I provide permission for REGENX Helath providers to inform my primary doctor about the management and treatment that I am about to receive (please check).

• 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.
• 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 take responsibility for any violation of my privacy if I initiate email communication outside of a secure portal system.

Contact Methods : E-Mail, Phone Call and SMS (Text Messenger)

 

E-mail, Phone Call and Text Messeging communication provides a fast and easy way to communicate with your healthcare provider for those issues that are nonemergent, non-urgent, or non-critical. It is not a replacement for the interpersonal contact that is the very basis of the patient-healthcare provider relationship; rather it can support and strengthen an already established relationship.

General Considerations

E-mail, Phone Calls, and Text Messaging communication will be considered and treated with the same degree of privacy and confidentiality as written medical records.

Standard e-mail services like Gmail, AOL, Yahoo, and Hotmail are not secure. This means that e-mail messages are not encrypted and can be intercepted and read by unauthorized individuals.

Transmitting an e-mail that contains protected health information through an e-mail system that is not encrypted does not meet the security guidelines as required by the Health Information Protection and Accountability Act (HIPAA).

Your E-mail address or phone number will not be used for external marketing purposes without your permission.

 

I consent for Regenx Health physicians and staff to contact me through email, phone calls, and text messaging in order to provide treatment.

Purpose:

I consent to the use of my photograph for telemedicine purposes, including diagnosis, identification, treatment, and medical documentation.

 
Use of Photograph:

1.The photograph will be securely stored in my medical record.

2.It will only be accessed by authorized healthcare professionals involved in my care.

3.It will not be shared or used beyond my treatment without additional consent.

 
Voluntary Consent:

My consent is voluntary and does not affect my access to care. I may withdraw it at any time in writing

INTRODUCTION

 

REGENX Health is not capable of serving or replacing your primary care provider.  If you become ill, you agree to contact your personal physician or visit an urgent care facility. 

 

Testosterone Replacement Therapy (TRT) is generally regarded as safe for healthy adults. However, there are some risks that you should be aware of as well. Some of the risks can be mitigated by following your treatment plan as advised by your doctor. However, no medical intervention is without risk or guarantee of success. The following are potential risks of TRT:

 

• Acne
• Breast Tenderness or Enlargement Moodiness or Aggressive Behavior
• Water Retention
• Hair thinning and baldness
• Hypogonadal symptoms may not improve
• Sleep Apnea/Sleep Disturbance
• Worsened Cholesterol Levels
• Worsened Liver Function tests
• Increased Red Blood Cell Levels
• Headache
• Prostate enlargement, worsening of urinary symptoms, worsening of prostate cancer, change in PSA levels, decreased sperm production, and infertility may continue after stopping testosterone. Testicular atrophy that may be permanent
• Increased risk of developing blood clots, heart attack, stroke & even death

 

A full list of risks and benefits of testosterone replacement therapy in men can be found at the American Urologic Association Testosterone Guidelines. We advise all patients to review the guidelines prior to undergoing testosterone replacement therapy. 

The FDA testosterone package insert can be found at FDA Testosterone Label Insert. We advise all patients to review the label insert before undergoing testosterone replacement therapy. 

On Feb 2.2025, the FDA advised of new label changes to testosterone products, which can be viewed at FDA Label Update. 

 

MEDICATION & TREATMENT COMPLIANCE

  

• I understand that I will only receive a prescription medication when medically necessary and that I do not automatically qualify for hormone replacement therapy upon my initial assessment. Obtaining a prescription is always at the physician's discretion and is determined based on medical assessment and a diagnosis.
• If I am found to be a candidate for any prescription medication at REGENX Health, I agree during my treatment to carefully follow the instructions given, and notify the doctor of any change in my medical history (especially heart or blood pressure problems).
• I agree during treatment at REGENX Health or while in possession of prescribed medication from a REGENX health provider not resell any medication nor share it with any individual.
• I agree not to visit other doctors for the purpose of obtaining additional or duplicate medication of the same type.
• I agree to immediately report to a REGENX Health provider any adverse reactions or problems, of whatever nature, whether or not said matters relate to treatment.
• I understand that restoring and balancing hormones accurately requires follow-up blood work and monitoring. If I fail to submit to requested follow-up request, I understand that my physician, at his/her discretion, will discontinue my therapy until the requested information is received.

