INFORMED CONSENT FOR HORMONE REPLACEMENT THERAPY

Because of the rapidly changing ideas about the safety and effectiveness of hormone therapy for anything other than birth control, it is important to be sure that you have information about the risks and benefits of hormone therapy before you begin the treatment we discuss. HRT is approved by the FDA for prescribed deficiencies only. Using it for other symptoms or problems is considered “off-label” use, and the liability is on the patient, not the practice or the medical provider. When hormone levels are brought back to “normal” for your age, there is clinical evidence that your overall health will benefit. HRT is the most effective treatment for hormone deficiencies. There may also be other long-term beneficial effects of treatment. Because standard practices continue to change as medical technology advances and more studies are conducted, it is important to discuss HRT with your doctor each year at your annual exam to find out what the newest information is.

NO GUARANTEE OF SERVICES

Amazing Meds does not guarantee that any services or medications will be provided to you until you have undergone the full preliminary sign up process and physician’s examination. At the physician’s discretion you will be provided medications and/or services during your program at Amazing Meds.

NO REFUND POLICY

Amazing Meds reserves the right to have a NO RETURN and NO REFUND policy.

TELEMEDICINE AUTHORIZATION

Telehealth or telemedicine involves the use of the Internet to facilitate electronic communication to enable healthcare providers at different locations to share individual patient medical information for the purpose of treatment and improving patient care. Providers may include medical practitioners, specialists, and/or subspecialists. The information may be used for diagnosis, treatment, follow-up, and/or education, and may include any of the following:

Patient medical records
Medical images or lab results
Live two-way audio and/or video
Output data from medical devices and sound and video files

Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification, and Amazing Meds will implement measures to safeguard patient data against intentional or unintentional corruption.

I understand that I have the right to revoke this authorization, in writing, at any time, except where uses or disclosures have already been made based upon my original permission. In order to revoke this authorization, I must do so in writing and send it to the appropriate disclosing party (Amazing Meds). I understand that uses and disclosures already made based upon my original permission cannot be taken back.

I understand that it is possible that information used or disclosed with my permission may be re-disclosed by the recipient and is no longer protected by the HIPAA Privacy Standards. I understand that treatment by any party may not be conditioned upon my signing of this authorization and that I may have the right to refuse to sign this authorization. A copy of this authorization is as valid as the original.

BY SIGNING THIS FORM, I UNDERSTAND THE FOLLOWING:
I understand that the laws protecting the privacy and confidentiality of medical information also apply to telemedicine, and that no information obtained through the use of telemedicine which identifies me will be disclosed to other entities without my consent.
I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time. (Depending on the patient's location, this may affect future care and treatment since Amazing Meds is located in Colorado Springs, Colorado.)
I understand that I have the right to inspect all information obtained and recorded in the course of a telemedicine interaction, and may receive copies of this information for a reasonable fee.
I understand that a variety of alternative methods of medical care may be available to me, and that I may choose one or more of these at any time. Amazing Meds has explained the options available to me.
I understand that I may expect anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured.

I have read and understand the information provided above, have discussed it with my provider or Amazing Meds team as designated, and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of telemedicine in my care. I hereby authorize Amazing Meds to use telemedicine in the course of my diagnosis and treatment.