OFFICE POLICY

Secure Your Wellness, a Forum Health Company
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 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 {patientsName} (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.

 

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 understand that electronic communication, including telemedicine consultation, should never be used for emergency situations. Emergency communications should be made to my provider’s office or to 911 services in my local community.

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.

Informed Consent for Semaglutide - Weight Loss Program 

This document (“Informed Consent”) summarizes information about the Semaglutide (with Methylated B12 and/or BPC-157 peptide) weight loss program, including the Treatment (as defined below) that I have requested from Secure Your Wellness, a Forum Health Practice and its medical providers (collectively, “Forum Health”), and gives my informed consent to proceed with Treatment (as defined herein). I have read and understood the following:  

A. Purpose/Background:  

Semaglutide (sometimes sold under the brand names Ozempic or Wegovy) is an injectable or sublingual medication that, when used in combination with a low-calorie diet and exercise, helps with chronic weight management in adult patients. It can also be used for individuals with an increased risk for Cardiometabolic diseases such as heart attack, stroke, and Type 2 diabetes. Semaglutide belongs to a class of medications called glucagon-like peptide-1 (GLP-1) agonists, which mimic the hormone GLP-1 in your body. This hormone slows down how fast your stomach empties food (called gastric emptying), stimulates your pancreas to release insulin (lowering blood sugar levels), it blocks a hormone that causes your liver to release sugar (glucagon). Together, these functions can help you feel less hungry, causing you to eat less food and lose weight. Like other prescription weight-loss drugs, Semaglutide is intended to be used as part of an overall weight-loss plan. It is indicated for people who are obese or overweight, and who have failed to lose enough weight with diet and exercise alone — not for people who want to lose just a few pounds.  

B. Possible Benefits:  

Possible benefits of Semaglutide include fat loss, weight loss, improved self-image, improved self-esteem, and improved cardiometabolic risk factors.  

C. Alternatives to Treatment

Alternatives to Semaglutide treatment include diet and exercise alone, other weight loss prescription medications, or procedure-based weight loss methods including gastric banding or bypass. 

D. Potential Risks and Contra-indications:  

Semaglutide is considered safe and effective when used as indicated. But safe doesn’t mean that there aren’t risks. Semaglutide carries a boxed warning about thyroid C-cell tumors occurring in rodents and Multiple Endocrine Neoplasia Type 2, and it shouldn’t be used if you or your family have a history of certain thyroid cancers or Multiple Endocrine Neoplasia Type 2. Semaglutide should not be used in people with Type-1 diabetes or a history of pancreatitis. Semaglutide should be used cautiously for people on other blood-sugar-lowering medications.  Patients may experience significant drops in blood sugars when using Semaglutide.

Although side effects are minimal for most people who follow the Treatment protocol, common potential side effects of Semaglutide include nausea, diarrhea, vomiting, constipation, stomach (abdomen) pain, headache, tiredness (fatigue), upset stomach, dizziness, feeling bloated, belching, gas, and heartburn.  Rare, but potential side effects include acute pancreatitis, acute gallbladder disease, hypoglycemia, acute kidney injury, diabetic retinopathy, heart rate increase, suicidal behavior, and ideation. Semaglutide usage has also been associated with gastroparesis which is where the stomach stops its normal movement (peristalsis) and causes the patient to vomit uncontrollably. Rare cases can lead to hospitalization from dehydration and esophageal bleeding.

Semaglutide may cause fetal harm. When pregnancy is recognized, discontinue Semaglutide immediately. Discontinue Semaglutide at least 2 months before a planned pregnancy because of the long half-life of the medication. 

By signing below, I acknowledge and agree as follows: My clinical team at Forum Health will not monitor the blood sugars of a non-diabetic patient.  I will take the medication only as directed by the medical provider according to the treatment guidelines established. I understand the risks associated with Treatment, and that not complying with the dosage recommendations and dietary restrictions could increase risks and alter the results. Product information is available upon request. Forum Health works in conjunction with, but cannot replace, my primary care physicians, such as general practitioners or other specialists in Family Medicine or Internal Medicine.  

E. Payment Obligation:  

Forum Health is committed to enabling its patients to obtain and maintain health and wellness naturally based upon a natural and preventative approach that are rarely covered by insurance companies. For this reason, Forum Health does not accept or bill insurance for this Treatment.  I acknowledge that my provider will not pre-certify Treatment with my insurance Brand or answer letters of appeal, and that I am solely responsible for the cost of Treatment.  

Once treatment is started, Forum Health cannot honor any refund requests based on scheduling conflicts, missed doses, or unsatisfactory results. I understand that payment is due in full at the time of service. I also understand that it is my responsibility to submit a claim to my insurance Brand for possible reimbursement. I have been advised that Forum Health does not expect Treatment is a covered benefit under my insurance benefit programs.

F. Informed Consent to Treatment: 

By knowingly and voluntarily signing my name below, I hereby certify that:

• I am at least 18 years old;
• I have received verbal or written information about Semaglutide;
• I have disclosed and discussed any and all health conditions or changes in my health condition since my last visit with my provider; 
• I want to proceed with and will follow the recommended course of care for Semaglutide with B12 weight loss injections that are described in this Informed Consent, together with the related care associated therewith (collectively, the “Treatment”);
• I have been advised of and understand the possible risks, complications, and side effects to the proposed Treatment;
• I have been advised of and understand the reasonable alternatives to the proposed Treatment (and related care/procedure(s)/treatment, including the risks and benefits of foregoing treatment altogether);
• I have been advised of and understand the possible benefits of the proposed Treatment;
• I have had the opportunity to think about my health status and condition, as well as educate myself about my health status/condition, and the proposed Treatment, and I have had an opportunity to review this Informed Consent;
• I have had the opportunity to ask any questions that I have about my health status/condition and the proposed Treatment (and answers have been provided to my satisfaction in terms that I understand);
• I agree to immediately report to my practitioner’s office any adverse reactions or problems after the Treatment; and
• I have not been promised or guaranteed any specific benefits from the course of Treatment; and
• I have informed my provider of any known allergies to medications or other substances and of all current medications and supplements I currently take. 

Based on the foregoing, I knowingly and voluntarily consent to proceed with the proposed Treatment and related (and future) care/procedure(s). I also consent to the performance of any additional procedures, or to comply with treatment recommendations made by my provider, determined in the course of the Treatment to be in my best interests and where delay might impair or adversely affect my health. I request and consent to daily/weekly dosing of Semaglutide with B12 and/or BPC-157 and will comply with strict dietary restrictions from my provider for the purpose of losing weight. I understand that as part of the program I will be given an orientation to the program, and I will be instructed on how to administer the injections myself or make arrangements to have someone do so. I agree to immediately report any complications or adverse changes in my health during Treatment to

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, a Forum Health Company
2595 N. W. Boca Raton Blvd., Suite 200
Boca Raton, Florida 33431
561-418-6421
telehealth@secureyourwellness.com