By clicking “I agree” check box to signify your acceptance or submitting your information to Alpha Hormones Inc., using any other acceptance protocol presented through the service or otherwise affirmatively accepting this consent, you acknowledge that you have reaped, accepted, and agreed to be bound by this consent. If you do not agree to this consent, do not create an account or use these services. You hereby grant agency authority to any party who clicks on the “I agree” button or otherwise indicates acceptance to this consent on your behalf.
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 by physicians, physician assistants, and nurse practitioners (“Providers”) using the online platforms owned and operated by Alpha Hormones Inc. (the Company).
Introduction
Telehealth involves 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. Providers may include primary care practitioners, specialists, and/or subspecialists. The information may be used for diagnosis, therapy, follow-up and/or education, and may include any of the following:
- Patient medical records
- Medical images
- Live two-way audio and video
- Output data from medical devices and sound and video files
Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.
Expected Benefits
The use of telehealth may have the following possible benefits:
- Making it easier and more efficient for you to access medical care and treatment for the conditions treated by your Provider(s).
- Allowing you to obtain medical care and treatment by Provider(s) at times that are convenient for you.
- Enabling you to interact with Provider(s) without the necessity of an in-office appointment.
- Obtaining expertise of a distant specialist.
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:
- The quality, accuracy or effectiveness of the services you receive from your Provider could be limited’ technology, including the Company, may contain bugs or other errors, including ones which may limit functionality, produce erroneous results, render part or all of such technology, including the Company, unavailable or inoperable, produce incorrect records, transmissions, data or content, or cause records, transmissions, data or content to be corrupted or lost.
- Failures of technology may also impact your Provider(s) ability to correctly diagnose or treat your medical condition.
- The inability of your Provider(s) to conduct certain tests or assess vital signs in-person may in some cases prevent the Provider(s) from providing a diagnosis or treatment or from identifying the need for emergency medical care or treatment for you.
- Your Provider(s) may not able to provide medical treatment for your particular condition and you may be required to seek alternative healthcare or emergency care services.
- Delays in medical evaluation/treatment could occur due to unavailability of your Provider(s) or deficiencies or failures of the technology or electronic equipment used.
- In very rare instances, the electronic systems or other security protocols or safeguards used could fail, causing a breach of privacy of your medical or other information.
- Given regulatory requirements in certain jurisdictions, your Provider(s) diagnosis and/or treatment options, especially pertaining to certain prescriptions, may be limited.
- In rare cases, a lack of access to all of your medical records may result in adverse drug interactions or allergic reactions or other judgment errors.
Follow-up Care and Emergency Situations
If the situation is an emergency, call 911. In some situations, telehealth is not an appropriate method of care. If you require immediate or urgent care, you must seek care at an emergency room facility or other provider equipped to deliver urgent or emergent care.
If you are not experiencing an emergency or do not require immediate or urgent care, you can communicate with Provider(s) through the secure message service in the Patient Portal. If a technical failure prevents you from communicating with your Provider(s) through the Patient Portal or Karla, our secure HIPAA compliant communication system, you should call the following number (213) 334-4111.
Data Privacy and Protection
The electronic systems used in the Company will incorporate network and software security protocols to protect the privacy and security of your information, and will include measures to safeguard data against intentional or unintentional corruption. Personal information that identifies you or contains protected health information will not be disclosed to any third party without your consent, except as authorized by law for the purposes of consultation, treatment, payment/billing, and certain administrative purposes, or as otherwise set forth in our Privacy Policy.
Your Acknowledgments
By clicking “I agree,” checking a related box to signify your acceptance or submitting your information to Alpha Hormones Inc., using any other acceptance protocol presented through the Company or otherwise affirmatively accepting this consent, you are agreeing and providing your consent with respect to the following:
- Healthcare services provided to you by Provider(s) via the Company will be provided by telehealth.
