protected health information that may be used to make decisions about your care. Usually, this includes medical and billing records. To inspect and copy protected health information that may be used to make decisions about you, you must submit your request in writing to Peak Plastic Surgery, LLC. If you request a copy of the information, we may charge a fee for the costs of copying, mailing, or other supplies associated with your request, and we will respond to your request no later than 30 days after receiving it. There are certain situations in which we are not required to comply with your request. In these circumstances, we will respond to you in writing, stating why we will not grant your request and describe any rights you may have to request a review of our denial.
If you feel that protected health information we have about you is incorrect or incomplete, you may ask us to amend or supplement the information. To request an amendment, your request must be made in writing and submitted to Peak Plastic Surgery, LLC. In addition, you must provide a reason that supports your request. We will act on your request for an amendment no later than 60 days after receiving the request. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request, and will provide a written denial to you. In addition, we may deny your request if you ask us to amend information that:
Was not created by us, unless the person or entity that created the information is no longer available to make the amendment.
Is not part of the protected health information kept by Peak Plastic Surgery, LLC.
Is not part of the information which you would be permitted to inspect and copy.
We believe is accurate and complete.
Right to an Accounting of Disclosures
You have the right to request an "accounting of disclosures." This is a list of the disclosures we made of protected health information about you. To request this list or accounting of disclosures, you must submit your request in writing to Peak Plastic Surgery, LLC. You may ask for disclosures made up to six years before your request (not including disclosures made before June 25, 2014). The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We are required to provide a listing of all disclosures except the following:
For your treatment.
For billing and collection of payment for your treatment.
For health care operations.Made to or requested by you, or that you authorized.Occurring as a byproduct of permitted use and disclosures.
For national security or intelligence purposes or to correctional institutions or law enforcement regarding inmates.
As part of a limited data set of information that does not contain information identifying you.
Right to Request Restrictions
You have the right to request a restriction or limitation on the protected health information we use or disclose about you for treatment, payment, or health care operations or to persons involved in your care. We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment, the disclosure is to the Secretary of the Department of Health and Human Services, or the disclosure is for one of the purposes described on pages 4-5. To request restrictions, you must make your request in writing to Peak Plastic Surgery, LLC.
You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. To request confidential communications, you must make your request in writing to Peak Plastic Surgery, LLC. We will accommodate all reasonable requests.
You have the right to a paper copy of this Notice at any time by contacting Peak Plastic Surgery, LLC.
We will obtain your written authorization before using or disclosing your protected health information for purposes other than those provided for above (or as otherwise permitted or required by law). You may revoke this authorization in writing at any time. Upon receipt of the written revocation, we will stop using or disclosing your information, except to the extent that we have already taken action in reliance on the authorization.
If you believe your privacy rights have been violated, you may file a complaint with Peak Plastic Surgery, LLC, or file a written complaint with the Secretary of the Department of Health and Human Services. A complaint to the Secretary should be filed within 180 days of the occurrence of the complaint or violation. If you file a complaint, we will not take any action against you or change our treatment of you in any way.