KIWI HEALTH LLC
COMPRENSIVE CONSENT FORMS, PRACTICE POLICIES, & HIPAA PRIVACY NOTICE

SECTION 1: General Consent & Financial Agreement

I voluntarily consent to diagnostic orders/procedures, telemedicine or in-person examinations, and routine medical treatment rendered by Kiwi Health LLC and it's Medical Providers. I agree to pay all fees per the current fee schedule and understand policies for late cancellations less than 4 hours or no-shows.

SECTION 2: TELEHEALTH INFORMED CONSENT

I voluntarily consent to diagnostic orders/procedures, telemedicine or in-person I understand that I am voluntarily engaging in a telemedicine consultation with Kiwi Health LLC.

I understand that video conferencing technology and/or phone consultations will not be the same as a direct, in-person visit because I will not be physically present with my provider.

I understand that a telehealth consultation has potential benefits, including easier access to care, reduced costs, and the convenience of attending visits from the comfort of my home.

I understand that there are potential risks to using telehealth technology, including interruptions, unauthorized access, and technical difficulties. If technical difficulties occur and a stable connection cannot be re-established, the consultation may be rescheduled or continued via phone if appropriate. Either my healthcare provider or I can discontinue the telehealth consultation at any time if the video or phone connection is inadequate.

Patient Location Attestation: I certify that, at the time of each telemedicine encounter, I will be physically located in a state where my Kiwi Health clinician is licensed to practice (currently NJ, PA, NY, FL, AZ). I will notify the clinic immediately if I am traveling or residing outside those states, and I understand that the visit may need to be rescheduled or converted to an in-person appointment.

Hybrid In-Person Requirements: I understand that certain prescriptions (e.g., Schedule II stimulants) federal regulations (e.g., the Ryan Haight Act) or state regulations (e.g., the New Jersey 90-day rule) may require me to appear for periodic in-person visits. I agree to attend such visits at the location and schedule provided by Kiwi Health.

Privacy and Confidentiality: I understand that Kiwi Health LLC complies with HIPAA regulations to protect my health information. However, I acknowledge that no technology is 100% secure, and in the unlikely event of a data breach, I will be informed.

Data Security Best Practices: I agree to protect my own privacy by ensuring that:

• I use a private, secure location during my telemedicine visit,
• I use a secure internet connection, and
• I do not share telemedicine login information or video conferencing links with unauthorized individuals.

I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. I will be informed if anyone else is present during my telehealth consultation, and I will disclose if someone else is with me. These individuals are required to maintain confidentiality. I understand I have the right to:

• Omit specific details of my medical history that are personally sensitive,
• Ask non-medical personnel to leave the telemedicine room, or
• Terminate the consultation at any time.

I understand that the alternative to a telemedicine consultation is to forgo evaluation and treatment with Kiwi Health LLC and seek an in-person evaluation elsewhere. Therefore, I freely choose to participate in this telemedicine consultation.

Limitations of Telemedicine: I understand that telemedicine has limitations, particularly regarding the physical examination. The physical exam may be limited to visual inspection via video conferencing. Certain physical tests, examinations, and vital signs may need to be conducted by someone at my location, at the direction of my healthcare provider, or not done at all.

Emergency Situations: I understand that telemedicine services offered by Kiwi Health LLC are not for emergency or urgent care situations. In the event of an emergency, I will call 911, visit the emergency department, or seek urgent care.

Follow-up and Continuity of Care: I understand that follow-up visits may be necessary to monitor my treatment and assess my health over time. I agree to adhere to any follow-up plans recommended by my provider or seek in-person care when advised.

Costs and Billing: I understand that I am responsible for the cost of the telehealth consultation and that payment is required according to Kiwi Health LLC's policies. I acknowledge that not all services may be covered by insurance, and I am responsible for verifying coverage with my insurance provider, if applicable.

SECTION 3: PRACTICE POLICIES

1.     APPOINTMENTS & CANCELLATIONS

• The standard meeting time for the initial visit is 30 minutes, and follow-up visits are 15-20 minutes.
• Payment is due before your appointment. You may lose your appointment if payment is not received by the scheduled time.
• Cancellations and rescheduled visits will be subject to a fee of $25 if NOT RECEIVED AT LEAST 4 HOURS IN ADVANCE. This is necessary because a time commitment is made to you and is held exclusively for you. If you are late for an appointment, you may lose some of the allotted time for that appointment.
• Exceptions to this policy may be made for emergency situations on a case-by-case basis based on the sole discretion of the Provider.

2.     TELEPHONE ACCESSIBILITY

If you need to contact Kiwi Health LLC between sessions, please call our main number or send us a message through the website. We are often not immediately available; however, we will attempt to return your call or message within 24 hours.

Face-to-face video visits are highly preferable to phone visits. However, if you are out of town, sick, or need additional support, phone sessions are available in certain states. Phone consultations may be subject to the same rates as video visits and should be scheduled through our online portal.

In case of a true emergency, please call 911 or go to your local emergency room.

3.     ELECTRONIC COMMUNICATION

We cannot ensure the confidentiality of any form of communication through electronic media, including but not limited to text messages, telephone communication, the Internet, facsimile machines, and email.

Telemedicine is broadly defined as the use of information technology to deliver medical services and information between two parties that are at different locations. The above electronic means of communication are considered telemedicine. Utilizing telemedicine services through Kiwi Health LLC is voluntary, and you need to understand:

• You have the right to withhold or withdraw your consent for telemedicine services at any time. If this occurs, you need to understand that we cannot provide care for you any longer, as Kiwi Health LLC is strictly a telemedicine practice.
• We will protect your protected health information (PHI) in the same fashion as a brick-and-mortar practice. However, data breaches can happen, and we cannot guarantee that your information is 100% protected.
• We will not use your PHI for research purposes unless you give us explicit consent to do so.
• There are potential benefits, risks, and subsequent consequences of telemedicine. Potential benefits include, but are not limited to, improved access to care, reducing costs, improving the quality of visits, and reducing travel time associated with medical visits. The medical provider will make assessments, diagnoses, and treatment plans based on the visual and auditory information provided during the video conference.

However, it is important to understand that telemedicine is limited in some ways. For example, the provider cannot perform a full physical examination, including observing your gait, smell, general appearance, or demeanor, as they would in an in-person encounter. This may lead to missing clinically significant information that you may not recognize as important to present verbally.

4.     ID VERIFICATION & MINORS

I will present a government photo ID on request.

Kiwi Health LLC does not currently treat those under the age of 18 on our platform. Case-by-case exceptions can be made based solely on the practice owner and provider’s discretion. In such cases, Parents or guardians must be present for the first part of the session to provide consent for treatment. If the minor is capable of managing their healthcare independently, parents may be asked to step out for the remainder of the session to maintain patient privacy, if appropriate.

If you are a minor, your parents may be legally entitled to some information about your treatment. We will discuss with you and your parents what information is appropriate for them to receive and which issues are more appropriately kept confidential. If we accept a minor, a separate Minor Consent will be provided

5.     TERMINATION

We can terminate treatment with you at any time. However, we will not terminate the medical relationship without first discussing and exploring the reasons and purpose for termination. If treatment is terminated for any reason, we will provide you with a list of qualified providers to continue your care, as well as necessary bridge prescriptions of your medication as deemed necessary by your Provider. You may also choose someone on your own or from another referral source.

Should you fail to show up for follow-up appointments, not obtain lab work in a timely fashion, or be non-compliant with treatment (unless other arrangements have been made in advance), for legal and ethical reasons, we must consider the professional relationship discontinued.

6.     PAYMENT & BILLING

Payment for services is required before the scheduled appointment. You may lose your appointment if payment is not received. While we prefer payment to be made at least 24 hours before the appointment, you are responsible for ensuring payment is completed before the start of the session. Any future appointments may be suspended until the outstanding balance is cleared. 

