This Notice describes the privacy practices of Misra Wellness® and Sulagna Misra, MD. It explains how your Protected Health Information (“PHI”) may be used and disclosed, your rights regarding your health information, and our responsibilities for protecting your information.

This Notice applies to health care provided through Misra Wellness®, including Direct Primary Care and concierge care, individual medical consultations, telemedicine services, and other medical services provided by the practice in California and New York.

YOUR RIGHTS

When it comes to your health information, you have certain rights.

Get a Copy of Your Medical Record

You may request to inspect or obtain an electronic or paper copy of your medical record and other health information maintained by Misra Wellness®. You may also request that a copy be transmitted to another person or entity as permitted by law.

We will provide access or a copy within the time required by applicable law. Any fee charged will be limited to the amount permitted by law.

Ask Us to Correct Your Medical Record

If you believe information in your medical record is incorrect or incomplete, you may ask us to correct or amend it. We may deny your request under circumstances permitted by law, but if we do, we will explain the reason in writing.

Request Confidential Communications

You may ask us to contact you in a particular way or at a particular location, such as only at a particular telephone number or email address. We will accommodate reasonable requests as required by law.

Ask Us to Limit What We Use or Share

You may ask us not to use or disclose certain health information for treatment, payment, or healthcare operations. We are generally not required to agree to your request.

However, if you pay for a healthcare service or item entirely out of pocket and ask us not to disclose information about that service or item to your health plan for payment or healthcare operations, we will comply when required by law.

Get a List of Certain Disclosures

You may request an accounting of certain disclosures of your health information made during the six years before the date of your request.

The accounting does not include every disclosure. For example, certain disclosures for treatment, payment, and healthcare operations, disclosures made directly to you, and other disclosures excluded by law may not be included.

Get a Copy of This Notice

You may request a paper or electronic copy of this Notice at any time, even if you previously agreed to receive it electronically.

Choose Someone to Act for You

If you have given someone medical power of attorney or another person is legally authorized to act on your behalf, that person may exercise your rights and make choices regarding your health information as permitted by law.

We may verify that the individual has appropriate authority before taking action on your behalf.

Be Notified of a Breach

You have the right to be notified as required by law if a breach occurs that may have compromised the privacy or security of your health information.

File a Privacy Complaint

You may file a complaint if you believe your privacy rights have been violated. You may complain directly to Misra Wellness® or to the U.S. Department of Health and Human Services Office for Civil Rights.

Misra Wellness® will not retaliate against you for exercising your privacy rights or filing a complaint.

YOUR CHOICES

For certain health information, you may tell us your preferences regarding what we share.

You may tell us whether you want us to share relevant information with family members, friends, caregivers, or others involved in your care or payment for your care.

If you are unable to communicate your preference, we may share relevant information when, using professional judgment and as permitted by law, we determine that doing so is in your best interest.

We may also share information as permitted by law in connection with disaster-relief efforts.

We will obtain your written authorization before using or disclosing your health information when authorization is required by law, including for most uses and disclosures of psychotherapy notes, certain marketing activities, and the sale of PHI.

Misra Wellness® does not sell your Protected Health Information.

If you give us written authorization, you may revoke that authorization in writing at any time, except to the extent that we have already acted in reliance upon it.

HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION

We may use or disclose your health information in the following circumstances, as permitted or required by law.

Treatment

We may use and disclose your health information to provide, coordinate, or manage your medical care.

For example, we may share relevant health information with another physician, pharmacy, laboratory, imaging facility, hospital, specialist, or other healthcare professional involved in your care.

Payment

We may use and disclose health information for payment-related activities.

Misra Wellness® is primarily a direct-pay practice and generally does not bill health insurance for professional services. Payment-related uses and disclosures may nevertheless occur as permitted by law.

Healthcare Operations

We may use and disclose your health information to operate the practice and improve the care and services we provide.

For example, we may use information for quality assessment and improvement, compliance activities, credentialing, business administration, record management, training, and other healthcare operations permitted by law.

Business Associates

We may disclose PHI to companies or individuals that perform services for Misra Wellness® when they require access to PHI to perform those services.

When required by law, business associates are contractually required to appropriately safeguard your health information.

