OFFICE POLICY

Secure Your Wellness
2595 N. W. Boca Raton Blvd., Suite 200
Boca Raton, Florida 33431
561-418-6421

The following policies are necessary to facilitate communication and care between patients, and the Secure Your Wellness team. The purpose is to maintain good and healthy relationships between Secure Your Wellness and our patients whom we care greatly for. We are happy to answer any questions regarding these policies that you may have.

I acknowledge and agree to pay the stated CONSULTATION FEE. I understand that once I have had the consultation, there are no refunds issued. I also acknowledge that paying the consultation fee does not guarantee treatment. I understand that the practice of medicine includes medical due diligence, thus necessitating telehealth consultation.

SECURE EMAIL COMMUNICATION:

While Secure Your Wellness strives to provide the best service possible, privacy and security of email correspondence cannot be guaranteed unless done through the website, a HIPAA compliant system. Please initiate all communication via the Contact Us page on the Secure Your Wellness website.

Doing so is an acknowledgment that you understand the vulnerabilities of communicating personal information via email or social media sources-even when a HIPAA compliant system is used.

I acknowledge that I take responsibility for any and all privacy breaches should I initiate any type of communication outside of approved Secure Your Wellness communication channels.

CONSENT TO USE PHI FOR BILLING PURPOSES

I hereby consent to the use by Secure Your Wellness and all associated staff persons, to use my medical information to submit bills to me and to any and all other payers for services provided to me by or through Secure Your Wellness.

I understand that I must give this specific written consent pursuant to Florida law, which prohibits a health care provider from using a patient’s medical information for billing purposes unless the patient authorizes the health care provider in writing to do so.

Billing Information:
Secure Your Wellness
2595 N. W. Boca Raton Blvd., Suite 200 Boca Raton, Florida 33431
561-418-6421

ACKNOWLEDGE OF RECEIPT OF NOTICE OF HIPAA PRIVACY PRACTICES (Click here to view file)

My signature on this form acknowledges that I received, on the date noted below, a copy of the Notice of HIPAA Privacy Practices from Secure Your Wellness. I understand that this document provides an explanation of the ways in which my health information may be used or disclosed by Secure Your Wellness. The Notice also explains my rights with respect to my health information. The office will provide me with a hard copy of the document if I request it.

MEDICARE PRIVATE CONTRACT FOR SERVICES FROM PHYSICIAN WHO HAS OPTED OUT

Doctor's Obligations. Doctor hereby informs Patient of the following and agrees to undertake the following actions:

• Doctor has not been excluded from participation in Medicare under §§1128, 1156 or 1892 of the Social Security Act. The decision to opt-out of Medicare was a strictly voluntary one.
• Doctor will make a copy of this Private Contract available to CMS upon its request.
• The expected or actual effective date and the expiration date of the opt-out period to which this Private Contract applies are as follows: 4/2019 to 4/2021 and automatically renews unless CMS is notified to change this status. ALL Secure Your Wellness Medical Providers intend to renew the Opt-out option indefinitely.
• Doctors and Patients must enter into a new Private Contract for each opt-out period.
• Doctor will provide a photocopy of this Private Contract to Patient or to Patient's legal representative before items or services are furnished to Patient under the terms of this Private contract.
• Doctor will retain an original of this Private Contract with original signatures of both parties, for the duration of the opt-out period.

The parties have read and understood the provisions of this Private Contract and enter into this agreement freely and voluntarily.

Patient's Obligations. The Patient or the Patient's legal representative agrees to the following:

• Patient accepts full responsibility for payment of Secure Your Wellness charge for all services furnished by Practitioner.
• Patient understands that Medicare limits do not apply to what Practitioner may charge for items or services furnished to Patient by Practitioner.
• Patient agrees not to submit a claim to Medicare or to ask the Practitioner to submit a claim to Medicare.
• Patient understands that Medicare payment will not be made for any items or services furnished by Practitioner that would have otherwise been covered by Medicare if there was no Private Contract and a proper Medicare claim had been submitted.
• Patient has entered into this Private Contract with the knowledge that Patient has the right to obtain Medicare-covered items and services from a practitioner who has not opted out of Medicare, and that Patient is not compelled to enter into Private Contracts that apply to other Medicare-covered services furnished by other practitioners who have not opted out.
• Patient understands that Medigap plans do not, and that other supplemental plans may elect not to, make payments for items and services not paid for by Medicare.
• Patient entered into this Private Contract at a time when Patient did not require any emergency or urgent care services.
• Controlling Law. The terms of this Private Contract shall be interpreted and controlled by applicable Medicare regulations, as amended from time to time. Both parties agree to comply with all such Medicare regulations and enter into such agreements as may be required from time to time by such regulations.
• Patient Representative. If this Private Contract is being signed by a Patient Representative on Patient's behalf, the Patient Representative will provide Practitioner with the documentation required to demonstrate that Patient Representative has the requisite legal authority to sign this Private Contract on Patient's behalf.

