Telemedicine Form – Your Labwork – Leading Authority in Naturopathic Endocrinology
Integrative Health Care, P.C

Telemedicine Form – Your Labwork

Integrative Health Care, P.C. (“Integrative Health Care”) is an Arizona professional corporation which provides Naturopathic care to patients through its physicians and staff.

The purpose of this form is to obtain your consent to participate in a telemedicine consultation with Integrative Health care in connection with the following procedure (s) and / or services:

Telemedicine/Phone Definition: The practice of health care delivery, diagnosis, consultation, and treatment, and the transfer of medical data through interactive audio, video or data communications that occur in the physical presence of the patient, including audio or video communications sent to a health care provider for diagnostic or treatment consultation. Arizona Revised Statute 36-3601

I understand that I will not use the Integrative Health Care’s telemedicine/phone consult services in any sort of emergency situation. I truly understand and I am fully aware that in case of emergency, I immediately should contact the right authorities such as 911 or any other emergency department.

1. Integrative Health has explained to me how the video conferencing technology will be used and that a virtual consultation will not be the same as a direct patient/health care provider visit due to the fact that I will not be in the same room as my health care provider.

2. I understand there are potential risks to this technology, including interruptions, the potential for unauthorized access, and technical difficulties. I understand that my healthcare provider or I can discontinue the telemedicine/phone consult if it is felt that the videoconferencing or phone connections are not adequate for the situation.

4. In the case your Telemedicine/phone consult is interrupted due to technological issues an Integrative Health Care staff member will reach out to you at their earliest available opportunity to coordinate follow up care.

5. I understand if I am not available for my scheduled appointment time it is my responsibility to alert Integrative Health Care of the need to cancel or reschedule 24 hours prior to my appointment. To avoid disruption to Integrative Health Care appointments and scheduled, late cancellations or missed appointments with the physician will forfeit the payment for that visit.

6. I understand that my medical records and payment records are privileged and confidential and may only be disclosed with my consent or the consent of my health care decision maker and in accordance with Arizona and federal law. I understand and authorize that my healthcare information may be shared with Integrative Health Care staff for scheduling and billing purposes. Other authorized Integrative Health Care staff may also be present during the consultation in addition to my health care provider and consulting health care provider. The above mentioned people will all maintain confidentiality of the information obtained. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history/physical examination that are personally sensitive to me; (2) ask non‐medical personnel to leave the telemedicine examination room: and or (3) terminate the consultation at any time. Arizona Revised Status 12-2292 and 36-3602 (B)

7. I have had the alternatives to a telemedicine/phone consultation explained to me, and am choosing to participate in a telemedicine/phone consultation. I understand that some parts of the exam involving physical tests may be conducted by individuals at my location at the direction of an Integrative Health Care consulting healthcare provider.

8. I understand that I may benefit from telemedicine/phone consult, but that results cannot be guaranteed or assured.

9. I understand the billing of the appointment will happen at the time of scheduling and not after the consultation. If any additional supplements or medication is needed this will be addressed and billed after the consultation.

10. I understand that I am free to obtain supplements and medications from the health food store or pharmacy of my choice. Due to variabilities in quality control and ingredient selection, Integrative Health Care cannot guarantee the quality or ingredients of any supplements or medications purchased from any source apart from Integrative Health Care.

11. I understand that Integrative Health Care cannot prescribe in all US states and may not be able to send prescriptions to my local pharmacy. Therefore, prescription medications may be sent to me from a pharmacy in Arizona or dispensed from Integrative Health in the case of thyroid medication.

12. I acknowledge and understand that hormone replacement therapy, specifically testosterone, is a DEA schedule III controlled substance and will require an initial in-person visit with my physician and follow up with my physician every 6 months to continue the prescription.

13. I have had a direct conversation with an employee or physician of Integrative Health Care, during which I had the opportunity to ask questions in regards to my treatment. My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language in which I understand.

14. I understand that I have a right to access my medical information and copies of medical records in accordance with Arizona law.

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