Appointment Reminders and Health-Related Communications

We may contact you regarding appointments and may communicate with you regarding treatment alternatives, follow-up care, or other health-related benefits or services that may be relevant to your care.

Public Health Activities

We may disclose health information for public health activities when permitted or required by law, including reporting certain diseases, injuries, births, deaths, adverse events, or other information to authorized public health authorities.

Preventing a Serious Threat to Health or Safety

We may use or disclose health information when necessary and permitted by law to prevent or reduce a serious and imminent threat to the health or safety of an individual or the public.

Health Oversight Activities

We may disclose health information to authorized health oversight agencies for activities permitted by law, including audits, investigations, inspections, licensing, credentialing, and disciplinary proceedings.

Required by Law

We may use or disclose your health information when federal, state, or local law requires us to do so.

Legal and Administrative Proceedings

We may disclose health information in response to a court or administrative order, subpoena, discovery request, or other lawful process when the requirements of applicable law have been satisfied.

Law Enforcement

We may disclose health information for certain law-enforcement purposes when permitted or required by law.

Coroners, Medical Examiners, and Funeral Directors

We may disclose health information to coroners, medical examiners, and funeral directors when permitted or required by law.

Workers’ Compensation

We may disclose health information as authorized by and to the extent necessary to comply with workers’ compensation and similar laws.

Research

We may use or disclose health information for research when the requirements of applicable federal and state law have been satisfied.

Organ and Tissue Donation

We may disclose health information to organizations involved in organ, eye, or tissue donation and transplantation when permitted by law.

Military, Veterans, National Security, and Protective Services

We may disclose health information for certain military, veterans, national security, intelligence, or protective-services activities when authorized or required by law.

Correctional Institutions and Lawful Custody

If you are an inmate of a correctional institution or in lawful custody, we may disclose health information to the correctional institution or authorized officials when permitted by law.

Disaster Relief

We may disclose relevant information to organizations assisting in disaster-relief efforts when permitted by law.

Deceased Individuals

Health information remains protected following an individual's death for the period required by federal law. We may disclose information concerning a deceased individual to personal representatives, coroners, medical examiners, funeral directors, family members involved in the individual's care or payment for care before death, and others as permitted or required by law.

OTHER USES AND DISCLOSURES

Uses and disclosures of your health information not described in this Notice will be made only with your written authorization when authorization is required by law.

If you provide an authorization, you may revoke it in writing at any time, except to the extent that Misra Wellness® has already acted in reliance upon the authorization.

SPECIAL PROTECTIONS FOR CERTAIN HEALTH INFORMATION

Certain types of health information may receive additional protection under federal or state law, including certain mental health information, psychotherapy notes, substance use disorder records, HIV-related information, genetic information, reproductive or sexual health information, and other specially protected health information.

Misra Wellness® will comply with applicable federal and state laws when those laws provide greater privacy protections than HIPAA.

Substance Use Disorder Records

Certain substance use disorder (“SUD”) patient records are subject to additional federal confidentiality protections, including 42 U.S.C. § 290dd-2 and 42 CFR Part 2.

When Misra Wellness® creates, receives, maintains, or transmits records protected by Part 2, those records will be used and disclosed in accordance with applicable federal law.

Part 2 records, or testimony describing information contained in Part 2 records, generally may not be used or disclosed in civil, criminal, administrative, or legislative proceedings against a patient unless authorized by the patient's specific written consent or by an appropriate court order after notice and an opportunity to be heard, as required by applicable law.

California

Misra Wellness® complies with applicable California privacy and confidentiality laws, including the California Confidentiality of Medical Information Act and other California laws that provide protections for particular categories of health information.

Where California law provides greater privacy protection than HIPAA, Misra Wellness® will follow the applicable California requirements.

New York

Misra Wellness® complies with applicable New York privacy and confidentiality laws.

HIV-related information receives additional protection under New York law and will be used or disclosed only as authorized or required by applicable law. When New York law requires a confidentiality notice to accompany a permitted disclosure of HIV-related information, Misra Wellness® will provide the required notice.

Other categories of health information receiving additional protection under New York law will be handled in accordance with applicable requirements.