I acknowledge that this Private Contract is entered into by and between YOU (each one referred to herein as "Patient") and Lisbeth W Roy DO ("Doctor") pursuant to the Medicare requirements that relate to physicians who have opted out of Medicare.

The Doctor has filed the required Affidavit with Medicare within the time period required for this Private Contract to be effective.

REQUEST FOR ADDITIONAL MEDICAL INFORMATION POLICY

I acknowledge and agree with the above "Request for Additional Medical Information Policy"

Secure Your Wellness does not submit to or participate in any insurance programs. However, if you decide to submit claims to your insurance company or subscribe to a service that submits on your behalf, you may be eligible for reimbursement.

During the claims process, some insurance companies may attempt to withhold reimbursement by requesting additional information and/or medical records from our office. By providing this information, your medical information can be used by insurance companies to raise your insurance premiums, deny additional services and prevent eligibility of other programs, like life insurance. We make it part of our daily practice to put our patient’s best interests first, and as such, your medical information is protected by our office.

It is our policy to deny requests for any medical information within your chart other than the information you originally submitted to your provider. Additional information will only be provided for those patients who have completed an Authorization for Release of Medical Records form.

ANY ATTEMPT BY YOUR INSURANCE PROVIDER TO OBTAIN ADDITIONAL INFORMATION WILL BE DENIED.

Please remember that you cannot submit any claims to government-funded programs including; Medicaid, Medicare, Medi-Gap and supplemental insurances, Champus or TriCare.

NOTICE OF NO MALPRACTICE INSURANCE

“Under Florida Law, physicians are generally required to carry medical malpractice insurance or otherwise demonstrate financial responsibility to cover potential claims for malpractice.

YOUR DOCTOR HAS DECIDED NOT TO CARRY MEDICAL MALPRACTICE INSURANCE.

This is permitted under Florida law subject to certain conditions. Florida law imposes penalties against non-insured physicians who fail to satisfy adverse judgments arising from claims of medical malpractice. This notice is provided pursuant to Florida law.”

 

INFORMED CONSENT FOR TELEMEDICINE SERVICES

I understand that telemedicine is the use of electronic information and communication technologies by a healthcare provider used to deliver services to an individual when he/she is at a different location or site than the provider.

I understand that the telemedicine visit will be done through a two-way video link-up. The healthcare provider will be able to see my image on the screen and hear my voice. I will be able to hear and see the healthcare provider.

I understand that the laws that protect the privacy and the confidentiality of medical information including HIPAA, also apply to telemedicine.

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, without affecting my right to future care.

I understand by signing this form I am consenting to receive health care services via telemedicine. I also understand and have read all the above information and give my consent for treatment at Secure Your Wellness

I acknowledge the Consent to use PHI for Billing Purposes.
I take responsibility for any violation of my privacy if I initiate email communication outside of a secure portal system.

IVERMECTIN/FLUVOXAMINE PRESCRIPTION REQUESTS ONLY:

PLEASE CHECK that you acknowledge and understand the WARNINGS BELOW.

 

PURPOSE OF INFORMED CONSENT

In order for you to be treated with ivermectin and/or fluvoxamine, you must sign this form to show that you agree to this off-label use and that you have been informed of the benefits and risks of taking such medication for off-label use, as well as the benefits and risks of declining or refusing such off-label use. You have the right to refuse to take ivermectin and/or fluvoxamine for any reason. The evidence at this time is not clear as to whether ivermectin and/or fluvoxamine will be beneficial for COVID-19 treatment or Long Haul treatment; your condition may deteriorate.
Off-label use of a drug is defined as the use of a drug to treat a condition, or target symptom(s), even though the drug is not specifically approved to do so by the US Food and Drug Administration (FDA).
Off-label use of ivermectin and/or fluvoxamine includes the use of ivermectin and/or fluvoxamine as a treatment for any viral infection or post-viral infection

BACKGROUND

Ivermectin in tablet form is approved by the FDA to treat people with intestinal strongyloidiasis and onchocerciasis, two conditions caused by parasitic worms. In addition, some topical forms of ivermectin are approved to treat external parasites like head lice and for skin conditions such as rosacea.

