Evernow Medical Group, P.C. Informed Consent for Telehealth Services
Telehealth involves the use of secure electronic communications, information technology, or other means to enable a healthcare provider and a patient at different locations to communicate and share individual patient health information for the purpose of rendering clinical care. This “Telehealth Informed Consent” informs the patient (“patient,” “you,” or “your”) concerning the treatment methods, risks, and limitations of using a telehealth platform.
Telehealth services offered by Evernow Medical Group, P.A., a Florida professional service corporation, Rafid A H Fadul, M.D., P.C., a California professional corporation, Evernow Medical Group of Kansas, P.A., a Kansas professional corporation, and Evernow Medical Group of New Jersey, P.C., a New Jersey professional corporation (collectively, “Group”), and the Group’s engaged providers (our “Providers” or your “Provider”) may include a patient consultation, diagnosis, treatment recommendation, prescription, and/or a referral to in-person care, as determined clinically appropriate (the “Services”).
Evernow, Inc. does not provide the Services; it performs administrative, payment, and other supportive activities for Group and our Providers.
The types of electronic transmissions that may occur using the telehealth platform include, but are not limited to:
- Appointment scheduling;
- Completion, exchange, and review of medical intake forms and other clinically relevant information (for example: health records; images; output data from medical devices; sound and video files; diagnostic and/or lab test results) between you and your Provider via:
- asynchronous communications;
- two-way interactive audio in combination with store-and-forward communications; and/or
- two-way interactive audio and video interaction;
- Treatment recommendations by your Provider based upon such review and exchange of clinical information;
- Delivery of a consultation report with a diagnosis, treatment and/or prescription recommendations, as deemed clinically relevant;
- Prescription refill reminders (if applicable); and/or
- Other electronic transmissions for the purpose of rendering clinical care to you.
- Improved access to care by enabling you to remain in your preferred location while your Provider consults with you. Our telehealth services are available 24 hours a day, 7 days a week.
- Convenient access to follow-up care. If you need to receive non-emergent follow-up care related to your treatment, please contact your Provider by sending a message to your Evernow provider using the Evernow website or iOS app.
- More efficient care evaluation and management. Communications are typically responded to in less that 24 hours, and are available 24 hours a day, 7 days per week. Note that there may be delays during holidays and weekends.
- The primary difference between telehealth and direct in-person service delivery is the inability to have direct, physical contact with the patient. Accordingly, some clinical needs may not be appropriate for a telehealth visit and your Provider will make that determination.
- Our 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. Please do not attempt to contact EVERNOW, INC., GROUP, or your Provider. After receiving emergency healthcare treatment, you should visit your local primary care PROVIDER.
- Our Providers are an addition to, and not a replacement for, your local primary care provider. Responsibility for your overall medical care should remain with your local primary care provider, if you have one, and we strongly encourage you to locate one if you do not.
- Group does not have any in-person clinic locations.
The electronic communication systems we use 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. All the Services delivered to the patient through telehealth will be delivered over a secure connection that complies with the requirements of the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”).
- Delays in evaluation and treatment could occur due to deficiencies or failures of the equipment and technologies, or provider availability.
- In the event of an inability to communicate as a result of a technological or equipment failure, please contact the Group at (877) 897-6320 or firstname.lastname@example.org.
- In rare events, your Provider may determine that the transmitted information is of inadequate quality, thus necessitating a rescheduled telehealth consult or an in-person meeting with your local primary care doctor.
- In very rare events, security protocols could fail, causing a breach of privacy of personal medical information.
I further acknowledge and understand the following:
- Prior to the telehealth visit, I have been given an opportunity to select a provider as appropriate, including a review of the provider’s credentials, or I have elected to visit with the next available provider from Group, and have been given my Provider’s credentials.
- I understand that I may be asked to provide my identification and confirm my physical location prior to or during the telehealth visit.
- If I am experiencing a medical emergency, I will be directed to dial 9-1-1 immediately and my Provider is not able to connect me directly to any local emergency services.
- I may elect to seek services from a medical group with in-person clinics as an alternative to receiving telehealth services from Group.
- I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time without affecting my right to future care or treatment.
- Federal and state law requires health care providers to protect the privacy and the security of health information. I am entitled to all confidentiality protections under applicable federal and state laws. I understand all medical reports resulting from the telehealth visit are part of my medical record.
- Group will take steps to make sure that my health information is not seen by anyone who should not see it. Telehealth may involve electronic communication of my personal health information to other health practitioners who may be located in other areas, including out of state. I consent to Group using and disclosing my health information for purposes of my treatment (e.g., prescription information) and care coordination, to receive reimbursement for the services provided to me, and for Group’s health care operations.
- Dissemination of any patient-identifiable images or information from the telehealth visit to researchers or other educational entities will not occur without my consent unless authorized by state or federal law.
- There is a risk of technical failures during the telehealth visit beyond the control of Group.
- In choosing to participate in a telehealth visit, I understand that some parts of the Services involving tests (e.g., labs or bloodwork) may be conducted at another location such as a testing facility, at the direction of my Provider.