ELECTRONIC COMMUNICATIONS

Misra Wellness® may communicate with you through telephone, voicemail, email, text message, patient portal, telemedicine platform, or other electronic communication methods that you provide or authorize.

Electronic communications, including ordinary email and SMS/text messaging, may carry privacy or security risks depending on the communication method and the devices, accounts, networks, or service providers involved.

Misra Wellness® will use reasonable safeguards consistent with applicable law.

You may request reasonable confidential-communication arrangements or restrictions regarding how Misra Wellness® communicates with you.

Communications requiring separate consent under applicable law, including certain marketing communications, will be handled in accordance with those requirements.

FUNDRAISING

Misra Wellness® does not currently use patients' Protected Health Information for fundraising purposes.

If our practices change, we will comply with applicable notice, authorization, and opt-out requirements.

OUR RESPONSIBILITIES

Misra Wellness® is required by law to maintain the privacy and security of your Protected Health Information.

We are required to provide you with this Notice describing our legal duties and privacy practices regarding your health information.

We must follow the duties and privacy practices described in the Notice currently in effect.

We will notify you as required by law if a breach occurs that may have compromised the privacy or security of your health information.

We will not use or disclose your health information other than as described in this Notice or as otherwise permitted or required by law. When written authorization is required, we will obtain it before making the use or disclosure.

CHANGES TO THIS NOTICE

Misra Wellness® reserves the right to change the terms of this Notice and its privacy practices as permitted by law.

Changes may apply to health information we already maintain as well as information we create or receive in the future.

When this Notice is revised, the current Notice will be made available as required by law. The current Notice will be available at Misra Wellness® offices, available upon request in paper or electronic form, and made available on the Misra Wellness® website as applicable.

QUESTIONS, REQUESTS, OR PRIVACY COMPLAINTS

For questions about this Notice, requests concerning your privacy rights, requests for a copy of this Notice, or complaints regarding Misra Wellness®'s privacy practices, please contact:

Sulagna Misra, MD
Privacy Contact
Misra Wellness®

California Office
18740 Ventura Blvd., Suite 204
Los Angeles, CA 91356

New York Office
65 W 36th Street, 10th Floor
New York, NY 10018

Phone: 818-431-5511
Email: admin@misrawellness.com

Privacy complaints to Misra Wellness® may be submitted in writing to the Privacy Contact at either address above or by email at admin@misrawellness.com.

You may also file a complaint with the:

U.S. Department of Health and Human Services
Office for Civil Rights
200 Independence Avenue SW
Washington, DC 20201
Phone: 1-877-696-6775

HHS Office for Civil Rights complaint information

There is no fee to file a complaint. Misra Wellness® will not retaliate against you for exercising your privacy rights or filing a complaint.

Effective Date: January 1, 2026

This Agreement applies to medical care provided by Sulagna Misra, MD and Misra Wellness®, whether I receive care through individual medical consultations, Direct Primary Care (“DPC”) membership, or transition between these models of care.

1.    Medical Consent

I consent to medical evaluation and treatment by Sulagna Misra, MD, Misra Wellness®, and other healthcare professionals involved in my care, as clinically appropriate. Services may include medical evaluation, diagnosis, treatment recommendations, prescriptions, medication management, laboratory testing, imaging, referrals, preventive care, chronic disease management, and other services related to my care.

Procedures, medications, treatments, or services requiring separate informed consent will be addressed separately when applicable.

2.    Models of Care

I understand that Misra Wellness® provides care through individual medical consultations and through ongoing membership programs, including Direct Primary Care.

Individual medical consultations provide medical evaluation and treatment during scheduled visits without the ongoing access and services associated with membership.

DPC membership provides an ongoing physician-patient relationship with greater continuity, access, communication, and care coordination as described in the Misra Wellness® membership materials provided to me.

I understand that DPC membership is not health insurance and does not replace health insurance or other coverage for healthcare services provided outside Misra Wellness®.

3.    Individual Medical Consultation Fees and Services

The current fee for an initial 60-minute individual medical consultation is $500. Subsequent individual consultations are currently $350 for 30 minutes or $500 for 60 minutes.

