Consent to Telehealth

Revised: 1/19/24

CLIENT CONSENT TO TELEHEALTH 

Levers Health LLC and its affiliates (“Levers Health”, “Levers.Health”, “Levers”, “we,” or “us“) owns and operates this website located at https://www.levers.health  (collectively, the ” Platform“ or the “Practice”). Your access and use of the Platform, any part thereof, or anything associated therewith, including its content (“Content“), any products or services provided through the Platform or otherwise by Levers Health, and any affiliated website, software or application owned or operated by Levers Health (collectively, including the Platform and the Content, the “Service“) are subject to this Consent to Telehealth unless specifically stated otherwise. Capitalized terms not otherwise defined in this Consent to Telehealth have the same meaning as set forth in the Levers Health Privacy Policy and Terms of Service. 

By signing this form, clicking a checkbox, or otherwise participating in any services offered by Levers Health, I voluntarily understand, acknowledge, and agree to the following with respect to medical services rendered by Levers Health and their physicians (each a “Physician”), associates, technical assistants, agents, and other healthcare providers (collectively, “the Practice” which operate in accordance with “the Platform”).

 

I request, voluntarily consent to, and authorize the services and treatment described herein, including without limitation telemedicine consultation, preventive medicine services, sexual wellness services, peptide therapy, diagnostic testing, as well as those additional services that are advisable in a Physician’s professional judgment that may be rendered.

I understand that no promises or expectations have been made to me about the results of any treatments or services.

I understand that I have read and understood each of the provisions appearing on this consent form. I also acknowledge that I have had the opportunity to ask any questions that I may have, and by my electronic agreement, I consent and agree to all provisions herein both individually and collectively. 

The consent will remain fully effective until it is revoked in writing. I have the right at any time to discontinue services.

Not Primary Care; Limit of Role

The Practice is acting in a specialist, supportive, consultative capacity and not as a primary care physician and does not provide emergency care. Accordingly, The Practice is not replacing care currently provided to me by other physicians, such as my current primary care physician, internist, urologist, cardiologist, gastroenterologist, or other specialty care provider. The Practice has advised me that the Practice does not admit patients to the hospital or treat hospitalized patients, and that I should maintain a relationship with a physician who is available to provide emergent and urgent care. The Practice does not provide immediate on-call services. 

IF I ENCOUNTER A MEDICAL EMERGENCY, I WILL CONTACT 911 OR REPORT TO A HOSPITAL EMERGENCY DEPARTMENT. If at any time I feel my condition has progressed, worsened, or has not improved over a long period of time, I agree to go to the nearest emergency room immediately.

I UNDERSTAND THAT THE PRACTICE IS CASH PAY ONLY AND DOES NOT SUBMIT CLAIMS OR BILLS FOR REIMBURSEMENT BY INSURANCE OR MEDICARE. I ACKNOWLEDGE AND AGREE THAT THE SERVICES MAY NOT BE COVERED BY INSURANCE OR MEDICARE.

I AGREE THAT ALL PERSONAL INFORMATION I PROVIDE, INCLUDING MEDICAL INFORMATION, IS TRUTHFUL, HONEST, AND ACCURATE; AND I EXPRESSLY WAIVE AND RELEASE ANY CLAIMS I MAY HAVE AGAINST THE PRACTICE AND THE PHYSICIAN FOR INJURIES OR DAMAGES THAT ARISE OUT OF UNTRUTHFUL, DISHONEST, OR INACCURATE INFORMATION THAT I PROVIDE.

Telemedicine Consent: I understand that the Practice may use telemedicine mechanisms to consult for, discuss, and recommend treatment. I also understand that telemedicine involves the delivery of clinical health care services by electronic communication (including two-way audio-visual communication and asynchronous messaging), as defined by applicable law. Use of telemedicine services by the Practice can result in benefits such as improved access to care and decreased exposure to community spread and person to person spread of illnesses. I acknowledge that use of telemedicine via the Service is adequate in establishing a valid provider-patient relationship and delivering the standard of care. Potential risks include gaps of failures in communication, complicating healthcare decision-making, notwithstanding reasonable efforts to ensure the quality and reliability of transmitted information. There may be limitations to image quality or other electronic problems that are beyond the control of the Practice.  Despite reasonable security measures, online communications can be forwarded, intercepted, or even changed or falsified without my knowledge. I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine. I understand and agree that during my telemedicine consultation, in addition to the Physician conducting the consultation, another Physician may be observing my consultation for training purposes. I fully understand, request, and agree to participate in telemedicine services.