- Persons may be present during the telehealth visit other than my Provider who will be participating in, observing, or listening to my consultation with my Provider (e.g., in order to operate the telehealth technologies). If another person is present during the telehealth visit, I will be informed of the individual’s presence and his/her role.
- My Provider will explain my diagnosis and its evidentiary basis, and the risks and benefits of various treatment options.
- I understand that by creating a treatment plan for me, my Provider has reviewed my medical history and clinical information and, in my Provider’s professional assessment, has made the determination that the provider is able to meet the same standard of care as if the health care services were provided in-person when using the selected telehealth technologies, including but not limited to, asynchronous store-and-forward technology.
- I have the right to request a copy of my medical records. I can request to obtain or send a copy of my medical records to my primary care or other designated health care provider by contacting the Group at: email@example.com . A copy will be provided to me at reasonable cost of preparation, shipping and delivery.
- It is necessary to provide my Provider a complete, accurate, and current medical history, as well as accurate vital signs when requested. I understand that I can log into my “Portal” https://care.evernow.com/ at any time to access, amend, or review my health information.
- There is no guarantee that I will be issued a prescription and that the decision of whether a prescription is appropriate will be made in the professional judgment of my Provider. If my Provider issues a prescription, I have the right to select the pharmacy of my choice.
- There is no guarantee that I will be treated by a Group provider. My Provider reserves the right to deny care for potential misuse of the Services or for any other reason if, in the professional judgment of my Provider, the provision of the Services is not medically or ethically appropriate.
Additional State-Specific Consents: The following consents apply to patients accessing Group’s website for the purposes of participating in a telehealth consultation as required by the states listed below:
Alaska: 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.
California: I have been informed of the following notice:
The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. It can be found at https://openpaymentsdata.cms.gov.
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.
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.
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 (or, alternatively, by accessing this URL in my browser: 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; Or, the Maine Board of Osteopathic Licensure’s website, here.
Oregon: 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.
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.
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 our website at 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 have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here; Or, the Vermont Board of Osteopathic Examiners’ website, here.
MEDICALLY-ASSISTED WEIGHT LOSS
Medically-Assisted Weight Loss (“MAWL”) may involve, but is not necessarily limited to, the use of prescription weight management medications which have inherent risks and may include taking medication for more than 12 weeks and when indicated in higher doses than the dosage indicated in the medication’s labeling. This “Weight Loss Informed Consent” informs the patient (“patient,” “you,” or “your”) concerning the treatment methods, risks, and limitations of MAWL treatment.
MAWL Service Risks and Benefits:
I understand each patients’ situation is unique (biology, environment, psychology) and it is up to my Provider to determine in the Provider’s professional judgment if and when a patient should try medication in addition to lifestyle modifications. I understand that any medical treatment, including MAWL, may involve risks as well as benefits. I agree to discuss such risks and benefits with my Provider prior to commencing MAWL treatment and acknowledge that I can contact my Provider if I have any questions regarding MAWL treatment and/or prescribed medications.
For a disclosure of indications and usage, limitations of usage, contraindications, warnings and precautions, adverse reactions, risk of drug abuse and dependence, overdosage and other related patient counseling information, I agree to carefully review the U.S. Food and Drug Administration’s (FDA) warning label information for any prescribed MAWL treatments on the FDA’s website.
Use of Off Label Medications
Off label prescribing is when a provider prescribes you a drug that the FDA has approved to treat a different condition and is not specifically approved in the labeling as an MAWL treatment. When prescribed, such treatments are expected by the provider to have a clinical benefit greater than any potential risk to your health. The benefits of Off Label medication use can include access to a wider variety of treatment options as well as personalization of a medication regimen. For more information on Off Label prescribing please visit the FDA’s website, here.
Nature of Medically-Assisted Weight Loss
Semaglutide is a human-based glucagon-like peptide-1 receptor agonist prescribed as an adjunct to a reduced calorie diet and increased physical activity for chronic weight management in adults with an initial body mass index (BMI) that is considered outside a healthy range.
While using Semaglutide, it is highly recommended that you:
- Eat a fibrous diet. Focus on fruits and vegetables that are high in fiber.
- Eat small high protein meals as digestion is slowed down while on this medication.
- Avoid foods high in fat as they take longer to digest.
- Limit alcohol intake as this medication can lower blood pressure.
- Drink at least 32oz of water a day to avoid constipation.
Do not take this medication if:
- You have a personal or family history of Medullary Thyroid Carcinoma (Thyroid Cancer)
- Multiple Endocrine Neoplasia Syndrome Type 2
Before taking this medication, tell your doctor if:
- You are pregnant or plan to become pregnant while taking this medicine.
- You are diabetic and/or taking any medications related to lowering your blood sugar levels without speaking with your endocrinologist.
- Specifically, if you are prescribed Insulin because the combination may increase your risk of hypoglycemia (low blood sugar) and dosage adjustments by your provider may be necessary.
- You have a history of Pancreatitis, gallbladder disease, or kidney disease
- If you have diabetic retinopathy (damage to the eyes caused by diabetes),
- You are allergic to BPC-157, Semaglutide or any other GLP-1 agonist such as: Adlyxin®, Byeta®, Bydureon®, Ozempic®, Rybelsus®, Trulicity®, Victoza®, Wegovy®;
- If you have other allergies. This product may contain inactive ingredients, which can cause allergic reactions or other problems. Talk to your pharmacist for more details.