Payment is required in full before the scheduled consultation. Consultation fees are nonrefundable.

Individual consultation fees cover the scheduled medical consultation and reasonable review of medical information submitted in connection with that consultation. The consultation may include medical evaluation, recommendations, treatment planning, prescriptions when clinically appropriate, and orders or referrals arising from the consultation.

Individual consultation care does not include the ongoing physician access, routine between-visit medical communication, continuing medical management, or level of care coordination available through DPC membership.

Substantive medical evaluation outside a scheduled consultation, including interpretation of new symptoms or results, treatment changes, review of substantial new medical information, or other medical decision-making, may require an additional consultation and applicable fee.

4.    Direct Primary Care Enrollment and Fees

The current initial DPC consultation fee is $350.

Following enrollment and acceptance into the DPC program, ongoing Direct Primary Care / Comprehensive Care membership is currently $249 per month.

Membership begins upon enrollment and acceptance into the DPC program and continues monthly until terminated in accordance with this Agreement.

Payment of an initial DPC consultation fee does not guarantee acceptance into membership if Dr. Misra determines that DPC is not appropriate for the patient's medical needs or that the practice cannot appropriately provide the care required.

DPC membership services, access, and practical information regarding how membership operates are described in the Misra Wellness® “Membership: How It Works” information provided as part of DPC enrollment.

5.    Transition Between Individual Consultations and DPC

Eligible patients receiving individual consultation care may transition to DPC membership when Dr. Misra and the patient agree that ongoing membership is appropriate.

Patients enrolled in DPC may terminate membership in accordance with this Agreement and may subsequently receive individual medical consultations, when clinically appropriate and subject to practice availability, at the then-current consultation fees.

Transitioning between individual consultation care and DPC does not require a new general Medical Consent, Financial, and Continuing Care Agreement unless Misra Wellness® requires updated documentation or the terms of this Agreement have materially changed.

The services, access, fees, and financial obligations applicable at any particular time depend upon the model of care in which the patient is then participating.

6.    Recurring Payment Authorization

For patients enrolled in DPC, I authorize Misra Wellness® and its payment processor to charge the payment method I provide for recurring monthly membership fees.

I agree to maintain a valid payment method and to pay applicable membership fees when due.

I also agree to pay separately disclosed Misra Wellness® charges for additional services that I request, authorize, or agree to receive.

Fees and program offerings may change. Changes to recurring membership fees will be communicated before the changed fee becomes applicable to the patient's membership.

7.    Failed Payments and Non-Payment

If a payment is declined, returned, reversed, disputed, or otherwise unsuccessful, Misra Wellness® may attempt to process the payment again and may request an alternative payment method.

I remain responsible for amounts properly due to Misra Wellness®.

Failure to pay amounts due may result in suspension of non-urgent membership services or termination of DPC membership, subject to applicable law and appropriate continuity-of-care obligations.

Termination or suspension does not eliminate financial responsibility for charges properly incurred before the effective date of termination or suspension.

8.    Services and Expenses Not Included

Unless specifically stated otherwise in writing, individual consultation fees and DPC membership fees do not include charges for laboratory testing, imaging, medications, supplements, compounded medications, procedures, infusions, medical supplies, pharmacy charges, shipping charges, specialist services, hospital services, emergency care, or services provided by outside healthcare professionals or facilities.

Misra Wellness® may offer additional services or programs, including medical weight loss, men's health and hormone management, iron deficiency evaluation and iron infusion services, physician-directed supplements and wellness products, and other services that may become available. Some services, products, medications, procedures, or programs may involve additional fees and may require separate eligibility requirements or informed consent.

Applicable Misra Wellness® fees for separately charged services will be disclosed before the corresponding service is provided when reasonably practicable.

9.    Insurance and Superbills

Misra Wellness® does not participate with health insurance plans, HMO panels, Medicare, Medicaid, or other third-party payors for professional services provided under this Agreement.

Misra Wellness® does not submit claims to health insurance or provide superbills for insurance reimbursement.

Patients may independently use health insurance for eligible services obtained outside Misra Wellness®, including laboratory testing, imaging, medications, specialist care, emergency care, hospitalization, and other healthcare services when applicable.

