PCOS SISTERS TELEHEALTH CLINIC & WELLNESS CENTER MEMBERSHIP & VISITS
PRACTICE POLICIES FLORIDA, NEW YORK, TEXAS, & GEORGIA
APPOINTMENTS AND CANCELLATIONS
The standard meeting time for the PCOS Sisters subscription visits or Single PCOS Evaluation Visit is 30 minutes. For a quick primary care visit with no PCOS Sisters membership, the standard meeting time is 20 minutes. Single PCOS Evaluation Visits do not require a membership. A membership is required for any medical weight loss medications. Payment is required at time of booking appointment.
Cancellations and re-scheduled visits will be subject to a full charge if NOT RECEIVED AT LEAST 48 HOURS IN ADVANCE. This is necessary because a time commitment is made to you and is held exclusively for you. If you are late for an appointment, you may lose some of the allotted time for that appointment. Your card will automatically be billed 24 hours prior to your appointment if payment is not received.
TELEPHONE ACCESSIBILITY If you need to contact PCOS Sisters Telehealth Clinic & Wellness Center between sessions, please send us a message through the patient portal or give us a call. We are often not immediately available; however, we will attempt to return your call or message within 24 hours. Please note that Face-to-face video visits are required for a telehealth visit. If a true emergency situation arises, please call 911 or go to your local emergency room.
ELECTRONIC COMMUNICATION
We cannot ensure the confidentiality of any form of communication through electronic media, including, but not limited to, text messages, telephone communication, the Internet, facsimile machines, and e-mail. By providing an e-mail address and cell phone number on patient intake, you authorize us to communicate with you by e-mail or text message regarding Your “protected health information” (PHI). Patient further acknowledges that all such communications may become a part of the medical record. If you consent to the above means of communication by participating, you expressly waive the Provider’s obligation to guarantee confidentiality with respect to same.
Telehealth is broadly defined as the use of information technology to deliver medical services and information between two parties that are at different locations. The above electronic means of communication are considered telehealth. Utilizing telehealth services through PCOS Sisters Telehealth Clinic & Wellness Center is voluntary in nature and you need to understand:
It is at the provider’s discretion to obtain an in-person physical examination of the patient prior to initiating treatment. An inspection examination will be performed during the initial video visit. A physical exam can be done by a local primary care provider or at an urgent care and sent to PCOS Sisters Telehealth Clinic & Wellness Center.
MINORS
We require parental consent for all visits done through telehealth. We require your parents to be present during a portion of the visit to ensure that they are consenting to treatment.
If you are a minor, your parents may be legally entitled to some information about your treatment. We will discuss with you and your parents what information is appropriate for them to receive and which issues are more appropriately kept confidential.
SCOPE OF SERVICES
I understand that I am voluntarily engaging in a telehealth consultation with PCOS Sisters Telehealth Clinic & Wellness Center providers, which may include Autonomous Advanced Practice Registered Nurses defined by Florida Statute ss. 464.001-464.027 as an Advanced Practice Registered Nurse who practices independently without supervision of a physician, only engaging in primary care practice including family medicine, general pediatrics, and general internal medicine; Definition of primary care includes physical and mental health promotion, assessment, evaluation, disease prevention, health maintenance, counseling, patient education, diagnosis and treatment of acute and chronic illnesses, inclusive of behavioral and mental health conditions. Per Georgia state statutes, Lynsey Johnson, DNP, FNP-C is supervised by Dr. Rita Beckford, MD. Our Texas Nurse Practitioners are supervised by Dr. Codie Vassar, MD and Dr. Clinton Fox, MD.
Your membership includes unlimited visits with your provider via telehealth, a personalized diet and exercise plan, and a PCOS evaluation visit.
I acknowledge that no controlled substances such as narcotic pain medications will be prescribed via telehealth visit per federal law requiring in-person visit.
I acknowledge that no medications termed “obesity medications” such as phentermine will be prescribed via telehealth visit per Florida law requiring in-person visit.
We do not bill health insurance or any other third parties for services included in the periodic fee.
This agreement is not health insurance and does not meet any individual health insurance mandate that may be required by law.