Before using this medication, tell your doctor/pharmacist your medical history.
Possible drug interactions: Anti-diabetic agents, specifically: Insulin and Sulfonylureas (e.g., glyburide, glipizide, glimepiride, tolbutamide) due to the increased risk of hypoglycemia (low blood sugar). Do not take with other GLP-1 agonist medicines such as: Adlyxin®, Byeta®, Bydureon®, Ozempic®, Rybelsus®, Trulicity®, Victoza®, Wegovy® . Other medications used in diabetes, please tell your provider about any medications that may lower your blood sugar.
Possible side effects include but are not limited to: Nausea, diarrhea, vomiting, constipation, abdominal pain, headache, fatigue, dyspepsia, dizziness, abdominal distension, belching, hypoglycemia, flatulence, gastroenteritis, and gastroesophageal reflux disease. This medication may cause changes in your blood sugar. You should know the symptoms of low and high blood sugar and what to do if you have these symptoms.
Subcutaneous Injections: Common injection site reactions may be characterized by itching, burning at site of administration with or without thickening of the skin (welting). The FDA is currently investigating a possible link between semaglutide and hair loss (alopecia). This has not yet been officially listed as a side effect, but understand it could be possible. If you notice other side effects not listed above, contact your doctor or pharmacist.
A very serious allergic reaction to this drug is rare. However, get medical help right away if you notice any symptoms of a serious allergic reaction, including rash, itching/swelling (especially of the face/tongue/throat), severe dizziness, trouble breathing. Report adverse side effects to your doctor or pharmacist. In the event of any emergency, call 911 immediately.
Do not reuse your injection needles and do not share needles with others to prevent the risk of transmission of blood-borne pathogens.
IF YOU HAVE ANY QUESTIONS AS TO THE RISKS OR HAZARDS OF THIS TREATMENT, OR ANY QUESTIONS CONCERNING THIS PROPOSED TREATMENT OR OTHER POSSIBLE TREATMENTS, ASK YOUR PROVIDER.
I further acknowledge and understand the following:
- If my Provider prescribes medications, I will carefully follow instructions, recommended dosage, and methods of administration of my MAWL treatment.
- I will participate in the initial and subsequent Provider visits, as required to safely monitor my MAWL treatment.
- I will be under the regular care of another physician or health care provider (e.g., primary care physician, urologist, endocrinologist, etc.) for all other medical conditions. I will consult my physician(s) for any other medical services I may require. I understand Group is a specialized practice focused solely on weight loss treatment.
- I understand that I may suspend or terminate MAWL treatment at any time and hereby agree to immediately notify my Provider of any desire to suspend or terminate this treatment so that such suspension or termination may be done safely.
- I understand my Provider may be assisted by other health professionals, as necessary, and agree to their participation in my care as it relates to the evaluation and treatment of the conditions I am seeking care for from Group.
- I certify that I am 18 years of age or older, am competent to sign this Weight Loss Informed Consent, and have done so of my own free will.
- I will immediately report any adverse side effects related to the use of my medications to my Provider.
- I will not share, sell or trade my medications for money, goods or services.
- I will keep my medications in their respective labeled container and will safeguard my medications from loss or theft.
- I will not attempt to obtain MAWL medications illegally or from any other health care practitioner without disclosing my current medication usage. I understand that it is against the law to do so.
- I am responsible for remaining up to date on all age-appropriate screenings including, but not limited to, colonoscopy, cardiac screenings as necessary (stress test, etc.) through other appropriate health care provider(s) (e.g., primary care provider, cardiologist, urologist, etc.).
- I will notify my Provider of any change in my medical history.
Additional State-Specific Notices: The following notices apply to patients prescribed MAWL treatment as required by the states listed below:
Florida: Florida Weight-Loss Consumer Bill of Rights
- Rapid weight loss may cause serious health problems. Rapid weight loss is weight loss of more than 1 ½ pounds to 2 pounds per week or weight loss of more than 1 percent of body weight per week after the second week of participation in a weight-loss program.
- Consult your personal physician before starting any weight-loss program.
- Only permanent lifestyle changes, such as making healthful food choices and increasing physical activity, promote long-term weight loss.
- Qualifications of your weight loss provider are available upon request.
You have a right to:
- Ask questions about the potential health risks of this program and its nutritional content, psychological support, and educational components.
- Receive an itemized statement of the actual or estimated price of the weight-loss program, including extra products, services, supplements, examinations, and laboratory tests.
- Know the actual or estimated duration of the program.
- Know the name, address, and qualifications of the person who has reviewed and approved the weight-loss program according to section 468.505(1)(j), Florida Statutes.
Patient Informed Consent
By checking this Box, I acknowledge that I have carefully read, understand, and agree to the terms of this “TELEHEALTH AND MEDICALLY-ASSISTED WEIGHT LOSS INFORMED CONSENT” and consent to receive the Services.