Treatment Consent

Medical Consent

By participating in Clover Meds services—whether for weight management or adjunct therapies such as NAD (Nicotinamide Adenine Dinucleotide) injections—you implicitly agree to the terms outlined in this medical consent. You acknowledge that you have read or have had read to you the below consent and understand the information presented.

The utilization of medications for weight management is recommended for individuals with a BMI of 30 or higher or a BMI of 27 or higher coupled with other medical conditions like high blood pressure, diabetes, or high cholesterol. Weight loss treatment and NAD therapy are both considered elective services, each with potential benefits and risks. By voluntarily participating in these treatments, you acknowledge your choice and agree to hold Clover Meds LLC and independent providers harmless for the use of such interventions.

You recognize that the extent of weight loss (and the effects of any adjunct treatments) varies among individuals and is influenced by personal dedication to diet, exercise, and consistency. No guarantees or specific claims about efficacy or a predetermined amount of weight loss are stated or implied. You acknowledge the significance of regular follow-ups with Clover Meds and your Primary Care Provider to track your progress during treatment. You understand that regular monitoring is crucial for safety and affirm you will adhere to the recommended follow-up schedule.

You hereby authorize Clover Meds and additional staff, including independent providers, to evaluate you for admission into the Clover Meds weight management program or other services offered, and treat you accordingly. You consent to continue regular care with your primary care provider for routine blood work. You certify that you are participating in this program of your free will and are competent to make your own medical decisions.

You have reviewed the mentioned risks and have determined that the benefits outweigh the possible risks associated with medically managed weight loss therapy or NAD injections with Clover Meds. You release any claim in court or any type of complaint that could result from treatment with Clover Meds, their Independent Providers, and any other staff associated with Clover Meds, and will not hold liable any independent provider or staff of Clover Meds LLC.

You understand that treatment modalities utilized by Clover Meds and their independent providers might not be supported by scientific/medical literature and could be seen as experimental or based on anecdotal claims. Many medical providers (including endocrinologists, surgeons, family practice doctors, etc.) may view these types of treatments as not medically necessary. You also understand that the medications being utilized within Clover Meds’ medically managed weight loss program or in NAD therapy are often compounded and do not undergo pre-market approval from the FDA. These treatments are prepared on a patient-specific basis rather than in large batches for the general public. As a result, there may be variations in dose, administration, side effects, and efficacy compared to commercially available brand-name drugs.

Telehealth Consent

Telehealth is a method of providing behavioral health services through audio-video interfaces, such as videoconferencing. The electronic systems used will incorporate network and software security protocols to ensure the confidentiality and integrity of client identification and imaging data.

Expected Benefits:

• Improved access to behavioral health care across distances and between programs.
• More efficient behavioral health care, including psychiatric evaluation and management.
• Access to the expertise of a distant specialist.
• Maintaining connections with established providers in other areas.

Possible Risks:

As with any medical procedure, there are potential risks associated with telehealth for behavioral health treatment. These risks include, but may not be limited to:

• Insufficient information transmission for appropriate medical decision-making.
• Delays in medical evaluation and treatment due to equipment deficiencies.
• Rare instances of security protocol failure leading to a breach of privacy.
• Lack of access to complete medical records potentially resulting in adverse outcomes.

By consenting to these forms, you understand the following:

• Privacy laws apply to telehealth, and no identifying information will be disclosed without my consent.
• You can withhold or withdraw consent to telehealth at any time without affecting future care.
• You have the right to inspect information obtained during a telehealth interaction.
• Alternative methods of behavioral health care are available, and you can choose them.
• It is in your best interest to inform all healthcare providers involved in my care.

Anticipated benefits from telehealth are expected, but results are not guaranteed.

Client Consent to the Use of Telehealth

You have read and understand the information provided regarding telehealth, have discussed it with your healthcare provider, and hereby give your informed consent for its use in Clover Meds services.

HIPAA Consent

The Health Insurance Portability and Accountability Act (HIPAA) establishes safeguards to ensure the confidentiality of your Protected Health Information (PHI). The implementation of HIPAA requirements officially commenced on April 14, 2003. This document serves as a simplified version, with a more comprehensive text available in the office and online.

Overview:

HIPAA imposes rules and restrictions on who may access or be informed of your PHI. These restrictions do not hinder the standard exchange of information necessary for office services. As a patient, you are entitled to specific rights and protections under HIPAA. We strive to balance these requirements with our commitment to providing quality professional service and care. Additional information is accessible from the U.S. Department of Health and Human Services website.

Adopted Policies:

1. Patient information will be kept confidential, shared only as necessary for service provision and administrative matters related to your care. This includes sharing information with healthcare providers, laboratories, and health insurance payers.
2. Patient files may be stored in open file racks without coding that identifies a patient's condition. Records may be temporarily left in administrative areas.
3. Appointment reminders may be sent via telephone, email, U.S. mail, or any convenient means requested by you. Other communications may inform you of policy or procedure changes.
4. The practice collaborates with vendors who may access PHI but must adhere to HIPAA confidentiality rules.
5. You agree to inspections of the office and document reviews, including PHI, by government agencies or insurance payers as part of their normal duties.
6. Concerns or complaints regarding privacy should be brought to the attention of the office manager or the doctor.
7. Your confidential information will not be used for marketing or advertising purposes.
8. Patients have access to their records in accordance with state and federal laws.
9. Provisions may be changed, added, deleted, or modified to better serve the needs of both the practice and the patient.
10. You have the right to request restrictions on the use of your PHI and changes in specific office policies related to your PHI. However, the practice is not obligated to alter internal policies to conform to such requests.

Consent

By continuing to use the services, you acknowledge and accept the terms outlined in the HIPAA INFORMATION FORM, including any subsequent changes in office policy. This consent remains in force from this time forward.

Financial Consent

You agree to keep a credit card on file for services, and any remaining balances will be paid in full. I authorize the release of necessary information for processing orders. I consent to auto-renewal of programs and automatic charges, with no refunds or exchanges.

Shipping Authorization

You understand that prescription medications will be dispensed in compliance with state and federal laws. You hold Clover Meds LLC harmless for any shipping delays or errors. You authorize the shipment of medication to the provided address and agree to the listed conditions.

Your continued use of the services constitutes your understanding and acceptance of the above terms.