Coverage and financial responsibility for outside services are determined by the patient's insurer and the outside provider.

10.Cancellation and Rescheduling of Individual Consultations

Individual consultation fees are nonrefundable.

Individual consultation appointments may be rescheduled one time with at least 72 hours' notice. Cancellations, missed appointments, or requests to reschedule with less than 72 hours' notice will result in forfeiture of the consultation fee.

I understand that Dr. Misra may review medical records, laboratory results, imaging, or other information submitted in preparation for my consultation before the scheduled appointment and that professional time may therefore be devoted to my care before the consultation occurs.

Late arrival does not extend the scheduled appointment time.

Appointment policies applicable to DPC members are described in the DPC membership information provided during enrollment.

11.Cancellation of DPC Membership

DPC membership continues on a month-to-month basis until terminated.

I may terminate my DPC membership by providing Misra Wellness® with at least 30 days' written notice. Membership fees already charged are nonrefundable, and applicable membership fees remain due through the effective date of termination.

Termination of DPC membership ends the access and services associated with membership but does not prevent me from subsequently requesting individual medical consultations, subject to clinical appropriateness, practice availability, and then-current fees.

Re-enrollment in DPC after termination is subject to practice availability, acceptance into the program, then-current eligibility requirements and fees, and completion of any required updated documentation.

12.Termination or Modification by Misra Wellness®

Misra Wellness® may terminate DPC membership or the physician-patient relationship when permitted by law, including for non-payment, repeated violation of practice policies, inappropriate or abusive conduct, misuse of prescribing services, failure to meet requirements necessary for safe medical care, breakdown of the physician-patient relationship, or circumstances in which continued care is no longer clinically or professionally appropriate.

When required, Misra Wellness® will provide appropriate notice and information regarding continuity of care consistent with applicable law and professional obligations.

Misra Wellness® may modify its fees, services, program offerings, or practice policies from time to time. Patients will be informed of material changes affecting their ongoing membership as applicable.

13.Medical Information and Coordination of Care

Misra Wellness® may obtain, use, and disclose medical information as permitted by law for treatment and coordination of care, including communication with physicians, other healthcare professionals, hospitals, laboratories, pharmacies, imaging facilities, and other healthcare entities involved in my care.

My Protected Health Information is handled in accordance with the Misra Wellness® Notice of Privacy Practices and applicable law.

14.Emergency and Outside Care

Misra Wellness® is not an emergency medical service.

Neither individual consultation care nor DPC membership replaces emergency services, hospitalization, specialist care, or other healthcare services that may be medically necessary outside Misra Wellness®.

DPC membership does not guarantee continuous or 24-hour physician availability.

15.Clinical Decision-Making

I understand that neither payment for an individual consultation nor enrollment in DPC guarantees any particular diagnosis, prescription, medication, treatment, laboratory test, imaging study, referral, procedure, or medical outcome.

Medical decisions remain subject to Dr. Misra's independent clinical judgment and what is medically appropriate for the individual patient.

16.Relationship to Other Misra Wellness® Forms

This Agreement governs the general medical and financial relationship between the patient and Misra Wellness® for individual medical consultations and Direct Primary Care.

The Misra Wellness® Notice of Privacy Practices, Telehealth Consent, Physician-Patient Arbitration Agreement, “Membership: How It Works” information when applicable, and treatment-specific informed consents are separate documents and remain applicable according to their terms.

17.Acknowledgment and Agreement

By signing below, I acknowledge that I have read and understand this Medical Consent, Financial, and Continuing Care Agreement and agree to its terms.

I understand that Misra Wellness® offers both individual medical consultation care and DPC membership and that the services, access, fees, and ongoing obligations differ between these models.

If I enroll in DPC, I understand that membership creates a recurring monthly financial obligation that continues until membership is terminated in accordance with this Agreement.

I understand that I may request a copy of this Agreement.

(California and New York)

CALIFORNIA PATIENTS

Article 1: Agreement to Arbitrate

It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, will be determined by submission to arbitration as provided by California law, and not by a lawsuit or resort to court process except as California law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration.