• I consent to have REGENX Health, including any provider or medical assistant that works for or with REGENX Health begin treatment, monitor treatment, and make recommendations for testosterone replacement therapy. I agree to periodically have blood tests performed to monitor my levels and adjust or cease medication at the advice of my REGENX Health provider. I have been informed that the benefits of therapy are not guaranteed and if I stop treatment my condition may return or get worse.

Our Legal Duty

We are required by applicable federal and state laws to maintain the privacy of your protected health information. We are also required to give you this notice about our privacy practices, our legal duties, and your rights concerning your protected health
information. We must follow the privacy practices that are described in this notice while it is in effect. We reserve the right to change our privacy practices and the terms of this notice at any time, provided that such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our notice effective for all protected information that we maintain, including medical information we created or received before we made the changes. You may request a copy of our notice (or any subsequent revised notice) at any time.

Uses and Disclosures of Protected Health Information

We will use and disclose your protected health information about you for treatment, payment, and healthcare operations. Following are examples of the types of uses and disclosures of your protected healthcare information that may occur. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by our office.

Treatment

We will use and disclose your protected health information to provide, coordinate or manage your healthcare and any related services. This includes the coordination or management of your health care with a third party. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. We will also disclose protected health information to other physicians who may be treating you. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you. In
addition, we may disclose your protected health information from time to time to another physician or health care provider (e.g., a specialist or laboratory) who, at the request of your physician, becomes involved in your care by providing assistance with your health care diagnosis or treatment to your physician.

Health Care Operations

We may use or disclose, as needed, your protected health information in order to conduct certain business and operational activities. These activities include but are not limited to, quality assessment activities, employee review activities, training of
students, licensing, and conducting or arranging for other business activities. For example, we may use a sign-in sheet at the registration desk where you will be asked to sign your name. We may also call you by name in the waiting room when your doctor is ready to see you. We may use or disclose your protected health information, as necessary, to contact you by telephone or mail to remind you of your appointment. We will share your protected health information with third-party "business associates" that perform various activities (e.g., billing, transcription services) for the practice. We may use or disclose your protected health information, as necessary, to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you. We may also use and disclose your protected health information for other marketing activities. For example, your name and address may be used to send you a newsletter about our practice and the services we offer. We may also send you information about products or services that we believe may be beneficial to you. You may contact us to request that these materials not be sent to you.

Uses and Disclosures Based on Your Written Authorization

Other uses and disclosures of your protected health information will be made only with your authorization unless otherwise permitted or required by law as described below. You may give us written authorization to use your protected health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Without your written authorization, we will not disclose your health care information except as described in this notice.

Others Involved in Your Health Care

Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your protected health information that directly relates to that person's involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose protected health information to notify or assist in notifying a family member personal representative or any other person that is responsible for your care of your location, general condition, or death.

Marketing

We may use your protected health information to contact you with information about treatment alternatives that may be of interest to you. We may disclose your protected health information to a business associate to assist us in these activities. Unless the information is provided to you by a general newsletter or in person or is for products or services of nominal value, you may opt out of receiving further such information by telling us using the contact information listed at the end of this notice.

Research

Death; Organ Donation: We may use or disclose your protected health information for research purposes in limited circumstances. We may disclose the protected health information of a deceased person to a coroner, protected health examiner, funeral director, or organ procurement organization for certain purposes.

Public Health and Safety

We may disclose your protected health information to the extent necessary to avert a serious and imminent threat to your health or safety, or the health or safety of others. We may disclose your protected health information to a government agency authorized to oversee the health care system or government programs or its contractors, and to public health authorities for public health purposes.

Health Oversight

We may disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs, and civil rights laws.

Abuse or Neglect

We may disclose your protected health information to a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, we may disclose your protected health information if we believe that you have been a victim of abuse, neglect or domestic violence to the governmental entity or agency authorized to receive such information. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.

Food and Drug Administration

We may disclose your protected health information to a person or company required by the Food and Drug Administration to report adverse events, product defects or problems, or biologic product deviations; to track products; to enable product recalls; to make repairs or replacements; or to conduct post-marketing surveillance, as required.

Criminal Activity

Consistent with applicable federal and state laws, we may disclose your protected health information, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. We may also disclose protected health information if it is necessary for law enforcement authorities to identify or apprehend an individual.

Required by Law

We may use or disclose your protected health information when we are required to do so by law. For example, we must disclose your protected health information to the U.S. Department of Health and Human Services upon request for purposes of determining whether we are in compliance with federal privacy laws. We may disclose your protected health information when authorized by workers' compensation or similar laws.