- Certain technology, including the Company, may be used while still in a beta testing and development phase, and before such technology is a final and finished product.
- Technology used to deliver care, including the Company, may contain bugs or other errors, including ones which may limit functionality, produce erroneous results, render part or all of such technology unavailable or inoperable, produce incorrect records, transmissions, data or content, or cause records, transmissions, data or content to be corrupted or lost, any or all of which could limit or otherwise impact the quality, accuracy and/or effectiveness of the medical care or other services that you receive from your Provider(s).
- The delivery of healthcare services via telehealth is an evolving field and the use of telehealth or other technology in your medical care and treatment from Provider(s) may include uses of technology different from those described in this Consent or not specifically described in this Consent.
- You understand that if others are present during the consultation other than your health care provider, they will maintain confidentiality of the information obtained. You further understand that you will be informed of their presence in the consultation and thus will have the right to request the following:
- Omit specific details of your medical history/physical examination that are personally sensitive to you.
- Ask non-medical personnel to leave the telehealth examination room.
- No potential benefits from the use of telehealth or other technology or specific results can be guaranteed.
- Your condition may not be cured or improved, and in some cases, may get worse.
- There are limitations in the provision of medical care and treatment via telehealth and technology, including the Company, and you may not be able to receive diagnosis and/or treatment through telehealth for every condition for which you seek diagnosis and/or treatment.
- There are potential risks to the use of telehealth and other technology, including but not limited to the risks described in this Consent.
- You have the opportunity to discuss the use of telehealth, including the Company, with your Provider(s), including the benefits and risks of such use and the alternatives to the use of telehealth.
- You have the right to withdraw your consent to the use of telehealth in the course of your care, without prejudice to any future care or treatment and without risking the loss or withdrawal of any health benefits to which your entitled, but you understand that the Providers who utilize the Company do not offer in-person treatment.
- Any withdrawal of your consent will be effective upon receipt of written notice to your Providers, except that such withdrawal will not have any effect on any action taken by Alpha Hormones Inc. or your Provider(s) in reliance on this Consent before it received your written notice of withdrawal. Any withdrawal of your consent will not affect any other provision of this Consent, and you will continue to be bound by this Consent.
- You understand that the use of telehealth involves electronic communication of your personal medical information to Provider(s).
- You understand that it is your duty to provide Alpha Hormones Inc. and your Provider(s) truthful, accurate and complete information, including all relevant information regarding care that you may have received or may be receiving from healthcare providers.
- You understand that each of your Provider(s) may determine in his or sole discretion that your condition is not suitable for diagnosis and/or treatment using telehealth technology, including the Company, and that you may need to seek medical care and treatment from your Provider(s), or a specialist or other healthcare provider, outside of such telehealth technology.
- You are free to obtain your medical examination from another healthcare provider that is not associated with the Company.
- Alpha Hormones Inc. will use its compounding pharmacy partner to fulfill your order directly to your door. You are free to obtain your prescription from any compounding pharmacy of your choice by contacting our support team.
- Alpha Hormones Inc. will use Quest, LabCorp, and other specialty labs for diagnostic tests. You are free to obtain your lab test whether its blood spot or blood serum, wet urine or dry urine, saliva test, etc. from any laboratory company.
- You have sole financial responsibility for use of the Company and any products provided to you and must pay the full amount of the costs associated with use of the Company, including any prescription you may receive.
- You have had the alternatives to a telehealth consultation explained to me, and in choosing to participate in telehealth with the Company.
- You have had a direct conversation with your healthcare provider, during which you had the opportunity to ask questions in regard to this procedure. Your questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language in which you understand.
- You have read and understand the information provided above regarding telehealth, have discussed it with your physician or such assistants as may be designated, and all of your questions have been answered to your satisfaction. You hereby give your informed consent for the use of telehealth in your medical care. You hereby authorize Alpha Hormones Inc. and its associates to use telehealth in the course of your diagnosis and treatment.
