This consent form is to inform you about the services provided by Checkmate Technology LLC (“Checkmate”) and to obtain your consent for receiving medical care from Kings Medical PC, a licensed medical provider affiliated with us. I understand that there is no implied or stated guarantee of success or effectiveness of any treatment. There has been no representation that any procedure is covered under my insurance plan or that I will receive reimbursement. I agree to pay the full cost of the service regardless if the treatment is stopped at any time prior to completion at the discretion of the technician/nurse/clinical assistant or myself.
INFORMED CONSENT FOR TREATMENT WITH PEPTIDES: I am executing this consent to confirm my discussion with Checkmate Health and my understanding of the risks, benefits, and alternatives to treatment with peptide therapy.The goals and possible benefits of this therapy are to try and prevent, reduce or control the dysfunction associated with the aging process, through hormonal balancing, control of oxidative stress, and stimulating the body's own innate repair systems. However, I understand that this treatment may be viewed by the mainstream medical community as new, controversial,and unnecessary by the Food and Drug Administration (FDA). The following are examples of some of the possible minor risks/adverse reactions reported for the peptide therapy that may be prescribed for me. At prescribed doses, there are not expected to be any significant risks/adverse reactions as long as full medical disclosure is achieved from the patient during the total time of therapy. For injectable CJC 1295/Ipamorelin adverse reactions include injection site redness, flushing, transient high blood sugar, development of antibodies to CJC 1295, and water retention. These side effects are dose related and usually eliminated by adjusting the dosage. This drug shouldnot be used in patients with known cancer. Oral or sublingual CJC/Ipamorelin doesn’t have any known side effects. For BPC 157 adverse reactions include injection site redness. Oral BPC-157 does not have anyknown side effects. By signing this form, I understand the possible risks associated with this treatment. I understand that Checkmate Health Strategies will monitor my treatment in an effort to manage any side effects, but cannot guarantee that I will not experience any side effects or adverse reactions. I understand that, as with any health treatment, there is no guarantee I will obtain satisfactory results through the use of this therapy. I certify that I have read the foregoing Informed Consent, discussed the issues noted above,had opportunities to ask questions, and agree and accept all of the terms above.
GENERAL RATES AND FEES
Checkmate Health is an “out of network” practice which means that insurance will NOT be billed for services provided. I am required to pay the full amount in advance or at time of service. Checkmate Health does not imply or guarantee that I will be reimbursed by insurance and I will not hold Checkmate Health financially accountable if I am not reimbursed.
RESCHEDULED, CANCELED AND MISSED APPOINTMENTS
When you schedule an appointment with Checkmate Health, that time is specifically for you. By making an appointment, you accept responsibility to pay the full fee for the professional time that is reserved for you. Our company has a policy of charging patients for the full cost of any appointment the patient fails to cancel or reschedule, UNLESS THE APPOINTMENT IS CANCELED AT LEAST 2 HOURS PRIOR TO APPOINTMENT WINDOW. To avoid charges, cancellations must be made by communicating to Checkmate Health, the patient’s desire to cancel the appointment at least 2 hours in advance of the scheduled appointment window. A credit card will be kept on file to pay for these charges.
Service Authorization
Provider Affiliation: You understand that Checkmate collaborates with a network of third-party medical professionals who are licensed and qualified to deliver comprehensive medical services. These individuals may include Emergency Medical Technicians (EMTs), Registered Nurses (RNs), Nurse Practitioners (NPs), Physician Assistants (PAs), Certified Registered Nurse Anesthetists (CRNAs), Doctors of Osteopathy (DOs), Medical Doctors (MDs), and other healthcare specialists. Although these providers are affiliated with Checkmate, they operate as independent contractors and are not direct employees of Checkmate.
Consent for Treatment: By agreeing to this consent, you authorize the medical professionals sourced by Checkmate to provide medical care and services. This care may include but is not limited to diagnostic evaluations, physical examinations, medical treatments, and any other services deemed necessary for your health condition.
Scope of Services: The medical services to be provided will be based on your individual health needs and may vary from general wellness care to specialized medical interventions. These services are intended to be conducted during in-home visits, where the affiliated healthcare provider will perform the agreed-upon medical care, tests, procedures, and supply the necessary medical equipment and supplies.
Informed Consent: Before receiving any treatment, you will be informed about the specific nature of the proposed medical services, the expected benefits, and the potential risks and side effects associated with them. I agree that Checkmate has communicated to me the risks and benefits associated with each treatment that I receive and have had an opportunity to ask the practitioner any questions I have on the risk associated with treatments/services that I receive. Knowing each of those risks, I am agreeing to proceed with services from Kings Medical PC. I understand that there is no implied or stated guarantee of success or effectiveness of any treatment. There has been no representation that any procedure is covered under my insurance plan or that I will receive reimbursement. I agree to pay the full cost of the service regardless if the treatment is stopped at any time prior to completion at the discretion of the medical provider or myself. Checkmate ensures that all patients are given enough information to make informed decisions about their healthcare, respecting patient autonomy and promoting informed choice.
Medical Services and Care
During an in-home visit, the attending provider may deliver and perform agreed-upon medical care, tests, procedures, and other necessary services.
You acknowledge having been informed of the risks and benefits associated with each treatment and have had the opportunity to ask questions regarding the risks associated with the services received.
Financial Agreement
General Rates and Fees: Checkmate Health operates as an “out-of-network” provider, meaning insurance will not be billed for services. Payment is required in advance or at the time of service.
Financial Responsibility: You agree to bear the full cost of the services and understand that there is no guarantee of insurance reimbursement.
You have been informed of possible risks such as discomfort, thrombophlebitis, fatigue, allergic reactions, redness, swelling, or irritation at the injection site, mild headaches or flushing, digestive changes (nausea, bloating, diarrhea, appetite shifts), dizziness, Water retention or joint aches, mood changes or sleep disturbance, hormonal shifts (e.g., changes in appetite, energy, or menstrual cycles) and others.
You agree to notify Checkmate of any pre-existing conditions like diabetes or heart disease that may affect the therapy.
Understanding and Agreement
By signing below, you acknowledge that you understand the terms of service and consent to the medical services provided by Checkmate Health and its affiliates. You affirm that all your questions have been answered satisfactorily and you agree to proceed with the treatments as discussed.
HIPAA NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
The terms of this Notice of Privacy Practices ("Notice") apply to KINGS MEDICAL SERVICES PC, its affiliates and its employees. KINGS MEDICAL SERVICES PC will share protected health information of patients as necessary to carry out treatment, payment, and health care operations as permitted by law.
We are required by law to maintain the privacy of our patients' protected health information and to provide patients with notice of our legal duties and privacy practices with respect to protected health information. We are required to abide by the terms of this Notice for as long as it remains in effect. We reserve the right to change the terms of this Notice as necessary and to make a new notice of privacy practices effective for all protected health information maintained by Checkmate & its affiliates. We are required to notify you in the event of a breach of your unsecured protected health information. We are also required to inform you that there may be a provision of state law that relates to the privacy of your health information that may be more stringent than a standard or requirement under the Federal Health Insurance Portability and Accountability Act ("HIPAA"). A copy of any revised Notice of Privacy Practices or information pertaining to a specific State law may be obtained by mailing a request to the Privacy Officer at the address below.
USES AND DISCLOSURES OF YOUR PROTECTED HEALTH INFORMATION:
Authorization and Consent: Except as outlined below, we will not use or disclose your protected health information for any purpose other than treatment, payment or health care operations unless you have signed a form authorizing such use or disclosure. You have the right to revoke such authorization in writing, with such revocation being effective once we actually receive the writing; however, such revocation shall not be effective to the extent that we have taken any action in reliance on the authorization, or if the authorization was obtained as a condition of obtaining insurance coverage, other law provides the insurer with the right to contest a claim under the policy or the policy itself.
Uses and Disclosures for Treatment: We will make uses and disclosures of your protected health information as necessary for your treatment. Doctors and nurses and other professionals involved in your care will use information in your medical record and information that you provide about your symptoms and reactions to your course of treatment that may include procedures, medications, tests, medical history, etc.
Uses and Disclosures for Payment: We will make uses and disclosures of your protected health information as necessary for payment purposes. During the normal course of business operations, we may forward information regarding your medical procedures and treatment to your insurance company to arrange payment for the services provided to you. We may also use your information to prepare a bill to send to you or to the person responsible for your payment.
Uses and Disclosures for Health Care Operations: We will make uses and disclosures of your protected health information as necessary, and as permitted by law, for our health care operations, which may include clinical improvement, professional peer review, business management, accreditation and licensing, etc. For instance, we may use and disclose your protected health information for purposes of improving clinical treatment and patient care.
Individuals Involved In Your Care: We may from time to time disclose your protected health information to designated family, friends and others who are involved in your care or in payment of your care in order to facilitate that person's involvement in caring for you or paying for your care. If you are unavailable, incapacitated, or facing an emergency medical situation and we determine that a limited disclosure may be in your best interest, we may share limited protected health information with such individuals without your approval. We may also disclose limited protected health information to a public or private entity that is authorized to assist in disaster relief efforts in order for that entity to locate a family member or other persons that may be involved in some aspect of caring for you.
Business Associates: Certain aspects and components of our services are performed through contracts with outside persons or organizations, such as auditing, accreditation, outcomes data collection, legal services, etc. At times it may be necessary for us to provide your protected health information to one or more of these outside persons or organizations who assist us with our health care operations. In all cases, we require these associates to appropriately safeguard the privacy of your information.
Appointments and Services: We may contact you to provide appointment updates or information about your treatment or other health-related benefits and services that may be of interest to you. You have the right to request and we will accommodate reasonable requests by you to receive communications regarding your protected health information from us by alternative means or at alternative locations. For instance, if you wish appointment reminders to not be left on voice mail or sent to a particular address, we will accommodate reasonable requests. With such request, you must provide an appropriate alternative address or method of contact. You also have the right to request that we not send you any future marketing materials and we will use our best efforts to honor such request. You must make such requests in writing, including your name and address, and send such writing to the Privacy Officer at the address below.
FINANCIAL CONSENT/ASSIGNMENT OF BENEFIT AND RELEASE OF INFORMATION
I hereby assign payment to (1) Checkmate Health; and (2) health care providers who are not employees of Checkmate Health, but who have a contract with Checkmate Health to provide services.