Fluvoxamine is a selective serotonin reuptake inhibitor (SSRI) and is approved by the FDA for the treatment of obsessive/compulsive disorder and other conditions including depression.

According to the Lancet article Volume 10, Issue 1, E42-E51, January 1, 2022, Fluvoxamine among high-risk patients was shown to decrease hospitalization when prescribed in early treatment. Hospitalization was defined as seen in an emergency setting or admitted to a hospital. Please be advised that there are drug-to-drug interactions that may preclude you as a candidate to receive this medication. This can be found at https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(21)00448-4/fulltext

However, there is the possibility that these medications may be of NO direct medical benefit to you. Your condition may get worse.

 

POSSIBLE RISKS AND KNOWN SIDE EFFECTS

It is possible that the medication prescribed may not improve your symptoms and not shorten the duration nor severity of the illness. Without limitation, it is possible that the medication will unexpectedly interfere with your ability to improve, hastens damage to the lungs or other organs, and shortens your life.

Please be advised that not all risks and side effects in the context of COVID-19 are known. In fact, as of February 11, 2021, the National Institute of Health (NIH) still notes that due to insufficient evidence, the NIH cannot recommend either for or against the use of ivermectin for the treatment of COVID-19.

I understand that Ivermectin has been approved by the FDA as a safe and effective antiparasitic medication since 1988. Since then, over 200 million people around the world use it 1-2 times a year as part of parasite treatment and disease prevention. In rare cases, ivermectin may cause pruritus, conjunctivitis, arthralgia, myalgia (including abdominal myalgia), fever, edema, nausea, vomiting, diarrhea, lymphadenopathy, orthostatic hypotension, tachycardia, asthenia, rash and headaches.

I understand that fluvoxamine can cause but is not limited to: headache, nausea, diarrhea, increased sweating, feeling nervous, restlessness, fatigue and insomnia.

I understand that fluvoxamine is contraindicated in those with a history of suicide attempt, liver problems, seizures, low sodium, peptic ulcer disease, bleeding problems, current use of another SSRI, stimulants, and a family or personal history of glaucoma.

I understand that although this is rare, fluvoxamine can cause prolonged QT intervals which may lead to a serious cardiac event even death.

I understand that I have reported my complete medical history to the practitioner. I acknowledge that failure to do so could cause serious harm to me.

 

ALTERNATIVES

At of December 11, 2021, the only FDA approved medication for use towards COVID-19 treatment is Veklury (Remdesivir), an antiviral drug approved for use in adults and pediatric patients [12 years of age and older and weighing at least 40 kilograms (about 88 pounds)] for the treatment of COVID-19 that requires hospitalization.

Of course, the FDA notes that the most effective ways to limit the spread of COVID-19 include getting a COVID-19 vaccine when it is available to you and following current CDC guidance.

They linked to their previous publication from March that can be found here: Why You Should Not Use Ivermectin to Treat or Prevent COVID-19 | FDA.

The letter to providers can be found at: 15400.pdf (ms.gov)

The warning can be found here: Merck Statement on Ivermectin use During the COVID-19 Pandemic - Merck.com and seems to be gaining attention.

In light of this information and these disclosures, I agree to release my telehealth practitioner from all medical liability and malpractice claims related to any and all care, including but not limited to preventive, acute and chronic treatments for COVID-19 and presumed and/or diagnosed post viral syndrome due to COVID-19 (to the fullest extent possible).

HOW MAY WE CONTACT YOU WHILE PROTECTING YOUR PRIVACY?

In order to protect your privacy, please check all of the ways we may contact you from this office. (Including, but not limited to: appointment reminders, phone calls and emails after appointments or procedures, billing or payment questions, lab results etc.).

Secure Your Wellness
2595 N. W. Boca Raton Blvd., Suite 200
Boca Raton, Florida 33431
561-418-6421
telehealth@secureyourwellness.com

Are you currently taking or have you recently taken any of the following medications:

If you have answered yes to any of the above questions you may not be a candidate for fluvoxamine.