Prescription Policy: I understand that there is no guarantee a prescription will be written by a Physician. Physicians shall use their own discretion and professional judgment to prescribe medications, or certain other drugs which may be harmful because of their potential for abuse. Physicians reserve the right to deny care for actual or potential misuse of medical care and any associated prescriptions. I agree that any prescriptions that I acquire from a Physician or the Practice will be solely for my individual personal use. I agree to fully and carefully read all provided prescription information and labels and to contact a Physician or pharmacist if I have any questions regarding the prescription.

Informed Consent of Off-Label Treatment

FDA Approval Status

The treatment you might be receiving may have not been approved by the FDA to treat my condition. The treatment you might be receiving may not have been approved by the FDA to treat any condition. Even if the ingredients of the treatment are FDA approved, you acknowledge that compounded medication is not specifically FDA-approved due to its custom formulary nature. All pharmacy partners that The Practice works with are 503A regulated and Inspected by the FDA.  

Off Label and No Label

When a drug or device is approved for medical use by the Food and Drug Administration (FDA), the manufacturer produces a “label” to explain its use. Once a device/medication is approved by the FDA, physicians may use it “off-label” for other purposes if they are well informed about the product, base its use on firm scientific method and sound medical evidence, and maintain records of its use and effects. Sometimes, Providers may also prescribe medications that are not approved by the FDA, and you acknowledge and assume any responsibility for using them. 

Email, Phone, & Text Consent: If at any time I provide an email or telephone number(s) at which I may be contacted, I consent to receiving appointment reminders and other healthcare communications/information at that email and/or telephone number(s) from the Practice via email, text message, push notification, chat, and/or voicemail message. I agree that all agreements and consents can be signed electronically and all notices, disclosures, and other communications that the Practice provides to me electronically satisfy any and all legal requirements that such notices and other communications be in writing.

Duty to Inform: I also understand it is my responsibility to keep the Practice informed of the name and contact information of my primary care physician and treating specialists, of any diagnoses I have received and of any treatments I have had or am now undergoing for current conditions. 

Physical Exam Acknowledgment: I have had an annual physical exam with my primary care physician of record. 

Alternatives Approaches: As alternative approaches to my healthcare, the Practice encourages me to speak with and consider the advice of other physicians or appropriate healthcare practitioners regarding my overall care.

Miscellaneous

My Participation: I understand that I am responsible to disclose to the Practice all medication, care, treatment, diagnoses, and assessments that I receive elsewhere and am responsible to provide medical records from other providers to ensure that care is coordinated and compatible.  Medical records can only be released with my authorization.  I will need to obtain any records and/or labs that I would like the Practice to review.

Off-Label Use: I understand that the Practice may prescribe medications for uses other than those indicated by the drug manufacturer and approved by the federal Food and Drug Administration (off-label use).  In such case, no one can be fully aware of all possible side effects and complications.  The details of such off-label use including expected benefits, material risks and alternatives, have been explained to me in terms I understand.  I have informed or will inform the Practice of all known allergies, and of all medications I am currently taking via a heath history questionnaire. 

No Claims or Guarantees:  I understand that the Practice makes no representations, claims or guarantees that my medical problems or conditions will be cured, solved, or helped by undergoing treatment by the Practice. 

Referrals: I understand that the Practice’s treatment may include recommendation that I seek other types of treatment from other health professionals who are not affiliated with the Practice. I understand that the Practice does not supervise these professionals and is not clinically or legally responsible for them.  I understand that they are not the Practice’s employees and that they will bill separately for their services.

