Patient Service Agreement and Consent Form
Patient Service Agreement and Consent Form
Updated October 6, 2023
Verde Medical Group, PC is honored to provide you with personalized support and care. Please read and sign the following agreement (“Agreement”), which lists services provided and the policies and procedures regarding scheduling, payment methods, confidentiality and compliance, and consent to email, text, and application messaging.
This Agreement governs the services provided by Verde Medical Group, PC and any affiliate or contracted medical care providers (“Provider”). Sunny Health PBC d/b/a Sunny provides management and administrative services to the Provider; these services include, without limitation, the provision of the telehealth platform and scheduling and billing services.
1. Services. You agree to receive medical services delivered via telehealth, including related care management and medication management services (the “Services”). Telehealth involves the use of synchronous (at the same time) and asynchronous (at different times) audio, video, or other electronic communications to interact with you, consult with your health care provider, and/or review your medical information for the purpose of diagnosis, therapy, follow-up, and/or education. During your telehealth consultation with providers from Provider, details of your medical history and personal health information may be discussed with other health professionals through the use of interactive video, audio, and telecommunications technology. The benefits of telehealth include having access to medical specialists and additional medical information and education without having to travel outside of your local health care community. A potential risk of telehealth is that because of your specific medical needs, or due to technical problems, a face-to-face consultation still may be necessary after the telehealth appointment. Additionally, in rare circumstances, security protocols could fail, causing a breach of patient privacy. The alternative to telehealth consultation is a face-to-face visit with a physician or other healthcare provider. You understand the risks, benefits, and alternatives of receiving these Services via telehealth and have had the opportunity to ask questions.The service offered by Provider is Medication Abortion. Provider only offers this service up to 11 weeks of pregnancy. Alternatives to having a medication abortion include the following:
- Procedural Abortion: You may decide to have an abortion procedure in a clinic.
- Parenting: You may decide to continue with the pregnancy, give birth, and raise the child.
- Adoption: You may decide to continue with the pregnancy, give birth, and place the child with another individual or family.
Risks of Medication Abortion:
All types of abortion are considered very safe. However, like with most medical treatments there can be some risks. Complications are rare but can happen. Serious complications happen in less than 0.4 percent of patients.
I understand these risks may include:
- Continuing pregnancy: In some cases, the pregnancy does not end after taking the medications. Because misoprostol can cause birth defects, if this happens you may need to take more medicine or have a procedure (called a “D&C” or “aspiration abortion”) to complete the abortion.
- Incomplete abortion: Some of the pregnancy tissue or the pregnancy may be left inside your uterus. This may lead to heavy bleeding, infection, or both. If this happens, you may need a procedure, other tests, or treatments.
- Hemorrhage: You may have too much bleeding or bleed for too long. If this happens, we may recommend medicine, a procedure, or, rarely, a blood transfusion or surgery to remove the uterus (hysterectomy).
- Infection: The infection rate from medication abortion is less than 1 percent. Antibiotics are used to treat the infection, and, rarely, a suction procedure.
- Allergic reaction: While rare, some people are allergic to the medicines used.
- Death: Death from medication abortion is very rare. The risk of death from childbirth is about ten times greater.
Side Effects of Medication Abortion: Side effects usually do not last long. They usually need little or no treatment. I understand the following:
- Cramping: This is normal and is supposed to happen. Cramping is usually worst when the pregnancy is passing. Milder cramps may last for a few days. If you are having pain in your belly that is unrelieved by pain medication more than 24 hours after taking misoprostol, please contact us.
- Bleeding: This is also normal and is part of the abortion process. Bleeding is usually heaviest when the pregnancy is passing. You should call us if you are soaking 2 pads an hour for more than 2 hours in a row. You may bleed or spot for 4 to 6 weeks after the abortion.
- Fever/chills: The misoprostol can make you feel as if you have a fever. We recommend you do not take your temperature for the first 24 hours. Having a temperature of 99-100°F is okay. If you have a fever greater than 100.4°F more than 24 hours after taking the misoprostol, please contact us.
- Other side effects: It is common to have diarrhea, nausea, vomiting, headache, dizziness, back pain, and tiredness. These should go away 24 hours after taking misoprostol. If you are still having these symptoms more than 24 hours after taking misoprostol, please contact us.
NOTE FOR EMERGENCIES
I understand that I should not use Provider in case of an emergency. Further, I understand that, in an emergency, I should dial 911 or go to an emergency department.
2. Scheduling Services. All services can be scheduled by clicking “Get Care” on www.mysunnyhealth.com.
3. Payment Methods. You understand and agree that payment for services shall be made prior to or at the time of service, except for the portion of the payment that may be covered by your insurance plan. Provider accepts payment in the form of credit or debit card. If we accept your insurance and you will be using insurance to cover some or all of the cost of your appointment, you should contact Provider ahead of your appointment to ensure that your insurance is accepted. You should be prepared to pay any co-payments at the time of the appointment. If Provider is out-of-network for your insurance, Provider will submit an out-of-network claim on your behalf, and bill you only for the co-payment, co-insurance or amount not covered.
4. Confidentiality and Compliance. Provider will take appropriate precautions to keep your health information confidential and to not disclose it without your consent. You are also protected under the provisions of the federal Health Insurance Portability and Accountability Act (“HIPAA”) and any other applicable federal and state laws related to protection of patient information. You have received a copy of our Notice of Privacy Practices (“NPP”). The most up-to-date NPP is posted on our website.
5. Consent to Email, Text, and Application Messaging. By providing your e-mail and/or phone number to the Provider, you agree to receive text messages or e-mails from Sunny and its agents, on your cell phone or other devices. You understand that text messages and e-mails sent by Sunny may include appointment reminders or changes in previously scheduled appointments, or may provide advice or education. Because e-mails sent over the Internet or texts sent over the control channel without encryption are not secure, you understand the risks associated with text messaging and e-mail, including, without limitation, that text messages or e-mails could be intercepted by unknown third parties, e-mail content can be changed without the knowledge of the sender or receiver, backup copies of e-mail may still exist even after the sender and receiver have deleted the messages, and e-mail can contain harmful viruses and other programs.
You understand that Sunny has recommended that you delete all messages and e-mails as soon as possible after reviewing them to limit any unauthorized exposure.
If you communicate with Sunny via e-mail or text message, you are consenting for Sunny to respond to your e-mail or any messages sent via text utilizing the same method that you used.
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