Consent to Telehealth Services

You have elected to have a telehealth visit instead of an in-person visit. You agree that your Provider will determine whether your condition is appropriate for telehealth, and you acknowledge that your Provider may recommend an in-person evaluation in place of, or in addition to, your telehealth visit.

You have had the opportunity to review your Provider’s credentials prior to your visit. All Providers made available through Ongo Weight Loss are independently licensed healthcare providers, registered with a National Provider Identifier (NPI), and licensed to practice in the state where you are located at the time of your telehealth visit.

You acknowledge that telehealth carries potential risks, including but not limited to:

• Information transmitted during a telehealth visit may be less comprehensive than what would be available during an in-person exam, which may affect the accuracy of diagnosis or medical decision-making;
• Delays in evaluation or treatment could occur due to technical failures or equipment issues;
• Security protocols could fail, resulting in a breach of privacy;
• Miscommunication may occur due to technology issues, and certain physical exams or diagnostic tests cannot be performed remotely;
• Your Provider may determine, in their sole clinical judgment, that your condition is not appropriate for treatment via telehealth or is not appropriate for treatment with the medication requested, and may decline to prescribe, or may refer you to in-person or emergency care instead.

Telehealth involves the electronic transmission of your PHI, which may include your individually identifiable health information, medical history, diagnoses, and communications with your other healthcare providers. As with any electronic transmission of information, there is a risk that PHI could be lost, delayed, or intercepted due to technical failure or unauthorized access, despite the safeguards described in our Notice of Privacy Practices. In the event of a breach affecting your information, we will notify you and take the steps required by applicable law, as described in our Notice of Privacy Practices. PHI obtained during your telehealth visit will not be disclosed to others without your consent, unless permitted by applicable law and in accordance with our Notice of Privacy Practices.

You have the right to request that we send information about your treatment with your Provider to your primary care physician. If you make this request and consent to the disclosure of PHI, we will send your medical record and/or a treatment summary to your primary care physician within seventy-two (72) hours of your consultation.

Telehealth is not intended for emergency situations. In the event of a medical emergency, call 911 immediately. If you are experiencing a mental health crisis, including thoughts of suicide, call or text 988 (Suicide & Crisis Lifeline). By using telehealth, you agree that: (a) your Provider encounter is not a replacement for your relationship with your primary physician; (b) you will contact your primary physician immediately if your condition changes or worsens; and (c) if emergency care is required, you will contact local emergency services immediately.

You have the right to withhold or withdraw your consent to telehealth at any time, without affecting your right to future care, treatment, or programs for which you are otherwise entitled. You understand that if others are present at your location during a telehealth visit, the confidentiality of that visit may be compromised.

You understand the alternatives to telehealth, such as an in-person evaluation, and understand that in choosing telehealth, some parts of an examination may require in-person testing at the direction of your Provider.

YOU UNDERSTAND THAT YOU ARE RESPONSIBLE FOR PAYMENT. THE PRACTICE DOES NOT ACCEPT INSURANCE. ALL OUT-OF-POCKET EXPENSES ASSOCIATED WITH YOUR TELEHEALTH VISIT ARE DUE PRIOR TO THE VISIT.

You understand that you must be physically located in your home state (the state associated with your primary residence on your Ongo profile) during each telehealth consultation, and you represent that you will be located in that state for the entirety of every telehealth visit. If you are not physically located in your home state at the time of a scheduled telehealth visit, your Provider may decline to treat you via telehealth.

Your Provider may exercise their professional judgment to prescribe medication to treat your diagnosed condition, but there is no guarantee you will be prescribed any medication. If a medication is prescribed, it may be dispensed as an FDA-approved branded product or, where your Provider determines an individualized clinical basis exists (such as an allergy or intolerance to an ingredient in the FDA-approved product, or a need for a dosage strength or form not commercially available), as a compounded medication prepared by a licensed compounding pharmacy.

For more information about the limitations of the information on this website and about compounded medications, see our Medical Disclaimer.

You have been advised of the potential risks, consequences, and benefits of telehealth, including risks related to the security of electronic communications. You have had the opportunity to ask questions about this Consent, and all your questions have been answered to your satisfaction.

By checking the box or otherwise affirmatively accepting this Consent, you acknowledge that you have read and understand the terms of this Telehealth Consent, and you agree to receive services from the Practice via telehealth. You represent and warrant that you are authorized to provide this consent, and that you are 18 years of age or older.

You may contact us at info@ongoweightloss.com or 1-888-655-5267 for a copy of this Telehealth Consent, or to withdraw your consent at any time.

The following disclosures apply if you are receiving telehealth services while located in the states listed below, as required by applicable state law:

California: You consent to the sharing of your health information among your Provider and care team for purposes of coordinating your care, consistent with the California Confidentiality of Medical Information Act (CMIA).

Texas: Medical records related to your telehealth visit may be sent to your primary care physician within seventy-two (72) hours of your visit, with your consent. If you have a complaint about a physician or other licensee of the Texas Medical Board, you may report it to: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018, or by calling 1-800-201-9353. More information is available at www.tmb.state.tx.us.

Kansas: If you have a primary care provider or other treating physician, your Provider will send a report of the treatment and services rendered to that physician within three (3) days of this consent being provided, if you have consented to such disclosure.

Florida: Your Provider may not be physically located in Florida when providing your telehealth visit. You consent to receive these services under Florida’s Telehealth Practice Act. Patient rights under Florida’s Patient Bill of Rights and Responsibilities are available at the Florida Agency for Health Care Administration website.

Illinois: Participation in telehealth is voluntary, and an in-person visit may be requested when available, consistent with the Illinois Telehealth Act (225 ILCS 150).

New York: All communications during your telehealth visit are secure, and your information remains confidential under New York law, including New York Public Health Law Article 27-F.

All other states: If you are located in a state not specifically listed above, your telehealth visit will still be conducted consistent with applicable state law governing telehealth, informed consent, and patient privacy. If your state has specific telehealth consent or disclosure requirements not reflected above, please contact us at info@ongoweightloss.com and we will provide the applicable disclosure.