Assumption of Risk; Indemnity: I choose to receive care that may involve clinical innovation and/or may differ from conventional medicine. Accordingly, I knowingly, voluntarily, and intelligently assume all risks involved in the same. 

As a result of my assumption of these risks, I agree to release, hold harmless, indemnify, and defend Practice, the Physician, Levers Health, LLC, and all of their respective predecessors, successors, assigns, parent, subsidiaries, partners, employees, agents, officers, directors, representatives, attorneys, administrators, contractors, subcontractors and/or consultants, and each of them (collectively, “Indemnitees“), from and against any and all claims which I (or my representatives) may have for any loss, damage, or injury arising out of or in connection with use of the treatments or services described herein. Further, I agree not to pursue a frivolous claim against any of the Indemnitees, merely because I am dissatisfied with the results of the above treatments or services.

AUTHORIZATION FOR LIMITED RELEASE OF PROTECTED HEALTH INFORMATION: I hereby authorize the Practice to send an electronic laboratory requisition to me via email at the email address I provided to the Practice for the purpose of helping to facilitate an optimal laboratory experience when I visit the laboratory. This authorization is in effect until I receive the requisition from the Practice via email, at which point it will expire. I authorize the use or disclosure of my individually identifiable health information as described above for the purpose listed. I have the right to withdraw permission for the release of my information. If I consent to this authorization to use or disclose information, I can revoke that authorization at any time. The revocation must be made in writing and will not affect information that has already been used or disclosed. I have the right to receive a copy of this authorization. I am signing this authorization voluntarily and treatment, payment, or my eligibility for benefits will not be affected if I do not sign this authorization. I further understand that a person to whom records and information are disclosed pursuant to this authorization may not further use or disclose the medical information unless another authorization is obtained from me or unless such disclosure is specifically required or permitted by law.

COVID-19 Release: I acknowledge that due to the current COVID-19 outbreak that entry into my home, office, or selected location for the purpose of my in-person exam (the “Property“) may pose a significant risk and hazard to all persons in or around the Property. I further acknowledge that the Indemnitees cannot assure safety against COVID-19 to any individual, including me, entering the Property. I ACKNOWLEDGE THAT I AM VOLUNTARILY CHOOSING TO INVITE THE PRACTICE TO ENTER THE PROPERTY WITH FULL KNOWLEDGE AND UNDERSTANDING OF THE DANGER AND RISK INVOLVED AND HEREBY AGREE TO ACCEPT AND ASSUME ANY AND ALL RISKS OF INJURY OR DEATH RELATED TO SUCH ENTRY. In consideration for any and all entry and access to the Property pursuant to this release, I hereby agree for myself and for my next of kin, successors, assigns, agents, attorneys, representatives, administrators, contractors, employees and any other persons or entities who may claim through me (collectively, "Releasors"), that the Releasors hereby release and forever discharge the Indemnitees, from and with respect to any and all manner of actions, causes of action, in law or in equity, suits, claims, judgment and demands, damages, losses, attorneys’ fees, rights, or liabilities, of any nature whatsoever, whether class, derivative, or individual in nature, costs or expenses of any nature whatsoever, known or unknown, suspected or unsuspected, fixed or contingent, which the Releasors ever had, now have, claim to have or may hereafter in the future have against Indemnitees for personal injury, death, property damage and any and all other direct and consequential damages occasioned or resulting from any matter, cause, fact, thing, act or omission whatsoever, arising from or in connection solely with my access or entry into the Property pursuant to this Statement and Release. I understand that the facts upon which this release is made may hereafter turn out to be other than or different from the facts now known or believed to be true. I accept and assume the risk of the facts to be different than now known or believed to be true. I agree that this release shall be and remain in all respects effective and not subject to termination or rescission by virtue of any difference of facts. California Civil Code §1542, which is hereby expressly waived with respect to this release reads as follows: “A general release does not extend to claims that the creditor or releasing party does not know or suspect to exist in his or her favor at the time of executing the release and that if known by him or her would have materially affected his or her settlement with the debtor or released party.” I similarly waive any and all rights or benefits conferred by any statute, regulation, or principle of common law or civil law of the United States or any state, commonwealth, territory, or other jurisdiction thereof or of any foreign country or other foreign jurisdiction which is similar, comparable or equivalent to § 1542 of the California Civil Code.

