Consent to treat & telehealth servicestoan
This Consent to Treatment & Telehealth Services (“Consent”) governs the provision of treatment and use of
telehealth services provided by Inner Balance, LLC. (“Inner Balance”) and its Providers (collectively, the
“Services”). All capitalized terms used in this Consent but not defined herein will have the meanings
you have read this information and made an informed decision that the Services are right for you. If you
have any questions, please email us at firstname.lastname@example.org
“Provider(s)” means the medical professionals contracted with Inner Balance to provide certain healthcare services on behalf of Inner Balance. Because Inner Balance providers function as a Clinical Team to provide healthcare services, the term “Provider” or “my Provider” as used herein refers to the Inner Balance Clinical Team as a whole.
“Telehealth” means the use of electronic information and communication technologies by Providers to deliver health care services to patients not at the same physical location, which may include the assessment, diagnosis, consultation, treatment, education, care management and/or self-management of a patient. Such communication can include electronic transfer of medical records, images/photographs, health information, or other Personal Information between you and the Providers, live conversations or other interactions between you and the Providers via messaging, audio, video, and/or media, and use and analysis of output data from medical or wearable devices, sound, video, and other related files.
Although the provision of healthcare services using telehealth may offer potential benefits, there are potential risks associated with the use of telehealth. These risks are described in more detail below. Telehealth services may not be a substitute for in-person health care in all cases.
The telehealth services provided by Inner Balance include an initial hormone health assessment via questionnaire as well as follow-up up that may include audio, email, chat, or text with Inner Balance healthcare team members and/or providers. Inner Balance’s telehealth services may provide an easier and more efficient way for you to obtain these healthcare services at a time and place most convenient for you and you can interact with the Providers without needing an in-office appointment. Your Provider will interact with you by computer messaging or smartphone instead of in person. You will be able to message the Provider and ask any questions. The Provider will then respond to your questions, or follow-up during regular business hours. The Provider will be able to assess your hormone condition, provide medical advice, and prescribe treatment (including medication), as appropriate.
Just as with an in-person encounter, there are potential risks associated with the use of telehealth.
These risks may include, but are not limited to:
• Limitations on the availability and/or appropriateness of specific health services as a result of the Services being offered remotely (e.g., information transmitted to the Providers may not be sufficient to allow for appropriate medical decision making by the Providers and the inability of your Providers to conduct certain tests or assess vital functions and signs in-person may prevent the Providers from providing a diagnosis or treatment).
• Risks to the confidentiality and security of your health information, including Personal Information, related to your use of potentially unsecure electronic and telecommunication technologies (see below).
• Technology issues that may occur while completing your questionnaire or while messaging with a provider (however, alternative communication methods may be available if you are having connectivity issues).
• Limitations in treatment options due to regulatory restrictions in certain jurisdictions.
In order to participate in Inner Balance’s services, you must review and agree to this Consent. By
accepting this Consent, you acknowledge your understanding and agree to the following:
• I have read the above information and have had an opportunity to ask questions.
• I understand the benefits and risks of receiving telehealth services.
• I voluntarily request and consent to medical care and treatment by Inner Balance Providers and give my informed consent to the use of telehealth by my Provider.
• My Provider may retrieve my medication history for treatment related purposes.
• My Provider will only prescribe medication as they deem medically appropriate.
• I have the right to refuse any treatment recommended by my Provider.
• I have the right to discuss my hormone treatment with my Provider.
• I understand that my Provider may determine, in their sole discretion, that: 1) prescription of medication is not medically appropriate; 2) my condition is not suitable for treatment using telehealth; and/or 3) that I may need to seek medical care and treatment in-person or from an alternative source.
• I understand that I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time by emailing email@example.com with such instruction; otherwise, this consent will remain in effect for as long as I receive services from Inner Balance and will be considered renewed upon each encounter (Telehealth, audio, or messaging) with my Provider.
• I understand that while the use of telehealth may provide potential benefits to me, as with any medical care service, no such benefits or specific results can be guaranteed.
• I understand that I have the right to access my health and wellness information pertaining to the Services delivered via telehealth in accordance with applicable laws and regulations.
• My Provider may share information regarding my telehealth exam and the Services I received from my Provider with other individuals, pharmacy and Inner Balance customer service members for treatment, payment, and health care operations purposes as described in Inner Balance’s Notice of Privacy Practices.
• Inner Balance may contact me via text message/SMS and/or email for treatment related purposes.
• Inner Balance may prescribe medication as part of services. Such medication may have side effects and potential risks as described on the label of each medication. I understand that I should review all potential side effects and risks of any medication prescribed by Provider with my Provider.
• Inner Balance does not provide urgent care or treat medical emergencies nor does Inner Balance offer or provide primary care services, or dispense other medications other than ones specified when subscribing or on purchase. If you ever have an urgent care need or medical emergency, you must dial 911.
• I understand that medical treatment doesn’t qualify for reimbursement from Medicare, or any other government insurance program. I agree to not submit any claims to Medicare or other government insurance program and agree to indemnify Inner Balance against any claim, action, or loss which results from submission of a claim.