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.

Telehealth Consent

This Medical Consent Form outlines your agreement to receive services from healthcare providers utilizing the Anchor MD, LLC ("Anchor MD," "we," "us," or "our") platform. Please read it carefully in conjunction with the Anchor MD Terms of Service, Privacy Policy, and other applicable policies located on our website. References to “I,” “my,” “me,” “you,” or “your” all refer to you, the patient/client/customer.

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Telehealth is the type of care that allows customers to access health services using audio-video interface such as videoconferencing, secure messaging, and other electronic means. Electronic systems used will incorporate network and software security protocols to protect the confidentiality of customer identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

Expected Benefits:

• Improved access to weight loss management services by enabling a customer to receive services remotely and across far distances.

• More efficient weight loss management health care including medical evaluation and management.

• Obtaining 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 the use of telehealth for weight loss management health treatment. These risks include, but may not be limited to:
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• Information and Communication Issues: A lack of access to your complete medical records (including those from other healthcare providers) may result in adverse drug interactions, allergic reactions, misdiagnosis, inappropriate treatment, or other judgmental errors by the Provider. It is crucial to provide accurate and complete information to your Provider.  Misunderstandings or miscommunications can occur between you and your Provider due to the absence of in-person visual and auditory cues. Language barriers or difficulties in expressing symptoms or concerns via electronic means could impact the quality of the consultation.

• Technology Failures and Delays: Delays in medical evaluation, diagnosis, or treatment could occur due to deficiencies or failures of the electronic equipment, including hardware, software, or internet connectivity issues on your end or the Provider's end. This could include dropped calls, platform unavailability, power outages, or other technical difficulties that interrupt or prevent the consultation.  If a technical failure prevents a timely consultation or follow-up, it could potentially impact your care.

• Privacy and Security Risks: In rare instances, security protocols could fail, or unauthorized access could occur (e.g., due to malware on your device, compromised account credentials, or use of an unsecured network), potentially causing a breach of privacy of your personal medical information. There is a risk that your Protected Health Information (PHI) could be stored unencrypted on your personal mobile device or computer if you download or save information from the platform, despite safeguards we implement. You are responsible for securing the devices you use to access the platform.    

• Continuity of Care and Follow-Up: Telehealth services may not be appropriate for all medical conditions or for all aspects of your care. Your Provider may determine that an in-person examination or procedure is necessary, which could lead to a delay in treatment if not anticipated or if access to in-person care is limited. Managing side effects of medications or complications from treatment remotely may be more challenging than inan in-person setting.

• Regulatory and Licensing Considerations: Healthcare providers are licensed to practice in specific states. Your access to a particular Provider may be affected if you change your location to a state where the Provider is not licensed.

• Limitations of Remote Evaluation: The information transmitted by you or your Provider may not be sufficient (e.g., poor resolution of images, unclear audio, limited views of affected areas) to allow for appropriate medical decision-making by the Provider. Telehealth cannot replicate all aspects of an in-person physical examination. The absence of a hands-on physical exam may limit the Provider's ability to diagnose certain conditions or may require an in-person follow-up for a more thorough assessment. Certain conditions may be more accurately diagnosed or managed through in-person care. Your Provider may determine that your condition is not suitable for telehealth, or that an in-person consultation is necessary.  

• Emergency Situations: Telehealth services provided through the Anchor MD platform are NOT for medical emergencies or urgent situations. Using telehealth in an emergency can delay access to critical care and may pose a risk to your health and safety.    

• Personal Environment and Technology Access: The effectiveness of a telehealth consultation can be impacted by your environment (e.g., lack of privacy, distractions). You may experience difficulties with the technology required for telehealth if you have limited internet access, incompatible devices, or are unfamiliar with the platform.

By consenting to these forms, I understand the following:

• I understand that the laws that protect privacy and the confidentiality of medical information (including HIPAA) also apply to telehealth, and that no information obtained in the use of telehealth which identifies me will be disclosed to researchers or other entities without my specific consent, except as permitted by law and described in the Anchor MD Notice of Privacy Practices along with all other applicable policies and agreements of Anchor MD.    

• I understand that a variety of alternative methods of health care (e.g., for weight loss management) may be available to me, and that I may choose one or more of these at any time.    

• 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, without affecting my right to future care or treatment.

• I understand that I have the right to inspect all information obtained and documented in the course of a telehealth interaction and may receive copies of this information for a reasonable fee.    

• I understand that it is in my best interest to inform the Anchor MD Providers I work with and my primary care physician or other clinical staff of any other healthcare providers involved in my medical care and any medications I am taking.

• I understand that I may expect the anticipated benefits from the use of telehealth in my care, but that no results can be guaranteed or assured.  

Customer Consent to the Use of Tele-health

I have read and understand the information provided above regarding telehealth, have discussed it with my physician or other clinical staff as may be designated, and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of telehealth in my weight loss management health care. I have been offered a copy of this form for my personal records.

I acknowledge and agree that my continued use of the Anchor MD services constitutes my acknowledgment, understanding, and acceptance of the terms set forth herein and I hereby authorize the use tele-health in the course of my diagnosis and treatment. I further acknowledge and agree that any electronic signature, checkbox selection, or comparable form of affirmative acknowledgment, understanding, and acceptance of the terms set forth herein and I hereby authorize the use tele-health in the course of my diagnosis and treatment.

HIPAA Consent

The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. Implementation of HIPAA requirements officially began on April 14, 2003. This form is a “friendly” version. A more complete text is available through the office.

What this is all about:

Specifically, there are rules and restrictions on who may see or be notified of your Protected Health Information (PHI). These restrictions do not include the normal interchange of information necessary to provide you with office services. HIPAA provides certain rights and protections to you as the patient. We balance these needs with our goal of providing you with quality professional service and care. Additional information is available from the U.S. Department of Health and Human Services. www.hhs.gov.

Electronic Communication and Privacy:

The Services involve electronic communication of your personal medical information. Your information will be handled in accordance with applicable privacy policies of Anchor MD, its affiliates, and Providers.

You understand and agree to inspections of the office and review of documents which may include PHI by government agencies or insurance payers in normal performance of their duties.
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You agree to bring any concerns or complaints regarding privacy to the attention of the office manager or the doctor.

We agree to provide patients with access to their records in accordance with state and federal laws. We may change, add, delete, or modify any of these provisions to better serve the needs of both the practice and the patient.
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You have the right to request restrictions in the use of your protected health information and to request change in certain policies used within the office concerning your PHI. However, we are not obligated to alter internal policies to conform to your request.

Financial Consent

In addition to what is provided for in the Terms of Service I understand and accept the terms in order to render services that a credit card may be kept on file and that any remaining balances for services rendered shall be paid in full. I authorize Anchor MD to submit on my behalf and the release of 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 Anchor MD or its applicable payment processing provider to make invoice changes and debit my account for orders placed, goods received, and/or services rendered not fully covered by third party vouchers or credits.

I authorize Anchor MD or its applicable payment processing provider to charge my credit card account upon any unpaid balances due.
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By default, all programs are auto-renewing and I consent to be automatically charged for any program I am a part of unless I explicitly request to cancel before my payment is processed. I certify that I am an authorized user of the credit card provided and that I will not dispute the payments with my credit card company.

Shipping Authorization

All prescription medications are dispensed according to state and federal law with the approval of the pharmacist in charge and in compliance with all laws applicable from the relevant Medical Boards and State Boards of Pharmacy.  

You agree to hold Achor MD harmless for any delays or errors during the shipping process. You hereby consent to Anchor MD shipping your medication to you at the address provided in your intake form or any other address provided and agree to all of the conditions listed herein.