PCOS SISTERS TREATMENT PROGRAM: DIET AND EXERCISE PLAN
I acknowledge that I am voluntarily entering into a medically managed weight loss program with PCOS Sisters Telehealth Clinic & Wellness Center. I fully realize that entering any program involving weight reduction, which includes moderate calorie restriction and exercise.
I understand that the Provider and I will determine what my daily caloric intake will be at my initial visit.
It is my understanding and I have been informed that there exists the remote possibility during exercise of adverse changes including, but not limited to, abnormal blood pressure, fainting, dizziness, disorders of heart rhythm, and in very rare instances heart attack, stroke, or even death. I further understand and I have been informed that there exists the risk of bodily injury including, but not limited to injuries to the muscles, ligaments, tendons, and joints of the body.
I fully understand the risks associated with exercise, including the risk of bodily injury, heart attack, stroke or even death, but knowing these risks, it is my desire to participate as herein indicated.
I acknowledge that I understand that the amount of weight loss varies from patient to patient, and is, to a large extent dependent on each patient’s personal motivation and commitment to their diet and exercise plan. No claims as to efficacy or specific amount of weight loss is either expressed or implied. I understand the importance of routinely following up with PCOS Sisters Telehealth Clinic & Wellness Center to monitor my progress during treatment. I understand this is vital to the safety of the treatment program and certify that I will be returning monthly as prescribed.
I acknowledge that the medically managed weight loss program recommended to me by PCOS Sisters Telehealth Clinic & Wellness Center is just one of multiple strategies to reduce weight. Alternative treatment options include: Diet and exercise alone with or without medication, the use of other kinds of medications to achieve appetite suppression, non-medical weight loss programs like Weight Watchers, and bariatric surgery.
MONTHLY SUBSCRIPTION SERVICE
Your monthly membership subscription allows for a PCOS evaluation visit, personalized diet & exercise plan, unlimited messages/check in’s to your provider, and unlimited telehealth visits.
Costs of labs, imaging, and prescriptions are not included in subscription. However, you may use your own insurance to cover these costs. If you do not have insurance, you may use PCOS Sisters discounted labs (Discounts not available for New York residents).
ADDITIONAL FEES
Cost of labs and imaging are not included in membership subscriptions. However, you may use your own insurance to cover these costs. Patient will be invoiced by PCOS Sisters Telehealth Clinic & Wellness Center for cost of PCOS Sisters discounted labs, if not using insurance and qualify per state law. A $25 lab interpretation fee is included with these labs.
*Per New York State Laws: New York patient subscription includes one monthly telehealth visit, all additional telehealth visits are $35 per visit. Discount labs not available. However, you may use your insurance to cover labs.
DURATION OF AGREEMENT AND AUTOMATIC RENEWAL PROVISIONS
I understand that my participation in PCOS Sisters Membership subscription is continuous, and charges will continue until my membership contract concludes, or I formally terminate my membership.
I acknowledge and understand that I am required to provide a credit card (to be kept on file) to participate in the PCOS Sisters Membership or pay for the annual membership in full.
I acknowledge and understand that my PCOS Sisters subscription fee will not be pro-rated.
I acknowledge and understand that the PCOS Sisters subscription fee is automatically charged, and it is my responsibility to notify PCOS Sisters Telehealth Clinic & Wellness Center of any changes with my credit card information.
I acknowledge and understand that fees incurred outside of my PCOS Sisters subscription fee are due at the time of service.
I acknowledge and agree to pay the monthly fee on the 1st of every month. I acknowledge that my membership may be terminated for non-payment.
I acknowledge and understand that PCOS Sisters Telehealth Clinic & Wellness Center may add or discontinue included services without notice.
I acknowledge and understand that PCOS Sisters Telehealth Clinic & Wellness Center may change my monthly fee at any time (but no more than once per calendar year), and that I will be given at least sixty-day notice of such fee schedule changes.
I acknowledge and understand that I am responsible for any charges incurred for health care services outside of PCOS Sisters Telehealth Clinic & Wellness Center including but not limited to emergency room, urgent care, hospital and specialty services, imaging, labs, and pharmaceuticals.