Article 2: Claims Subject to Arbitration

It is the intention of the parties that this Agreement apply to claims arising out of or relating to medical treatment or services provided by Sulagna Misra, MD and Misra Wellness®, including claims alleging professional negligence or medical malpractice.

To the extent permitted by applicable law, this Agreement is intended to bind the patient and persons whose claims arise through or on behalf of the patient, including the patient's spouse, heirs, representatives, and children, whether born or unborn.

Article 3: Arbitration Procedures and Applicable Law

A demand for arbitration must be communicated in writing to the other party. Arbitration shall be conducted in accordance with applicable California law governing arbitration agreements and disputes involving healthcare providers.

Unless the parties mutually agree to another procedure, each party shall select one arbitrator, and the two party-selected arbitrators shall select a neutral third arbitrator.

Discovery shall be conducted as permitted by applicable California law. Each party may be represented by counsel at that party's own expense. Arbitration fees, costs, attorneys' fees, witness fees, and other expenses shall be allocated as required or permitted by applicable law or as determined by the arbitrator.

Article 4: General Provisions

Claims arising from the same incident, treatment, transaction, or related circumstances may be arbitrated in one proceeding to the extent permitted by law.

Any claim subject to this Agreement must be brought within the applicable statute of limitations.

If any provision of this Agreement is determined to be invalid or unenforceable, the remaining provisions shall remain in effect to the fullest extent permitted by law.

Article 5: Revocation

For California patients, this Agreement may be rescinded by written notice to Sulagna Misra, MD or Misra Wellness® within 30 days after signature, as provided by California law.

Unless timely rescinded, this Agreement is intended to govern medical services covered by this Agreement as permitted by applicable law.

Article 6: Retroactive Application

This Agreement is intended to apply to medical services provided after it is signed. If the patient and physician agree that this Agreement will also apply to medical services previously provided, that agreement may be separately documented.

NOTICE FOR CALIFORNIA PATIENTS:

NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT.

NEW YORK PATIENTS

Article 7: Agreement to Arbitrate

For medical services provided to a patient in New York, the patient and Sulagna Misra, MD/Misra Wellness® agree that disputes arising out of or relating to medical treatment or services provided by Sulagna Misra, MD or Misra Wellness®, including claims alleging professional negligence or medical malpractice, shall be submitted to binding arbitration to the extent permitted by applicable law.

The parties understand that arbitration is an alternative to resolving a dispute through a lawsuit in court. By agreeing to binding arbitration, the parties understand that claims subject to this Agreement will be decided by a neutral arbitrator rather than by a judge or jury, subject to the rights and judicial review available under applicable law.

Article 8: New York Arbitration Procedures

For disputes arising from medical services provided in New York, arbitration shall be governed by applicable New York law, including Article 75 of the New York Civil Practice Law and Rules, to the extent applicable.

A demand for arbitration shall be provided in writing to the other party.

The arbitration shall be conducted before a neutral arbitrator mutually agreed upon by the parties or selected through a neutral arbitration organization or other lawful selection process if the parties cannot agree.

The patient and Misra Wellness® may each be represented by an attorney. The arbitrator may permit discovery and other procedures consistent with applicable law and the fair resolution of the dispute.

Article 9: New York General Provisions

Any claim subject to arbitration must be brought within the applicable statute of limitations.

If any provision of the New York portion of this Agreement is determined to be invalid or unenforceable, that provision shall be severed to the extent permitted by law, and the remaining provisions shall remain effective.

The New York provisions apply only to the extent permitted and enforceable under applicable federal and New York law.

ACKNOWLEDGMENT

I understand that the provisions applicable to my care depend upon the state in which medical services are provided to me.

I acknowledge that I have read this Physician-Patient Arbitration Agreement and understand that, to the extent permitted by applicable law, I am agreeing to resolve claims covered by this Agreement through binding arbitration rather than through a court or jury trial.

I understand that I have the right to receive a copy of this Agreement.

NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT:

 

TELEHEALTH CONSENT FORM

Misra Wellness® provides medical consultations and ongoing medical care through telehealth. This consent applies to medical care provided through telehealth or telemedicine.

