Hormone Therapy Agreement for Treatment

SAPW and Patient agree that these guidelines and conditions are an essential factor in maintaining a successful relationship.  Adverse side effects and/or psychological dependence may develop after repeated usage of these medications and so, these prescriptions are prescribed with caution.

The patient agrees and accepts the following conditions:

1. Medical treatment offered by SAPW are not accompanied by any claims, guarantees, promises, or warrantees.
2. SAPW is an Insurance Free Entity.  Patient understands that he/she will not request SAPW to submit a claim to any third-party payor, even if patient is entitled to benefits, for any portion of the fee or any services rendered to patient.  SAPW will not accept assignment from any third-party payor as payment for services.  Patient understands that Medicare, Medicaid, and Champva require a waiver that states the patient acknowledges the waiving of rights to file a claim to seek reimbursement from these entities or secondary insurance coverage. 
3. Patient authorizes SAPW to obtain, on Patient’s behalf, medical laboratory, diagnostic testing, Physician(s) consulting, and compounding pharmacy supplies.  In addition, Patient authorizes SAPW to provide medical care and prescribed pharmaceuticals based on the Medical History Questionnaire, laboratory testing, and other information submitted to SAPW under this agreement.  
4. Medications I have purchased are prescribed for me based on symptoms and/or diagnoses derived from my submitted medical history, laboratory blood work, and physical exam.  They are used exclusively for treatment of symptoms of my conditions.
5. Patient understands and agrees that, although each hormone has been approved by the FDA, the FDA only approves or denies usage of products made by manufacturers which are produced in a specific dosage and form.  Therefore, the FDA does not approve or disapprove of hormones which are given in an individual dosage or form for each patient by providers of SAPW.  I also understand that SAPW may choose to discuss with me and provide medications that are off-label in order to offer the widest range of therapies possible.  Off-label prescribing is a common and legal practice by most providers in the US whereby medications are prescribed for purposes other than originally approved.
6. I will not attempt to obtain “controlled” or “scheduled” HRT medications illegally or from any other healthcare provider without disclosing my current medication usage.  I also understand that it is illegal to do so.
7. I will immediately report any adverse side effects related to the use of my medications to SAPW and discontinue use until advised to resume usage by SAPW.
8. I will safeguard my medication from loss or theft, and I will not share, sell, or trade my medications for money, goods, or services.
9. I will use my medications at the prescribed rate and dosage and will keep the medication in its respective labeled containers.
10. SAPW does not replace my current primary care provider (PCP).  If I do not have a PCP, I agree to establish care with a physician for my general health issues.
11. SAPW will obtain laboratory testing from certified and registered labs in Texas, including Quest Lab, LabCorp, LabTech Diagnostics or Clinical Pathology Laboratories.  SAPW will assist the patient in filing laboratory fees to patient’s insurance for reimbursement.  However, patient understands and agrees that patient’s insurance coverage may involve co-pays and/or deductibles, which may require patient to be financially responsible for laboratory fees.
12. Patient understands and agrees that SAPW offers communication via email for non-urgent matters such as lab results.  Although SAPW has implemented reasonable technical safeguards, SAPW cannot guarantee privacy, security, or confidentiality of emails sent or received.  SAPW is not responsible for emails that are lost due to technical failure during composition, transmission, or storage.  SAPW will not forward emails to third parties without your prior written consent, except as authorized or required by law.  Until new technologies are adopted, patient understands and agrees that email communications are not encrypted.  SAPW respects and protects the privacy of our patients.  SAPW will never sell or rent your email address to third parties.  You may discontinue receiving emails as a means of communication by sending an email or letter to SAPW.  
13. To cancel an appointment, I must call 210-455-3309 at least 24 hours prior to my scheduled appointment or, regrettably, a $100 no-show fee will be charged.