 

POLICIES

 

By signing this form, I acknowledge that, with respect to services rendered by the Practice, I understand the following:

 

Cancellation Fee: You will only be charged after you choose to consult with a doctor and if you are approved for a prescription. You may cancel your order with no charge before your medical history forms are approved and notice is sent.

 No Refunds after Pharmacy Order: The Practice does not offer any refund of any kind for orders that have been placed with the Pharmacy. Each pharmacy order is custom-made for each patient, which is why we cannot offer refunds once the order has been placed with the pharmacy.  

Payments, Recurring Payments, Subscriptions: You understand by providing your payment information to the Practice you authorize the Practice to charge or facilitate the charge of such payment information, including for automatic recurring payments, for all services and/or treatments. Certain services are offered on a subscription basis. For subscription-based services, your chosen payment method will be charged at regular intervals automatically as described for that service. You understand that when joining or signing up for subscription-based services, in which three months of products and/or medications are dispensed to you, you agree to be bound to at least a three-month subscription. If you cancel your subscription and/or terminate the payment method (and do not replace the payment method) for such subscription, you agree that you are responsible and obligated to pay for the remainder of the payments for such three-month subscription. Subject to the foregoing sentence, you may cancel a subscription at any time up to forty-eight (48) hours before the applicable monthly processing date of your subscription by emailing service@levers.health You understand that the cost of services, including medications, are final and not refundable (except as otherwise set forth herein). You understand you will not receive refunds for any treatments or medications, including unused or unopened treatments and medications, unless otherwise set forth herein.  You agree that the Practice may store any payment information that you provide for the purposes of recurring payments that you have chosen to participate in as part of any membership or subscription programs or plans.

If you are delinquent on any payments, the Practice reserves the right to discontinue services. The Practice may use third-party services for the purpose of facilitating payment and the completion of the purchases for services rendered by the Practice in conjunction with the services. By submitting your payment information, you grant the Practice the right to provide information to these third parties. You represent and warrant that (i) any payment information you supply is accurate, true, and complete, (ii) any charges incurred for services will be honored by your credit/debit card company or bank, (iii) you will pay all charges incurred by you including applicable taxes, and (iv) the payment card is in your name and you are authorized to use such card for purchases.

 

Electronic Signatures and Acknowledgement: I agree that electronic signatures below or clicking a checkbox are the legal equivalent of manual signatures on this Agreement, and manifest consent to be legally bound by this Agreement’s terms and conditions.

 

Digital Records: Provider may store medical and office records digitally. While the Practice will make reasonable efforts to keep the data secure according to legal requirements, and maintains the privacy and confidentiality of patient data, I understand that no system is 100% secure. You agree that Levers Health, LLC and/or the Practice may de-identify your information such that it is no longer considered protected health information or personally identifiable information and may convey, sell, transmit or provide such de-identified information to third parties.

Office Insurance Practices and Patient Financial Responsibility 

Payment: The Practice accepts credit cards only and is exclusively cash pay. I agree that the Practice may store any payment information that I provide for the purposes of recurring payments that I have chosen to participate in as part of any membership or subscription programs or plans.

No Participation in Insurance Plans: The Practice is an out-of-network provider for services within this Practice; the Practice does not participate in any insurance panels, and does not accept assignment from any insurance company. Consequently, I am responsible for payment in full and all charges as determined by the Practice. 

No Responsibility To Determine Eligibility for Benefits: the Practice is not responsible for determining eligibility for benefits or for assisting me with collecting insurance benefits and has no responsibility to correspond with or telephone or email any insurer with which the Practice is an out-of-network provider. 

My Financial Responsibility: I am financially responsible for any charges for services. I also agree to be responsible for costs and expenses, including court costs, attorney fees and interest, should it be necessary for the Practice to take action to secure payment of an outstanding balance. 