Process and Proceedings

We may disclose your protected health information in response to a court or administrative order, subpoena, discovery request or other lawful process, under certain circumstances. Under limited circumstances, such as a court order, warrant or grand jury subpoena, we may disclose your protected health information to law enforcement officials.

Law Enforcement

We may disclose limited information to a law enforcement official concerning the protected health information of a suspect, fugitive, material witness, crime victim or missing person. We may disclose the protected health information of an inmate or other person in lawful custody to a law enforcement official or correctional institution under certain circumstances. We may disclose protected health information where necessary to assist law enforcement officials to capture an individual who has admitted to participation in a crime or has escaped from lawful custody.

Patient Rights Access

You have the right to look at or get copies of your protected health information, with limited exceptions. You must make a request in writing to the contact person listed herein to obtain access to your protected health information. You may also request access by sending us a letter to the address at the end of this notice. If you request copies, we will charge you $25.00 for each page or $10.00 per hour to locate and copy your protected health information, and postage if you want the copies mailed to you. If you prefer, we will prepare a summary or an explanation of your protected health information for a fee. Contact us using the information listed at the end of this notice for a full explanation of our fee structure.

Accounting of Disclosures

You have the right to receive a list of instances in which we or our business associates disclosed your protected health information for purposes other than treatment, payment, health care operations and certain other activities. We will provide you with the date on which we made the disclosure, the name of the person or entity to which we disclosed your protected health information, a description of the protected health information we disclosed, the reason for the disclosure, and certain other information. If you request this list more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests. Contact us using the information listed at the end of this notice for a full explanation of our fee structure.

Restriction Requests

You have the right to request that we place additional restrictions on our use or disclosure of your protected health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency). Any agreement we may make to a request for additional restrictions must be in writing signed by a person authorized to make such
an agreement on our behalf. We will not be bound unless our agreement is so memorialized in writing.

Confidential Communication

You have the right to request that we communicate with you in confidence about your protected health information by alternative means or to an alternative location. You must make your request in writing. We must accommodate your request if it is reasonable, specifies the alternative means or location, and continues to permit us to bill and collect payment from you.

Amendment

You have the right to request that we amend your protected health information. Your request must be in writing, and it must explain why the information should be amended. We may deny your request if we did not create the information you want amended or for certain other reasons. If we deny your request, we will provide you with a written explanation. You may respond with a statement of disagreement to be appended to the information you wanted to be amended. If we accept your request to amend the information, we will
make reasonable efforts to inform others, including people or entities you name, of the amendment and to include the changes in any future disclosures of that information.

Electronic Notice

If you receive this notice on our website or by electronic mail (e-mail), you are entitled to receive this notice in written form. Please contact us to obtain this notice in written form.

Questions and Complaints

If you want more information about our privacy practices or have questions or concerns, please contact us. If you believe that we may have violated your privacy rights, or you disagree with a decision we made about access to your protected health information or in response to a request you made, you may contact us. We support your right to protect the privacy of your protected health information.

Financial Agreement for Payment of Services

Our practice relies upon open communication with our patients regarding our financial policy and will assist in providing the best service to you. Payment is expected at the time services are rendered. We accept credit cards. All payments must be made from a payment source on which you are the named Account holder. All payments are not refundable, for any reason. You will be charged for the Services at the end of each month on a subscription basis. If we do not receive the full amount of your Service Fees within 15 days of the Billing Date your account will be deactivated without further notice. In the event that your account becomes delinquent and is therefore in default of payment, you will be responsible for the principal amount owed and all reasonable costs associated with the collection of this debt, including collection service fees, attorney’s fees, court costs, and additional legal expenses associated with the recovery of the debt. You agree to pay us all reasonable attorney's fees and costs incurred by us to collect any past due amounts Please contact us at any time with any questions regarding your account and/or balance.

 

You agree that we will not be liable for any loss caused by any unauthorized use of your credit card or any other method of payment by a third party in connection with the Site. You waive your right to dispute any payment made into Your Account and you will bear all costs. Any attempt to defraud the Site through the use of credit cards or other methods of payment or any failure by you to honor charges or requests for payment will result in immediate termination of Your Account and civil and/or criminal prosecution. In the case of suspected or fraudulent payment, including the use of stolen credentials, by anyone, or any other fraudulent activity, we reserve the right to block Your Account. We shall be entitled to inform any relevant authorities or entities (including credit reference agencies) of any payment fraud or other unlawful activity and may employ collection services to recover payments. Returned Checks- A $35.00 cash fee will be charged for any returned checks. We will be unable to accept your checks for any future services. You agree to pay any outstanding balance in full within 30 days of cancellation or termination of the Services. We may change our fee structure at any time with thirty (30) days' notice. 