I acknowledge and understand that PCOS Sisters Telehealth Clinic & Wellness Center will NOT be required to reimburse me for any charges that I may incur for any care outside of the PCOS Sisters Telehealth Clinic & Wellness Center.
TERMINATION
Both the patient and provider may terminate the agreement by giving the other party at least 30 days’ advance written notice.
I further understand that upon termination of my subscription, for any reason, it must be canceled before the monthly autodraft if purchasing the monthly continuous package. For the pre-paid 3, 6, 9, 12 month memberships, there are no refunds as you are receiving discounts for these packages if you commit to a non-refundable subscription service. Once the subscription package ends, you are responsible for purchasing another if desired, as pre-paid packages terminate at end of respective 3,6, 9, 12 month membership term. If membership is cancelled, there will be a $50 re-enrollment charge, if I choose to re-enroll as a subscribed member in the future.
The agreement may provide for immediate termination due to a violation of the physician-patient relationship or a breach of the terms of the agreement. We will not terminate the medical relationship with you without first discussing and exploring the reasons and purpose of terminating. If treatment is terminated for any reason, we will provide you with a list of qualified providers to continue your care. You may also choose someone on your own or from another referral source. Should you fail to not show up for your follow up appointments, not obtain lab work in a timely fashion or are non-compliant with treatment, unless other arrangements have been made in advance, for legal and ethical reasons, we must consider the professional relationship discontinued.
PROVIDER ABSENCE
From time to time, due to vacations, illness, conflicting obligations, or personal emergency, the provider may be temporarily unavailable to provide the services referred to above in this paragraph one. In order to assist patients in scheduling non-urgent visits, clinic will notify patients of any planned provider absences as soon as the dates are confirmed. In the event of the provider’s unplanned absences, Patients will be given the name and telephone number of an appropriate provider for the Patient to contact. Any treatment rendered by the substitute provider is not included under this Agreement.
AFTER HOURS ACCESS
Clinic will make all reasonable efforts to provide telephone and text access to the provider after hours for urgent needs. Patient shall be given a phone number where patient may reach the provider directly for guidance regarding concerns that arise unexpectedly after office hours.
INSURANCE POLICIES
Neither the Practice, nor its Provider, participate in any health insurance or HMO plans or panels.
This agreement is not an insurance plan or a substitute for health insurance. This agreement does not replace any existing or future health insurance or health plan coverage that you may carry. The Agreement does not include hospital services, or any services not personally provided by the PCOS Sisters Telehealth Clinic & Wellness Center or its staff. You acknowledge that we have advised you to obtain or keep in full force, health insurance that will cover you for and for hospitalizations, catastrophic events, and all other healthcare not personally provided by the PCOS Sisters Telehealth Clinic & Wellness Center.
Due to regulatory restrictions, services are not available to patients who are eligible for or enrolled in
Medicare, Medicaid, or other government healthcare programs. By signing below, you deny that you are currently enrolled in Medicare or Medicaid. You understand that if you should enroll in Medicare or Medicaid, we will no longer be able to provide you services. If Patient becomes a Medicare beneficiary Patient has a responsibility to inform Provider and PCOS Sisters Telehealth Clinic & Wellness Center of that change in status. Patient acknowledges and accepts this responsibility.
I acknowledge and understand that PCOS Sisters Telehealth Clinic & Wellness Center does not guarantee reimbursement for any PCOS Sisters Telehealth Clinic & Wellness Center service or fees from any third-party health plans, including insurance plans and savings accounts (health savings or flexible spending).
This agreement is not health insurance and the primary care provider will not file any claims against the patient’s health insurance policy or plan for reimbursement of any primary care services covered by the agreement. This agreement does not qualify as minimum essential coverage to satisfy the individual shared responsibility provision of the Patient Protection and Affordable Care Act, 26 U.S.C. s. 5000A. This agreement is not workers’ compensation insurance and does not replace an employer’s obligations under chapter 440. This is not a Health Maintenance Organization (HMO) defined by New York state law as an organization that provides comprehensive health service plans to maintain good health. An annual physical exam is necessary to maintain comprehensive health services. As a telehealth only practice, we do not provide this service.
BY SIGNING BELOW, I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.
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