Charges: The Practice may recommend additional specific products or services such as prescriptions,  blood or urine tests, or supplements that may be additional costs.

 Physician-Patient Arbitration Agreement

 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 Arizona law, and not by a lawsuit or resort to court process except as Arizona 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: All Claims Must be Arbitrated:  It is the intention of the parties that this agreement bind all parties whose claims may arise out of or relate to treatment or service provided by the physician including any spouse or heirs of the patient and any children, whether born or unborn, at the time of the occurrence giving rise to any claim. In the case of any pregnant mother, the term “patient” herein shall mean both the mother and the mother’s expected child or children. All claims for monetary damages exceeding the jurisdictional limit of the small claims court against the physician, and the physician’s partners, associates, association, corporation or partnership, and the employees, agents and estates of any of them, must be arbitrated including, without limitation, claims for loss of consortium, wrongful death, emotional distress or punitive damages. Filing of any action in any court by the physician to collect any fee from the patient shall not waive the right to compel arbitration of any malpractice claim.

 

Article 3: Procedures and Applicable Law: A demand for arbitration must be communicated in writing to all parties. Each party shall select an arbitrator (party arbitrator) within thirty days and a third arbitrator (neutral arbitrator) shall be selected by the arbitrators appointed by the parties within thirty days of a demand for a neutral arbitrator by either party. Each party to the arbitration shall pay such party’s pro rata share of the expenses and fees of the neutral arbitrator, together with other expenses of the arbitration incurred or approved by the neutral arbitrator, not including counsel fees or witness fees, or other expenses incurred by a party for such party’s own benefit. The parties agree that the arbitrators have the immunity of a judicial officer from civil liability when acting in the capacity of arbitrator under this contract. This immunity shall supplement, not supplant, any other applicable statutory or common law. Either party shall have the absolute right to arbitrate separately the issues of liability and damages upon written request to the neutral arbitrator.

 

The parties consent to the intervention and joinder in this arbitration of any person or entity which would otherwise be a proper additional party in a court action, and upon such intervention and joinder any existing court action against such additional person or entity shall be stayed pending arbitration. The parties agree that provisions of Arizona law applicable to health care providers shall apply to disputes within this arbitration agreement.

 

Article 4: General Provisions: All claims based upon the same incident, transaction or related circumstances shall be arbitrated in one proceeding. A claim shall be waived and forever barred if (1) on the date notice thereof is received, the claim, if asserted in a civil action, would be barred by the applicable Arizona statute of limitations, or (2) the claimant fails to pursue the arbitration claim in accordance with the procedures prescribed herein with reasonable diligence. With respect to any matter not herein expressly provided for, the arbitrators shall be governed by the Arizona Code of Civil Procedure provisions relating to arbitration.

 

Article 5: Revocation: This agreement may be revoked by written notice delivered to the physician within 30 days of signature. It is the intent of this agreement to apply to all medical services rendered any time for any condition.

 

Article 6: Retroactive Effect: If patient intends this agreement to cover services rendered before the date it is signed (including, but not limited to, emergency treatment) patient should initial below:

 

If any provision of this arbitration agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision.

 

I understand that I have the right to receive a copy of this arbitration agreement. By my signature (electronic or otherwise), I acknowledge that I have received a copy.

 

NOTICE:  BY SIGNING THIS AGREEMENT 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 AGREEMENT.

 

I have carefully read this entire document, which is printed in English, and acknowledge that English is a language I read and understand, and that I understand the document.  I do not feel rushed or impaired, nor am I under the influence of a sedative or sleep-inducing medication.

 

I accept and agree to all of the terms above. I am free to refuse or withdraw my consent and to discontinue participation in any treatment, service, or research at any time without fear of reprisal against or prejudice to me. I may request and receive a copy of this document from the Practice. If any portion of this form is held invalid, the rest of the document will continue in full force and effect.

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7067 East Dale Lane
Scottsdale, AZ 85266