Telemedicine Consent & Service Agreements, Controlled Substance Consent, and Pharmacy Consent Forms

Patient Consent and Service Agreement

Nature of Services

Provider offers healthcare services through telemedicine. These services may include evaluation, diagnosis, consultation, treatment, prescription management, and follow-up via electronic communication methods (e.g., video, phone, or secure messaging).

Consent to Treatment

• The Patient hereby consents to the rendering of medical care and treatment by the Provider and acknowledges that the medical care and treatment has been adequately explained.
• Patient understands that Patient has the right to refuse any treatment.
• Patient has had the opportunity to ask questions and all questions have been answered to Patient’s satisfaction.
• Patient accepts full responsibility for payment of the Provider’s charges for all services furnished to Patient.

Consent to Telemedicine

The Patient understands:

• Telemedicine involves the use of electronic communications to interact with healthcare providers.
• The scope of telemedicine services may include diagnosis, treatment, medication, management, education, and administrative support.
• Limitations of telemedicine may include the inability to conduct certain physical examinations or tests.
• The Patient may withdraw consent at any time by providing written notice, but this will not affect services already rendered.

Risks and Benefits

The Patient acknowledges:

• Telemedicine has risks, including interruption, unauthorized access, or technical failures.
• Despite these risks, the benefits include improved access to care, convenience, and real-time communication.

Privacy and Confidentiality

• Provider complies with HIPAA and applicable state and federal laws.
• Electronic communication will be conducted through secure platforms.
• The Patient is responsible for securing their own devices and maintaining privacy during remote visits.

Insurance and Payment

• Provider will bill insurance for covered services if the Patient has active coverage and has provided complete information, subject to such policy’s rules.
• Certain services may not be covered and may result in out-of-pocket charges.
• The Patient is responsible for any co-pays, deductibles, or fees not covered by insurance.

Limitation of Liability

• The Patient agrees not to hold Provider, its agents, or affiliates liable for any damages arising out of the use or failure of telemedicine technologies or from delays due to technical issues.
• This Agreement does not waive the Patient’s right to file a claim in the event of gross negligence or willful misconduct.

Legal Venue

Any disputes arising from this Agreement will be governed by the laws of the State of Ohio and resolved in the appropriate court of Mahoning County, Ohio.

Pricing, Membership and Access Fee Agreement

Membership Terms

• Membership is month-to-month.
• Fees are auto-charged monthly and non-refundable.
• Services not used during the billing period do not roll over.
• The Member may cancel or change membership at any time in writing, but the current month’s charge remains in effect.

Services Not Included

• Hospital care, emergency services, specialist visits outside of sleep medicine appointments, or procedures are not included.
• Insurance will still be billed for medically necessary services, and membership does not replace insurance.

Termination of Agreement

• Provider may terminate this Agreement with notice if payment is not received or if the Member violates office policies.
• Member may cancel without penalty but is not entitled to a refund for partial months.

Indemnification and Disclaimer

• The Member understands this Agreement provides access to enhanced convenience, not insurance coverage.
• Provider disclaims liability for any adverse outcomes outside the scope of covered services.
• Member agrees to hold Provider harmless for delays or limitations inherent to asynchronous care models.

Patient Controlled Substance Agreement

Purpose of Agreement

This Controlled Substance Use Agreement is intended to inform the patient and establish mutual understanding about the safe, effective, and appropriate use of controlled substances for medical treatment.

Scope of Treatment

Controlled substances may be prescribed for the treatment of sleep disorders, pain, ADHD, and other medically appropriate conditions when deemed necessary by the Provider.

Patient Responsibilities

• Take medications exactly as prescribed. No dose changes without Provider approval.
• Use only one pharmacy to fill controlled substances and notify Provider of any changes.
• Do not obtain controlled substances from any other provider without disclosure to this Provider.
• Do not share, sell, or misuse medication under any circumstances.
• Store medications securely to prevent loss or theft.

Monitoring and Compliance

• Random urine drug screens may be requested to verify compliance.
• Pill counts may be conducted to ensure proper use.
• Missed appointments, inconsistent drug screens, or evidence of misuse may result in discontinuation of controlled substances.

Refills and Lost Medications

• Early refills will not be granted.
• Lost or stolen medications will not be replaced without a police report and are not guaranteed to be refilled.
• Refills require a follow-up visit and periodic reassessment.

Prohibited Substances

The use of illicit drugs, including marijuana (where not legally permitted), or alcohol abuse while using controlled substances may result in immediate termination of prescriptions.

Termination of Agreement

• The provider reserves the right to discontinue controlled substance prescribing at any time for non-compliance, concerning behavior, or adverse clinical outcomes.
• This does not terminate the provider-patient relationship but may alter the treatment plan.

Acknowledgement

I understand and agree to the above terms regarding the use of controlled substances. I understand violations of this agreement may terminate the controlled substance prescriptions but not necessarily the patient-physician relationship.

Prescription History Consent

Authorization to Access Prescription History

I hereby authorize the Provider and its affiliated staff to access and review my external prescription history from pharmacy benefit managers, pharmacies, and other healthcare providers for the purpose of providing safe and effective medical care. This may include but is not limited to:

• Viewing medications prescribed by other providers
• Identifying potential drug interactions
• Improving medication adherence and continuity of care
• Ensuring accurate and up-to-date medication records

Patient Acknowledgment

• I understand that my prescription history will be retrieved and used only in accordance with federal and state privacy laws, including the Health Insurance Portability and Accountability Act (HIPAA).
• I understand that I may revoke this authorization at any time by submitting a written request, except to the extent that actions have already been taken based on this consent.
• I acknowledge that refusing to provide access to my prescription history may affect the quality of care I receive, especially related to medication safety.

Consent

By signing below, I consent to the Provider’s access to my external prescription history for treatment purposes. These agreements supersede all prior oral or written understandings. No modifications are valid unless in writing and signed by both parties.