 

Insurance Policy

 

Currently, our practice does not accept insurance. REGENX Health strives to provide quality medical care along with affordable access to compound medications, blood tests, and nutritional supplements. Many of the therapies and medications are not covered by insurance, and the cost of overall treatment is often less than when using insurance. On a case-by-case basis, some insurance companies do reimburse for Hormone Replacement Therapy and Sexual Performance medication. It is each patient's responsibility to contact their own insurance company to confirm reimbursement. REGENX Health will not contact your insurance company nor will take any responsibility for any additional forms your insurance requires. 

 
Provider Responsibilities

The Provider will attempt to electronically confirm your e-mail address by requesting a return response to all email messages. Your provider may route your e-mail messages to other members of the staff for informational purposes or for expediting a response. Designated staff may receive and read your e-mail.
The provider will make every attempt to respond to your email message within 1 business day. If you do not receive a response from the provider within 1 business day, please contact the office. Copies of e-mails sent and received from and to you will be incorporated into your medical record. You are advised to retain all electronic correspondence for your own files.

Patient Responsibilities

E-mail messages should not be used for emergencies or time-sensitive situations. In the event of a medical emergency, you should contact 911. For emergent or time-sensitive situations, you should contact your healthcare provider through the office. E-mail messages should be concise. Please key in your full name and the topic, i.e., medication question, in the subject line. This will serve to identify you as the sender of the e-mail. Please acknowledge that you received and read the provider’s message by return e-mail to the provider Due to the importance of using email we want to make sure that every patient who provides us with their email address is able to receive our communication. In order to protect your privacy many email providers have strict rules which filter any incoming emails containing large attachments or specific content. Health information such as blood test results are sent by email in an attachment which can be blocked by your email provider’s security filter which is designed to protect you from receiving anything which might harm your computer. Unfortunately, this security feature can also block legitimate emails unless the sender's address is approved by the recipient. If you would like to use email as a means of communication, please be sure to unblock emails from REGENX Health. Depending on your email service provider, there are ways to unblock email addresses and approve the sender so that you may receive emails. Also, be sure to check your SPAM or junk email inboxes for emails sent.

 

 

Receipt of Notice of privacy practices acknowledgment: I have received and reviewed the privacy practice notice, and understand its contents in full. 

Processing of Account Payments 

REGENX Health uses third party electronic payment processors and/or financial institutions ("ESPs") to process financial transactions.You irrevocably authorize us, as necessary, to instruct such ESPs to handle such transaction and you irrevocably agree thatThe company may give such instructions on your behalf in accordance with your requests as submitted on the Site. You agree to be bound by the terms and conditions of use of each applicable ESP, and in the event or conflict between these Terms and the ESP's terms and conditions then these Terms shall prevail

One Time Charge

 

You authorize REGENX Health to charge your credit card or bank account. You will be charged an initial fee of $325.00 for the initial consultation and laboratory blood panel, unless otherwise noted. A service charge is applied to transactions; however, we offer a cash discount that immediately reduces this service charge for cash payments in office. All advertised and marked prices reflect cash prices. A receipt for the payment will be provided to you upon request and the charge will appear on your credit card or bank statement. You agree that once your blood panel has been ordered and/or consultation has been provided no refund can or will be provided. 

Recurring Subscription Charge

 

You authorize REGENX Health to schedule charges to your credit card or bank account. Our services are provided on a monthly subscription basis.

Only Patients who qualify for therapy will be charged the amount of 275$ monthly, which includes certain medications (including but not limited to Testosterone Cypionate, Oral Testosterone Tablets, Testosterone Cream, and Arimidex), doctor visits, medical supplies, and routine follow-up laboratory blood work.

Our subscription charge is subject to change and you will be notified of any changes during your care. To cancel your subscription at any time you must contact your REGENX Health provider via text and email.  Any changes or charges for additional medication in addition to your subscription service will be notified in writing, by email, or verbally before the charge. By signing this agreement you further agree to such conviencence and method to update new and/or recurring charges by methods and/or means listed above.