Medical Consent for Made Ya Skinny, LLC

Medical Consent for Made Ya Skinny, LLC (dba Made Ya Skinny)

Last Updated: July 9, 2025(v1.0)

WE ARE NOT A REPLACEMENT FOR EMERGENCY MEDICAL SERVICES. IF YOU HAVE A MEDICAL EMERGENCY SEEK EMERGENCY MEDICAL CARE IMMEDIATELY IN-PERSON OR DIAL 911 OR YOUR LOCAL EMERGENCY NUMBER. ‍ We may change these terms at any time, as required by law. This may include changing, adding, or removing terms. We may do this in response to legal, business, competitive environment or other reasons not listed here

Telehealth Consent

Telehealth is care delivered when you and your provider are not in the same place. At Made Ya Skinny it can include an online intake and health questions that a licensed provider reviews (called asynchronous, or store-and-forward, care), secure messages in your patient portal, and live video or phone visits. Our systems use security protocols to protect the privacy of your information.

Expected benefits

• Care without travel or a waiting room. • Review of your health history by a licensed provider from wherever you are. • Easier follow-up through your patient portal.

Possible risks

• The information you send may not be enough for your provider to make a decision. If so, your provider may ask for more information, records, lab work, photos or a live visit. • Care can be delayed if equipment or connections fail. • In very rare cases, security protocols could fail and your information could be exposed. • If your provider does not have your complete medical records, a drug interaction, allergic reaction or other error could occur. Tell us about every medication and condition you have.

By consenting, I understand the following:

1. The laws that protect the privacy of my medical information also apply to telehealth. 2. I may withhold or withdraw my consent to telehealth at any time without affecting my right to future care, including in-person care. 3. I may request copies of my records as allowed by law. 4. My provider may decide that telehealth is not right for my situation and ask for a live or in-person visit. Some states and some medications, including controlled substances, require a live first visit before the first prescription. 5. I will tell my provider about any other healthcare providers involved in my care. 6. No results can be guaranteed. 7. I must be physically located in a state where Made Ya Skinny provides telehealth care (currently Texas, Florida, Ohio or Colorado) when I receive care.

Patient Consent to the Use of Telehealth

I have read and understand the information above about telehealth. I have had the chance to ask questions, and my questions have been answered. I give my informed consent to the use of telehealth in my care. I have been offered a copy of this form.

HIPAA Consent

The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. Implementation of HIPAA requirements officially began on December 1, 2023. What this is all about: Specifically, there are rules and restrictions on who may see or be notified of your Protected Health Information (PHI). These restrictions do not include the normal interchange of information necessary to provide you with services. HIPAA provides certain rights and protections to you as the customer. We balance these needs with our goal of providing you with quality professional service and care. Additional information including the full list of HIPAA required rights is available here from the U.S. Department of Health and Human Services ( hhs.gov ) . We have adopted the following policies: 1. Patient information will be kept confidential except as is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately. This specifically includes the sharing of information with other healthcare providers, laboratories, health insurance payers as is necessary and appropriate for your care. Patient files may be stored in open file racks and will not contain any coding which identifies a patient’s condition or information which is not already a matter of public record. The normal course of providing care means that such records may be left, at least temporarily, in administrative areas such as the reception office, examination room, etc. Those records will not be available to persons other than office staff and third-party providers. You agree to the normal procedures utilized within the office for the handling of charts, patient records, PHI and other documents or information. 2. It is the policy of this office to remind patients of their appointments. We may do this by telephone, e-mail, U.S mail, or by any means convenient for the practice and/or as requested by you. We may send you other communications informing you of policy or procedure changes that you might find valuable or informative. 3. The practice utilizes a number of vendors in the conduct of business. These vendors may have access to PHI but must agree to abide by the confidentiality rules of HIPAA. 4. You understand and agree to inspections of the office and review of documents which may include PHI by government agencies or insurance payers in normal performance of their duties. 5. You agree to bring any concerns or complaints regarding privacy to the attention of the office manager or the doctor. 6. Your confidential information will not be used for the purposes of marketing or advertising of products, goods or services. 7. We agree to provide patients with access to their records in accordance with state and federal laws. 8. We may change, add, delete or modify any of these provisions to better serve the needs of the both the practice and the patient. 9. You have the right to request restrictions in the use of your protected health information and to request change in certain policies used within the office concerning your PHI. However, we are not obligated to alter internal policies to conform to your request. My continued use of the services constitutes my understanding and acceptance of the above terms set forth in the HIPAA INFORMATION FORM and any subsequent changes in office policy. I understand that this consent shall remain in force from this time forward.

Financial Consent

I understand and accept the terms in order to render services that a credit card must be kept on file and that any remaining balances for services rendered shall be paid in full. I authorize Made Ya Skinny, LLC (DBA: Made Ya Skinny), to submit on my behalf and the release of any medical records or other information necessary to process my consultation order. Fee schedules and receipts for all professional services are available upon request. I authorize Made Ya Skinny, LLC (DBA: Made Ya Skinny), to make invoice changes and debit my account for orders placed, goods received, and/or services rendered not fully covered by third party vouchers or credits. I authorize Made Ya Skinny, LLC (DBA: Made Ya Skinny), to charge my credit card account upon any unpaid balances due. All programs are auto-renewing, and I consent to be automatically charged for any program I am a part of unless I cancel before my next shipment goes out. Refunds and cancellations are handled under the Cancellation and refund policy in our Terms and Conditions at madeyaskinny.com/terms-and-conditions. I certify that I am an authorized user of this credit card and that I will not dispute the payments with my credit card company.

For any questions about Medical Consent, please contact us at: info@madeyaskinny.com