7.     EMERGENCY CONTACT PROCEDURES

If you are unable to reach us within 24 hours and require urgent medical attention, please visit your nearest urgent care center or emergency room. For life-threatening emergencies, call 911 immediately.

8.     TELEMEDICINE LIMITATIONS

It is your responsibility to inform your provider of any symptoms that may not be visible over a telemedicine visit. Telemedicine may not be suitable for diagnosing certain conditions that require a physical examination or lab testing. If necessary, we will refer you for an in-person follow-up visit.

SECTION 4: CONTROLLED SUBSTANCE AGREEMENT

For every controlled substance prescribed by Kiwi Health, I agree that:

• I will disclose all prescriptions, supplements, and recreational drugs I am taking, and will not seek controlled substances from other sources.
• I will not give or sell my medication to anyone else.
• I will follow my treatment plan and schedule follow-up appointments to receive refills.
• I understand that Kiwi Health does not provide refills for lost or stolen medications, with exceptions made only by the Provider's judgement. 
• I understand that Kiwi Health can only provide up to a 1-month prescription for Schedule-II medications like stimulants at a time
• I consent to real-time PDMP (Prescription Drug Monitoring Program) checks in each prescribing state
• I understand I may be asked to complete random urine drug screens to confirm adherence
• I agree to remote or in-person pill counts if requested
• I will complete a monthly video visits and in-person visit in a cadence as required by federal and state law.

 

SECTION 5: ELECTRONIC COMMUNICATION (EMAIL / SMS) CONSENT

I authorize Kiwi Health LLC to correspond with me via the electronic channels I have verbally or electronically provided (email, SMS, portal messaging). I understand these channels are not 100 % secure and accept that risk. I may revoke this permission in writing at any time.

COMBINED ACKNOWLEDGMENT & SIGNATURE

 

BY SIGNING BELOW, I ACKNOWLEDGE THAT I HAVE READ SECTIONS 1-5 ABOVE, HAD AN OPPORTUNITY TO ASK QUESTIONS, AND VOLUNTARILY CONSENT TO TREATMENT

NOTICE OF PRIVACY PRACTICES (HIPAA) - ACKNOWLEDGEMENT

OUR LEGAL RESPONSIBILITIES

We are required by law to provide you with this notice, which explains how we may use and disclose your protected health information (PHI) and describes your rights and our obligations regarding the use and disclosure of that information. We will maintain the privacy of your PHI and provide you with notice of our legal duties and privacy practices with respect to your PHI.

We have the right to change these policies at any time. If we change our privacy policies, we will notify you of these changes immediately. This current policy is in effect unless stated otherwise. Any policy changes will apply to all your current and past health information.

You may request a copy of our notice at any time. You may contact Kiwi Health LLC at 20 North Orange Avenue, Suite 1100, Orlando, FL 32801, (407) 565-9597 to request a copy of this privacy policy.

HOW WE MAY USE OR DISCLOSE YOUR PROTECTED HEALTH INFORMATION

The following examples describe how we may use your PHI for treatment, payments, healthcare operations, etc., but please note that not every possible use or disclosure in a category will be listed.

• Treatment: We may use and disclose your PHI to provide you with treatment. This includes disclosing your PHI to other medical providers, trainees, therapists, medical staff, and office staff involved in your healthcare.
  Example: Your medical provider might need to consult with another provider to coordinate your care. Additionally, the office staff may need to use and disclose your PHI to individuals outside of our office, such as a pharmacy, when a prescription is called in.
• Payment: We may use your PHI to obtain payment from an insurance company or another third party. This may include providing your PHI to an insurance company for a pre-authorization for a medication we prescribed.
• Health Care Operations: We may use or disclose your PHI to operate this medical practice. This includes training students, reviewing cases with employees, improving the quality of care, and contacting you by telephone, email, or text to remind you of appointments.
  If we share your PHI with third-party “business associates” (such as a billing service), we will have a written contract in place to protect the privacy of your PHI.
• Marketing: Kiwi Health will not use or disclose your protected health information for marketing purposes without your written HIPAA Authorization, and you may revoke that authorization at any time.

