Consent to Treat

I hereby give my informed consent for medical treatment and procedures to be administered by the healthcare professionals at Cloud Health Medical Group, P.A., Cloud Health Medical Group of California, P.C., Cloud Health Medical Group of New Jersey, P.A. Cloud Health Medical Group of Kansas, P.C., Cognitive Nutrition & Wellness LLC and Pesto Health, Inc. (collectively “Providers”).

I understand and acknowledge the following:

• Nature of Consent:

I understand that by signing this form, I am authorizing Providers and its healthcare providers to provide medical evaluations, conduct diagnostic tests, and perform necessary procedures to diagnose and treat my medical condition.

• Telehealth:

Telehealth services involve interactive video conferencing equipment and devices that let your health care provider deliver health care services to you from a location that is different than your location. I confirm that I have read this form (or had it explained to me) and understand the following:

• I will not be physically in the same room as my health care provider during the visit. I will be told about and asked for my consent before any other Providers staff or trainees actively assist my health care provider during this visit.
• There are risks and consequences associated with telehealth services. These include, but are not limited to:
  • disruption of the appointment caused by technology failures;
  • the limited ability of my health care provider to respond to emergencies during the visit;
  • interruption or violations of confidentiality by people who do not have permission to be at the visit. While Providers takes all reasonable steps to secure telehealth visits and breaches are very rare, no technology is completely secure; and
  • the chance that I or my health care provider decides that the video conferencing equipment or connection is not adequate for this visit and decides to stop the telemedicine visit, switch to an alternate Providers-approved video conferencing service, or make other arrangements to continue the visit;
  • the chance that during a telehealth visit, my provider may not identify medical conditions that otherwise may be identified during an in-person visit.
• I have the right to refuse to participate or stop participating in a telehealth visit, and my refusal will be written in my medical record. I understand that my refusal may impact my right to future care or treatment at Providers.
• The laws that protect the privacy and confidentiality of my health care information apply to telehealth services.
• My health care information may be shared with other individuals for scheduling and billing purposes.
  • I understand that health plan payment policies for telehealth visits may be different from policies for in-person visits.
  • I understand that I am responsible for any out-of-pocket costs such as copayments or coinsurances that apply to my telehealth visit.
• I understand that during the telehealth visit, I must be physically located in a state where my provider is licensed, or my provider will not be able to conduct the visit, and it will need to be rescheduled. If I am in a state other than the state I previously provided at the time of my visit, I will tell the provider’s office before the visit to confirm that they can see me.
• I have had all my questions about this telehealth service answered to my satisfaction. The risks, benefits, and alternatives to telehealth visits have been shared with me in a language I understand.

• Risks and Benefits:

I understand that all medical treatments and procedures carry certain risks and potential benefits. While Providers will take necessary precautions to minimize risks, I acknowledge that no guarantees or assurances can be made regarding the outcome of any treatment or procedure.

• Privacy and Confidentiality:

I acknowledge that Providers is committed to protecting the privacy and confidentiality of my personal health information in accordance with applicable laws and regulations. I authorize the collection, use, and disclosure of my health information for the purposes of treatment, payment, and healthcare operations.

• Financial Responsibility:

I understand that I am financially responsible for all medical services rendered by Providers. I agree to pay all charges for services not covered by my insurance, including deductibles, co-pays, and any outstanding balances.

• Right to Refuse or Withdraw Consent:

I can refuse or withdraw my consent for medical treatment at any time. I understand that this decision may have consequences and that I should discuss any concerns or questions with my healthcare provider.

• Communication and Follow-up:

I understand the importance of open and honest communication with my healthcare provider. I agree to provide accurate and complete information about my medical history, current medications, allergies, and other relevant details. I understand I should follow any post-treatment instructions and attend follow-up appointments as recommended.

• Authorization for Medical Decision-Making:

I authorize Providers and their healthcare providers to make necessary medical decisions on my behalf if I cannot do so, based on their professional judgment and in accordance with applicable laws and regulations.

• Choice of Pharmacy Services:

If you receive a prescription as a result of your use of the Services, you may choose to have your prescription fulfilled through the pharmacy of your choice. You give us consent to send and disclose to the pharmacy of your choice all information provided by you, health care records, and other applicable health care information and personal information (such as your name, location and demographic information) so that you may receive pharmacy services.

• Agreement and Consent:

I have read and understood the contents of this Medical Consent Form, and I voluntarily consent to receive medical treatment and procedures from Providers.

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