If I am signing on behalf of a minor, incapacitated or otherwise legally dependent patient, I certify that I am a person with legal authority to act on behalf of the patient, including the authority to consent to medical services, and I accept financial responsibility for services rendered.

1. By using the Made Whole Healthcare telehealth portal, I agree to receive telehealth services. Telehealth involves the delivery of health care services, including assessment, treatment, diagnosis, and education, using interactive audio, video, and data communications. During my visit, my Made Whole Healthcare Solutions' provider and I will be able to see and speak with each other from remote locations.
2. I understand and agree that:
• I will not be in the same location or room as my medical provider.
• My Made Whole Healthcare Solutions' provider is licensed in the state in which I am receiving services. I will report my location accurately during registration.
• Potential benefits of telehealth (which are not guaranteed or assured) include: (i) access to medical care if I am unable to travel to my Made Whole Healthcare Solutions' provider’s office; (ii) more efficient medical evaluation and management; and (iii) during the COVID-19 pandemic, reduced exposure to patients, medical staff and other individuals at a physical location.
• Potential risks of telehealth include: (i) limited or no availability of diagnostic laboratory, x-ray, EKG, and other testing, and some prescriptions, to assist my medical provider in diagnosis and treatment; (ii) my provider’s inability to conduct a hands-on physical examination of me and my condition; and (iii) delays in evaluation and treatment due to technical difficulties or interruptions, distortion of diagnostic images or specimens resulting from electronic transmission issues, unauthorized access to my information, or loss of information due to technical failures. I will not hold Made Whole Healthcare Solutions responsible for lost information due to technological failures.
• I further understand that my Made Whole Healthcare Solutions Provider’s advice, recommendations, and or decisions may be based on factors not within his/her control, including incomplete or inaccurate data provided by me. I understand that my Made Whole Healthcare Solutions provider relies on information provided by me before and during our telehealth encounter and that I must provide information about my medical history, condition(s), and current or previous medical care that is complete and accurate to the best of my ability.
• I may discuss these risks and benefits with my Made Whole Healthcare Solutions' provider and will be given an opportunity to ask questions about telehealth services. I have the right to withdraw this consent to telehealth services or end the telehealth session at any time without affecting my right to present or future treatment by Made Whole Healthcare Solutions.
• I understand that the level of care provided by my Made Whole Healthcare Solutions provider is to be the same level of care that is available to me through an in-person medical visit. However, if my provider believes I would be better served by face-to-face services or another form of care, I will be referred to the nearest Made Whole Healthcare Solutions medical center, hospital emergency department or other appropriate health care provider.
• I have the right to receive face-to-face medical services at any time by traveling to a Made Whole Healthcare Solutions medical center that is convenient to me.
• In case of an emergency, I will dial 911 or go directly to the nearest hospital emergency room.
3. I consent to, understand and agree that:
• I have the right to discuss the risks and benefits of all procedures and courses of treatment proposed by my health care provider(s), together with any available alternatives.
• Made Whole Healthcare Solutions will provide care consistent with the prevailing standards of medical practice but makes no assurances or guarantees as to the results of treatment.
• Before prescribing any controlled substance to me, Made Whole Healthcare Solutions may review information from the Prescription Drug Monitoring Program in my state of residence regarding my prior receipt of controlled substances.
• My Made Whole Healthcare Solutions provider will not prescribe opioids to me during a telehealth visit.
• I have the right to review and receive copies of my medical records, including all information obtained during a telehealth interaction, subject to Made Whole Healthcare Solutions’ standard policies regarding request and receipt of medical records and applicable law.
• The laws of the state in which I am located will apply to my receipt of telehealth services.

Made Whole Healthcare Solutions Notice of Privacy Practices (“Privacy Notice”)

Made Whole Healthcare Solutions will protect the privacy of my health information and will not use or disclose it except as permitted by law. Made Whole Healthcare Solutions’ privacy policies are more fully described in the Privacy Notice, which is available for review and download here: https://www.patientfirst.com/patient-first-privacy-practices. By signing this Consent, I acknowledge receipt of the Privacy Notice and consent to Made Whole Healthcare Solutions’s use and disclosure of my health information in accordance with its terms. I understand that all existing confidentiality protections that apply to in-person treatment apply to telehealth services.

New Jersey patients only: By signing this consent electronically, I authorize Made Whole Healthcare Solutions to disclose information related to HIV/AIDS for treatment, payment, health care operations, and other purposes consistent with the Privacy Notice. I may revoke consent by sending written notice as required by the Privacy Notice. Revocation will be effective upon receipt, except to the extent that Made Whole Healthcare Solutions has already taken action in reliance on my consent.

Payment Policy

I acknowledge, understand and agree that:

1. It is my responsibility to determine whether Made Whole Healthcare Solutions’ services are covered by my insurer. I will pay the cost of any service that is not covered by my health plan for any reason or are covered but applied to a deductible.

• I will pay at time of service any required co-payments, co-insurance and deductibles, as well as charges for services not covered by insurance, outstanding balances and delinquent accounts.
• I assign to Made Whole Healthcare Solutions all health care benefits to which I am entitled under any insurance policy or benefit plan and authorize payment of benefits directly to Made Whole Healthcare Solutions.
• If I have health care benefits, Made Whole Healthcare Solutions will submit a claim to my insurer and allow 60 days for a response. If my insurer does not respond within 60 days, Made Whole Healthcare Solutions will assume that the visit is not covered and will, to the extent permitted by law, bill me for the visit charges.
• By providing my credit card information and receiving telehealth services, I (i) authorize Made Whole Healthcare Solutions to charge my credit card for any and all unpaid amounts that Made Whole Healthcare Solutions or my insurer determines are my responsibility, and (ii) agree to pay all amounts charged pursuant to this consent and authorization in accordance with the issuing bank cardholder agreement. I agree that Made Whole Healthcare Solutions may charge my credit card for such amounts at the end of my telehealth visit or at a later date.
• I will be billed for all unpaid balances deemed by Made Whole Healthcare Solutions or my insurer to be my responsibility and agree to pay such amounts in full. Made Whole Healthcare Solutions will charge late fees of 1.5% per month on unpaid balances starting 30 days after the first statement, as well as a $30 fee for returned checks. Delinquent accounts may be turned over to a collection agency at which time I am responsible for a $40 collections charge and all associated legal fees in addition to the amount owed.
• Made Whole Healthcare Solutions reserves the right to deny non-emergency services if my account is delinquent.

I understand that I may access and print a copy of this Consent by clicking here: