I hereby grant permission for you to release confidential health information about me, by releasing a copy of medical record, or a summary or narrative of my protected health information to Olive Health for

1. I give permission for Olive Health, LLC to give medical treatment to 

2. I allow Olive Health, LLC to file for insurance benefits to pay for the care I receive.

Olive Health, LLC will have to send my medical record information to my insurance

company. I must pay my share of the costs. Imust pay for the cost of these services if my insurance does not pay or I do not have

I have the right to refuse any procedure or treatment. I have the right to discuss all medical treatments with my clinician.

You have the right, as a patient, to be informed about your condition and the recommended surgical, medical or diagnostic procedure to be used so that you may make the decision whether or not to undergo any suggested treatment or procedure after knowing the risks and hazards involved. At this point in your care, no specific treatment plan has been recommended. This consent form is simply an effort to obtain your permission to perform the evaluation necessary to identify the appropriate treatment and/or procedure for any identified condition(s

This consent provides us with your permission to perform reasonable and necessary medical examinations, testing and treatment. By signing below, you are indicating that (1) you intend that this consent is continuing in nature even after a specific diagnosis has been made and treatment recommended; and (2) you consent to treatment at this office or any other satellite office under common ownership. The consent will remain fully effective until it is revoked in writing.

You have the right at any time to discontinue services. You have the right to discuss the treatment plan with your physician about the purpose, potential risks and benefits of any test ordered for you. If you have any concerns regarding any test or treatment recommended by your healthcare provider, we encourage you to ask questions.

By affixing my signature below, I voluntarily request a physician, and/or mid level provider (Nurse Practitioner, Physician Assistant, or Clinical Nurse Specialist), and other health care providers or the designees as deemed necessary, to perform reasonable and necessary medical examination, testing and treatment for the condition which has brought me to seek care at this practice. I understand that if additional testing, invasive or interventional procedures are recommended, I will be asked to read and sign additional consent forms prior to the test(s) or procedure(s

I certify that I have read and fully understand the above statements and consent fully and voluntarily to

COMMUNICATION DISCLAIMERS

By providing your contact information, you consent to receive communications from Olive Health via text message, phone call, and/or email. Message and data rates may apply for text messages. Message frequency varies. Reply STOP to opt out of text messages or HELP for assistance. Standard calling rates may apply for phone calls. You can unsubscribe from emails at any time by clicking the "unsubscribe" link in any email. Your consent is not required as a condition of service.

CONSENT TO RECEIVE PROTECTED HEALTH INFORMATION VIA EMAIL

I understand that Olive Health, LLC may need to communicate with me about my healthcare, including sending medical records, test results, appointment information, and other protected health information (PHI) via email.

RISKS OF EMAIL COMMUNICATION

I acknowledge and understand the following risks associated with email communication:

Lack of Encryption: Standard email is not encrypted and may not be secure
Unauthorized Access: Email may be intercepted, forwarded, or accessed by unauthorized individuals
Misdirected Messages: Email may be sent to wrong recipients due to human or technical error
Storage Risks: Email may be stored on servers or devices that could be compromised
No Delivery Guarantee: There is no guarantee that email will be delivered or received

MY CONSENT

Despite understanding these risks, I voluntarily consent to receive my protected health information via email at the address listed above. I understand that:

I have the right to request alternative forms of communication at any time
I can withdraw this consent at any time by providing written notice
I am responsible for informing Olive Health of any changes to my email address
I should notify Olive Health immediately if my email account is compromised
Olive Health will make reasonable efforts to protect my information but cannot guarantee complete security

PATIENT RESPONSIBILITIES

I agree to:

Keep my email address current and notify Olive Health of any changes
Use a secure, private email account that only I can access
Not share my login credentials with others
Report any suspected unauthorized access to my email account
Understand that email should not be used for urgent medical matters

SCOPE OF CONSENT

This consent applies to communication between myself and:

Healthcare providers at Olive Health

PRIVACY POLICY

Overview

At Olive Health, we respect your privacy. This Privacy Policy explains how we collect and use your personal information when you submit an inquiry through our website.

Information We Collect

When you contact us through our website, we collect:

Your name
Phone number
Email address
Any additional information you provide in your inquiry
How We Use Your Information

We use your information to:

Respond to your inquiry
Follow up with you regarding your request
Provide you with information about our services
Send you periodic email communications about our products, services, and updates
Send you text messages related to your inquiry or about our services
You can opt out of receiving marketing emails at any time by clicking the "unsubscribe" link at the bottom of any email or by contacting us directly. You can opt out of text messages at any time by replying "STOP" to any text message or by contacting us directly.

We will not sell, rent, or share your personal information with third parties for marketing purposes.

Data Security

We take reasonable measures to protect your information from unauthorized access or disclosure.

Your Rights

You have the right to:

Request a copy of the information we have about you
Request that we delete your information
Opt out of future communications
To exercise these rights, please contact us at frontdesk@olivehealthfl.com

Contact Us

If you have questions about this Privacy Policy, please contact us:

Email: frontdesk@olivehealthfl.com
Phone: 813-417-4767

Changes to This Policy

We may update this Privacy Policy from time to time. Any changes will be posted on this page with an updated date.

By submitting your information through our website, you agree to this Privacy Policy.

 

By signing below, I acknowledge that I have read and understand this consent form and privacy policy, including the risks of email communication, and I voluntarily consent to receive protected health information via email, text message, and phone calls from Olive Health.

