Medical Consent

IMPORTANT NOTICE:
WE ARE NOT A REPLACEMENT FOR EMERGENCY MEDICAL SERVICES. IF YOU HAVE A MEDICAL EMERGENCY, SEEK EMERGENCY MEDICAL CARE IMMEDIATELY IN-PERSON OR DIAL 911 OR YOUR LOCAL EMERGENCY NUMBER.

I. Changes to Terms

We may change these terms at any time, as required by law. This may include adding, removing, or modifying terms in response to legal, business, competitive, or other reasons not listed here.

II. Telehealth Consent

Telehealth Overview:

Telehealth is a method of providing healthcare services through audio-video interfaces, such as videoconferencing.

Data Security:

The electronic systems we use incorporate security protocols to protect the confidentiality of client identification and imaging data, ensuring its integrity against intentional or unintentional corruption.

Expected Benefits:

  • Improved access to weight loss management healthcare by enabling services across distances.
  • More efficient healthcare delivery, including medical evaluation and management.
  • Access to expertise from distant specialists.
  • Continuity of care with established providers in other locations.

Possible Risks:

  • Insufficient information transmitted (e.g., poor image resolution) that may hinder appropriate medical decision-making.
  • Delays in evaluation and treatment due to equipment failures.
  • Rare security breaches that may compromise personal medical information.
  • Adverse drug interactions or allergic reactions due to incomplete medical records.

By consenting to telehealth services, I understand the following:

  • Confidentiality Protection: Laws protecting the privacy of medical information also apply to telehealth. My identifiable information will not be disclosed to researchers or other entities without my consent.
  • Right to Withdraw Consent: I have the right to withhold or withdraw my consent for telehealth services at any time without affecting my right to future care.
  • Access to Information: I have the right to inspect all information obtained during telehealth interactions and may receive copies for a reasonable fee.
  • Alternative Methods: I understand that various alternative methods of weight loss management are available and that I may choose them at any time.
  • Disclosure of Other Providers: It is in my best interest to inform my healthcare provider about any other healthcare providers involved in my care.
  • Anticipated Benefits: I may expect the anticipated benefits from telehealth services, but no results can be guaranteed.

Client Consent to Telehealth:
I have read and understood the information regarding telehealth and have discussed it with my healthcare provider. All my questions have been answered to my satisfaction. I hereby give my informed consent for the use of telehealth in my weight loss management healthcare. I have been offered a copy of this form for my records. My continued use of the services constitutes my understanding and acceptance of these terms, and I authorize the use of telehealth in my diagnosis and treatment.

III. HIPAA Consent

The Health Insurance Portability and Accountability Act (HIPAA) safeguards your privacy. Implementation of HIPAA requirements began on April 14, 2003. This is a simplified version; a complete text is available in our office.

What This Means:

HIPAA regulates who may see or be notified of your Protected Health Information (PHI). It also ensures certain rights and protections for patients. We balance these needs with our commitment to providing quality care. More information is available at the U.S. Department of Health and Human Services website: www.hhs.gov.

Our Policies:

  • Patient information is confidential and shared only as necessary to provide services and manage administrative matters, including sharing information with other healthcare providers, laboratories, and health insurance payers.
  • Patient files may be stored in open file racks without coding that identifies the patient’s condition or other sensitive information not already public.
  • Records may be temporarily left in administrative areas and will be accessible only to staff and authorized providers.
  • Appointment reminders may be communicated via phone, email, U.S. mail, or any method requested by you.
  • We utilize vendors who may access PHI but must comply with HIPAA confidentiality rules.
  • You may expect inspections and document reviews by government agencies or insurance payers in the normal course of duties.
  • Your confidential information will not be used for marketing or advertising products, goods, or services.
  • We will provide you access to your records per state and federal laws.

You have the right to request restrictions on the use of your PHI and changes in office policies. However, we are not obligated to change internal policies based on your requests.

My continued use of services constitutes my understanding and acceptance of the terms in the HIPAA Information Form and any future policy changes.

IV. Financial Consent

I understand and accept the terms that a credit card may be kept on file, and that any remaining balances for services rendered must be paid in full. I authorize Benhuri Wellness Clinic to submit on my behalf and release any medical records or other information necessary to process my consultation order. Fee schedules and receipts for all professional services are available upon request.

  • I authorize Benhuri Wellness Clinic to make invoice changes and debit my account for orders placed, goods received, and/or services rendered that are not fully covered by third-party vouchers or credits.
  • I authorize Benhuri Wellness Clinic to charge my credit card account for any unpaid balances due.
  • All programs are auto-renewing, and I consent to be automatically charged for any program I participate in unless I explicitly request to cancel before my payment is processed. There are no refunds or exchanges. I certify that I am an authorized user of this credit card and will not dispute payments with my credit card company.

Contact Information:

Benhuri Wellness Clinic 9400 Brighton Way, Suite 210 Beverly Hills, CA 90210 Email: [email protected] Phone: (310) 362-1255

V. Shipping Authorization

All prescription medications are dispensed according to state and federal law, approved by the pharmacist in charge, and in compliance with relevant Medical Boards and State Boards of Pharmacy. By requesting shipping, I disclaim and agree to hold harmless Benhuri Wellness Clinic for any delays or errors during shipping. Medication is considered dispensed when it is signed out for shipping, not when it is delivered. My continued use of the services constitutes my understanding and acceptance of the above terms, and I give permission for Benhuri Wellness Clinic to ship medication to me at the address provided in my intake form or any other address I provide.