By signing this form, I understand and agree to the following:

Telehealth involves the delivery of healthcare services through electronic communications when the patient and physician or other authorized healthcare professional are in different locations. Telehealth may include video, audio, electronic messaging, photographs, medical records, laboratory or imaging results, and other electronic health information used in connection with my care.

Telehealth may be used for medical evaluation, diagnosis, treatment recommendations, medication management, follow-up care, patient education, review of laboratory or imaging results, and other healthcare services when clinically appropriate.

I understand that telehealth has potential benefits, including improved access to medical care and the ability to receive care without traveling to a medical office. I also understand that telehealth has limitations. A remote examination may not provide the same information as an in-person physical examination, and Dr. Misra may determine that an in-person examination, laboratory testing, imaging, consultation with another healthcare professional, or other evaluation is necessary.

I understand that telehealth relies upon electronic communications and technology. Technical problems may occur, including interrupted or dropped connections, poor audio or video quality, equipment failure, or other technological difficulties. If a telehealth visit cannot be completed adequately, the visit may need to be continued by another method or rescheduled as appropriate.
Misra Wellness® will take reasonable measures to protect the privacy and security of my health information in accordance with applicable federal and state privacy laws and the Misra Wellness® Notice of Privacy Practices. I understand that electronic communications and technology may nevertheless carry privacy or security risks.

I understand that healthcare personnel or technology support personnel may assist with a telehealth visit when reasonably necessary for my care or for operation of the telehealth technology. Such individuals are required to maintain the privacy and confidentiality of my health information as required by applicable law.

I understand that I may choose to have a family member, caregiver, legal representative, or other person present during my telehealth visit. By allowing another person to participate in my visit, I authorize Misra Wellness® to discuss my health information in that person's presence to the extent reasonably necessary for the visit. I may ask that person to leave at any time.

I understand that I should participate in telehealth visits from a location that provides reasonable privacy and allows me to communicate appropriately with Dr. Misra. I understand that Misra Wellness® cannot control the privacy or security of my physical surroundings or the internet connection, device, or network that I choose to use.

I understand that I am responsible for providing accurate and complete information regarding my medical history, current symptoms, medications, allergies, medical conditions, and other information relevant to my care. Telehealth recommendations and medical decisions may depend upon the information available to Dr. Misra at the time care is provided.

I understand that the same professional standards of medical care applicable to an in-person medical encounter apply to care provided through telehealth. The use of telehealth does not guarantee any particular diagnosis, treatment, prescription, or medical outcome.

I understand that prescriptions will be provided only when Dr. Misra determines that they are medically appropriate and permitted by applicable federal and state law. A telehealth consultation does not guarantee that any medication, including a controlled substance, will be prescribed.

I understand that telehealth is not appropriate for every medical condition or situation. If Dr. Misra determines that telehealth is insufficient for appropriate evaluation or treatment, I may be advised that an in-person examination, diagnostic testing, referral, emergency evaluation, or other additional evaluation is necessary.

I understand that Misra Wellness® does not provide emergency medical services through telehealth. Telehealth communications, email, text messaging, patient portals, and other practice communication methods should not be used for medical emergencies.

I understand that my ability to receive telehealth medical care from Dr. Misra depends upon applicable licensing and other legal requirements, including the state in which I am physically located at the time medical care is provided. I agree to accurately disclose my physical location at the time of each telehealth encounter.

I understand that I have the right to ask questions about telehealth and may withdraw my consent to receive care through telehealth at any time. Withdrawal of consent will not affect care already provided. I understand that withdrawing consent to telehealth does not guarantee that Misra Wellness® will be able to provide the same services through an in-person visit.

I understand that information from my telehealth encounters will become part of my medical record and will be maintained in accordance with applicable law and the Misra Wellness® Notice of Privacy Practices.

CONSENT AND ACKNOWLEDGMENT

I have read and understand the information above regarding telehealth. I have had the opportunity to ask questions and consent to the use of telehealth in the provision of my medical care by Misra Wellness®.

By signing below, I certify that I am the patient and am legally authorized to consent to my medical care, or that I am the patient's legally authorized representative and have authority to provide this consent.

I consent to receive medical care through telehealth from Misra Wellness®.