Dear Patient,

As part of your onboarding with Olive Health LLC, please review and sign this notice regarding fees associated with administrative form completion services. This notice covers, but is not limited to, FMLA (Family and Medical Leave Act) paperwork, disability forms, and other administrative documentation you may request during the course of your care.

How to Avoid Form Completion Fees

Form completion fees apply only when forms are requested outside of a scheduled appointment. Simple and moderate forms (1–3 pages) can be completed during your appointment at no additional charge — however, you must notify our office of the forms you need prior to your appointment so adequate time can be allocated. Complex forms (4+ pages) require additional provider time and cannot be completed during a standard appointment; these will be subject to the fees listed below regardless of when they are requested. To avoid fees on simple or moderate forms, please contact us in advance of your visit.
Applicability — Medicare, Medicaid, and Private-Pay Patients

This notice applies to patients covered by Medicare, Florida Medicaid (fee-for-service and managed care plans), and those without insurance coverage. Form completion services are not covered by Medicare or Florida Medicaid. In accordance with Medicare and Florida Medicaid policy, you are being notified in advance and in writing that these services are non-covered and that you will be personally responsible for the fees listed below. Your signature below confirms your agreement to pay prior to the service being performed. If you are enrolled in a Florida Medicaid managed care plan, please be aware that your plan’s provider agreement also does not cover administrative form completion, and the same terms apply.

Fee Schedule

Fees apply to requests made outside of a scheduled appointment, or for complex forms regardless of when requested:

•       Simple forms (1 page): $15 — No charge if requested prior to appointment

•       Moderate forms (2–3 pages): $30 — No charge if requested prior to appointment

•       Complex forms (4+ pages, narrative required, or multiple forms): $75

•       Rush completion (within 48 hours): Additional $50

Fees are due prior to form completion. Forms will not be released until payment is received. Please allow 5–10 business days for standard form completion. Submitting a request does not guarantee a specific medical opinion or outcome.

I understand and consent to participate in Chronic

Care Management (CCM) services provided by Olive Health.

WHAT IS CHRONIC CARE MANAGEMENT (CCM)?

Chronic Care Management is a Medicare and insurance-covered service designed to help

patients with multiple chronic conditions receive coordinated, comprehensive care

between oKice visits. CCM services include:

• Care Coordination: Regular communication between your healthcare team

members

• Medication Management: Review and monitoring of your medications

• Health Monitoring: Regular check-ins about your symptoms and conditions

• Care Plan Development: Creating and updating a personalized care plan

• 24/7 Access: Access to healthcare providers for urgent questions

• Specialty Care Coordination: Help managing referrals and specialist

appointments

CCM SERVICES PROVIDED

I understand that CCM services may include:

✓ Monthly phone calls or secure messaging to discuss my health status

✓ Review of my medications and potential interactions

✓ Coordination with specialists and other healthcare providers

✓ Development and updates to my comprehensive care plan

✓ Health education and self-management support

✓ 24/7 access to clinical staK for urgent questions

✓ Electronic health record management and care coordination

BILLING AND INSURANCE

• CCM services are typically covered by Medicare and many insurance plans

• I understand there may be copays or deductibles associated with these services• I authorize Olive Health to bill my insurance for CCM services

• I am responsible for any amounts not covered by insurance

COMMUNICATION PREFERENCES

I consent to be contacted via (check all that apply):

• ☐ Phone calls to: _______________________

• ☐ Text messages to: ____________________

• ☐ Secure patient portal messaging

• ☐ Email to: ____________________________

PATIENT RIGHTS AND RESPONSIBILITIES

My Rights:

• I can refuse CCM services at any time without aKecting other care

• I can revoke this consent at any time by contacting the practice

• I have the right to a copy of my care plan

• I can request changes to my communication preferences

My Responsibilities:

• Participate actively in my care management

• Keep scheduled appointments and respond to outreach attempts

• Inform the care team of changes in my condition

• Update contact information when it changes

PRIVACY AND CONFIDENTIALITY

I understand that:

• My health information will be protected according to HIPAA regulations

• Information may be shared among my care team members for coordination

purposes

• Electronic communication carries some privacy risks, which have been explained to

me

CONSENT AND SIGNATURES

I have read and understand this consent form. I have had the opportunity to ask questions

about CCM services. I voluntarily consent to participate in Chronic Care Management

services. I understand I can withdraw from CCM services at any time

ACKNOWLEDGMENT AND AGREEMENT

I understand and acknowledge the following:

1. Coverage Limitation: This telehealth service will not be billed to my Medicaid plan. I understand that my provider has elected not to submit telehealth services to Medicaid and that I

am responsible for payment at the time of service. This decision is specific to telehealth

consultations and does not affect any other services billed to my Medicaid plan.

2. Payment Responsibility: I agree to pay $75.00 out-of-pocket for each telehealth

consultation. I understand this fee is my sole financial responsibility.

3. Payment Terms: Payment is due at the time of service unless alternative arrangements

have been discussed and agreed upon in advance with the practice.

4. No Insurance Billing: I understand that this telehealth service will not be billed to 

Medicaid, or any other insurance carrier. No claim will be submitted on my behalf for this service.

5. Voluntary Service: I am voluntarily choosing to receive this telehealth service with full

knowledge that I am financially responsible for the entire cost of the consultation.

By signing below, I confirm that I have read, fully understood, and agree to all of the terms stated above. I acknowledge that I have had the opportunity to ask questions and that they have been answered to my satisfaction.