We will not use or disclose your PHI for any purpose other than those identified in this policy without your specific, written authorization. You may give us written authorization to use your PHI for any purpose. You can revoke this authorization at any time, but it will not affect PHI already disclosed while the authorization was in effect.

• Appointment Reminders: We may contact you via text, phone, or email as a reminder that you have an upcoming appointment for your initial visit, follow-up, or lab work.
• Others Involved in Your Health Care: We may disclose your PHI to family members or friends if we obtain your verbal agreement to do so, or if we give you an opportunity to object to such a disclosure and you do not raise an objection.
  Example: If your spouse or friend is present during your evaluation, we may disclose PHI to this person. If you are unable to agree or object, we may disclose necessary information based on our professional judgment in urgent or emergent situations.
• Research: We will not use or disclose your health information for research purposes unless you give us authorization to do so.
• Organ Donation: If you are an organ donor, we may release your PHI to organizations that handle organ procurement or organ, eye, or tissue transplantation if necessary to facilitate this process.
• Public Health Risks: We may disclose your PHI if necessary to prevent or control disease, report adverse events from medications or products, or prevent injury, disability, or death. This information may be disclosed to healthcare systems, government agencies, or public health authorities. We may also disclose your PHI to the Food and Drug Administration (FDA) to report adverse events, defects, problems, enable recalls, etc., as required by FDA regulations.
• Health Oversight Activities: We may disclose PHI to health oversight agencies for audits, investigations, inspections, or licensing purposes. These disclosures are necessary for state and federal agencies to monitor healthcare systems and compliance with civil law.
• Required by Law: We will disclose PHI about you when required to do so by federal, state, and/or local law.
  Workers' Compensation: We may disclose your PHI to workers' compensation or similar programs as needed.
• Lawsuits: We may disclose your PHI in response to a court action, administrative action, or subpoena.
• Law Enforcement: We may release your PHI to a law enforcement official in response to a court order, subpoena, warrant, or as otherwise required by law.

YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION

• Access to Medical Records: You have the right to access and receive copies of your PHI used to make decisions about your care. You must submit a written request to obtain your PHI. We reserve the right to charge a fee for the time it takes to retrieve, copy, and provide you with your PHI.
• Amendment: If you believe that the PHI we have about you is incorrect or incomplete, you may request an amendment. You will need to submit a written request explaining why the information should be amended. If we deny your request, we will provide a written explanation. We may deny your request if the PHI is accurate and complete.
• Accounting of Disclosures: You have the right to receive a list of instances in which we disclosed your PHI, unless the disclosure was for treatment, payment, healthcare operations, pursuant to a valid authorization, or as otherwise provided by federal and state laws. You must submit a written request for this accounting of disclosures. We reserve the right to charge a reasonable fee for this process.
• Restriction Requests: You have the right to request a restriction or limitation on the PHI we use or disclose for treatment, payment, or healthcare operations. We will accommodate your request unless the disclosure is required by law. You must submit a written request to the contact listed below.
• Confidential Communication: You have the right to request that we communicate with you about healthcare matters in a specific way or at a certain location. We must accommodate reasonable requests that allow us to continue to collect payments and bill you.
• Paper Copy of This Notice: You may request a hard copy of this notice if you reviewed and signed it electronically. Contact us at the address below to obtain a paper copy.
• Complaints: If you believe your privacy rights have been violated, you may file a complaint with our office or with the U.S. Department of Health and Human Services. Upon request, we will provide the address to file your complaint with the U.S. Department of Health and Human Services.
  
  CONTACT INFORMATION:
  Kiwi Health LLC
  Primary Business Address
  20 North Orange Avenue Suite 1100
  Orlando, FL 32801
  
  Phone: 407-565-959
  Fax: 407-550-3923
  Email: Privacy@MyKiwiHealth.com

BY SIGNING BELOW, I ACKNOWLEDGE RECEIPT AND UNDERSTANDING OF THE KIWI HEALTH LLC NOTICE OF PRIVACY PRACTICES LAST UPDATED MAY 12, 2025.