Patient Consent to Treatment
By affirmatively selecting the “Consent to Treatment,” I acknowledge that I have been given the opportunity to review the below terms as they relate to receiving medical care from the professional corporation with which Twentyeight Health, Inc. partners, New Jersey Birdie Health, P.C. (the “P.C.”) and its individual licensed physicians who shall be independent contractors of the P.C. (each of whom may be a “Treating Physician”).
I acknowledge and agree that selection of the “Consent to Treatment, shall serve as my consent to receive from P.C. and Treating Physicians, diagnostic, therapeutic, or other medical care connected to prescription of birth control medication (collectively the “Treatment”) through the use of a telemedicine platform. Treatment shall be provided only when it is determined to be necessary in the professional medical judgment of my Treating Physician. I may decline Treatment at any time. I understand that the Treatment may be dependent on review of my medical history, medical records, and current medical status (collectively “Medical Information”). I further consent to provide or that such Medical Information may be provided to the P.C. and my Treating Physician for purposes of Treatment.
I confirm that the Medical Information I provide is accurate and truthful to the best of my knowledge at the time it is given. In the event my Medical Information changes after providing it to the P.C. or a Treating Physician but prior to any subsequent interactions with the P.C. or a Treating Physician I will update the P.C. and Treating Physician to such changes.
I understand that my Treating Physician will provide a description of the Treatment, the indications for the Treatment, alternatives to the Treatment, the material risks and benefits of the Treatment or of declining such Treatment. I further understand that I shall have the opportunity to ask questions about the Treatment and that my Treating Physician shall clearly and fully answer such questions.
I also understand that the practice of medicine or receiving Treatment does not confer a guaranteed or specific medical outcome and I acknowledge that no such guarantee has been made to me. I further consent that the P.C. may retain the Medical Information for the purposes of documenting my health status. I understand that my Medical Information to the extent required by law, shall be maintained by the P.C., or entities with which the P.C. contracts to coordinate my care, in compliance with all applicable laws, including but not limited to the Health Insurance Portability and Accountability Act of 1996, as amended by and supplemented by the Health Information Technology for Clinical Health Act of the American Recovery and Reinvestment Act of 2009, and their respective implementing regulations, as amended from time to time (collectively “HIPAA”). To the extent permitted by applicable law, P.C., a Treating Physician and Twentyeight Health, Inc. may access and use Medical Information for purposes of defending itself in case of any litigation it is party to in connection with the Treatment.
For the avoidance of doubt, I acknowledge and understand that Twentyeight Health is not a licensed medical provider and is not providing me any Treatment or other medical care. Twentyeight Health acts only to coordinate my ability to receive Treatment from P.C., as it is determined to be appropriate in the professional medical judgment of the PC and Treating Physicians.