Informed Consent to Telehealth

Informed Consent for Telehealth

Purpose: This form obtains yourinformed consent to participate in telehealth services with Vivid Beauty byAshley, in accordance with Michigan law.

 Telehealth Explanation: I understand that telehealth involves the delivery of health services via secure electronic communication (audio/video calls, online messaging, etc.) instead of in-person visits. I understand that Iwill not be physically in the same location as thehealthcare providerduringtelehealth sessions.

 Voluntary Participation: I hereby consent to receive medical care, treatment, and counselingthrough telehealth. I understandthat I have the right to withhold or withdraw consent to telehealth at any time without a ecting myright to future care ortreatment.

 Provider Identiﬁcation: Atthe start of each telehealth session,the providerwill introduce themselves and their credentials. I understandthe provideris a licensed healthcare professional authorized to practice telehealth in the state of Michigan.

 Technology& Security: I understand that telehealthwill be conducted using HIPAA-compliant, secure video conferencingorcommunication tools toprotect my privacy. The audio/video connection will be encrypted to prevent unauthorized access. I willensure that Iparticipate from a private location and use my own secure network if possible.

 Beneﬁts & Limitations: The telehealthprocess, includingits capabilities and limitations, has been explained to me. I understandthat beneﬁts of telehealth include convenient access tocare andno need to travel. Limitations may include occasionalpoorvideo connection, technical di iculties, orlack of hands-on examination.The providerhas explained that someissues maynot beeasily assessable via telehealth,and that they will recommend in-person evaluation if needed forpropercare.

 Alternative Options: I understandthat Icanrefuse telehealth services and request traditional in-person care as analternative. The providerhas explained anyavailable alternatives toa telehealth consultation formy weightloss treatment (such as anin-person referral if necessary).

 Medical Information & Records: I consentto the release ofrelevantmedical informationbetween Vivid Beautyby Ashley and myselfthrough telehealth.I understand that the providerwill have access tomy medical history and information I provide, and that telehealth sessions mayinvolve discussionof mypersonal health information. Telehealth communications and records will be maintained conﬁdentiallyin compliance withprivacy laws.

 Privacyand Conﬁdentiality: I have been informed that the laws and regulations protecting privacy and the conﬁdentialityof medical information (such as HIPAA)apply to telehealth just as they do for in-person care. Vivid Beautyby Ashley will notrecord telehealth sessions without my written consent,and I agree not to record sessions without theprovider’s consent. Boththe providerand I will take precautions to maintain privacy onour ends (e.g., usingaprivate room, using headphones if needed).

 Patient Responsibilities: I agree tobe located in the state ofMichigan (or astate where the provideris licensed)duringtelehealthappointments, and Iwill inform the providerof mycurrent location at the start of each session forsafetyreasons. I will also provide a contact numberand the location of a nearby emergency facility in case of atechnology failure oremergencyduringa session. If Iexperience a medical emergencyduringa telehealthsession, Iwill call 911orseek emergency services immediately.

 Technical Issues: I understand that technical problemsmayinterrupt ordegrade the quality of telehealthsessions. If such issues occur, the session mayneed tobe rescheduled or continued via alternative means (forexample, by telephone). I will attemptto ensure I havea reliable internet orphone connection foreach session.

 Standard ofCare: I understandthat the telehealthproviderwill delivercare consistentwith the qualityofcare I would receivein person. The providerwill determine whethertheinformation obtained via telehealthis su icientfor diagnosis and treatment. If the providerbelieves that telehealth is notadequate formy speciﬁcissue, they will discuss alternative care options orask meto obtain additional in-person evaluation.

 Medical Records Consent: I consentto allow Vivid Beauty byAshley to share informationfrommytelehealthvisits withotherhealthcare entities (such as laboratories, pharmacies, ormy primarycare physician)as needed fortreatment, payment, and healthcare operations, in accordance withHIPAA.

 Teleprescribing: I understand that the provider mayprescribe medications forme as part of my weight loss treatment. I acknowledge that Michigan law prohibits prescribing controlledsubstances viatelehealth, and I will not be prescribed any controlled substance medications through telehealth

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. Non-controlled prescription orders (such as compounded semaglutide ortirzepatide) can be made if medically appropriate, andthese will be sent to a pharmacy ordelivered tome as discussed.

 Risks ofTelehealth: The providerhas explained that there are potential risks to usingtelehealth, including, butnot limited to: (a)incompleteordelayed information transmission that could result in suboptimal decision-makingby the provider; (b) security protocols thatcould fail, causinga breach of privacy of personalmedical information; (c) in rare cases, misdiagnosis ortreatment delay due totechnological limitations. Iunderstand these risks and agree toproceed withtelehealth despite them.

 Patient Rights: I understandI have the right to ask questions and seek clariﬁcation on anyaspect of telehealthormy treatment.I can request that we discontinue the video session at any time if Ifeel it’s necessary. I alsohave the rightto access my medical informationand get copies of mymedical records from telehealthvisits, just as I would for in-person visits.

 Follow-up Care: If atelehealthsessionresults in aprescription, recommendation, ororder for follow-up (such as lab tests or referrals), I agree to comply and understand itis my responsibility tocarry out those recommendations (e.g., getting lab work done, scheduling a follow-up appointment).

 NoGuarantee: I understandthat, as withany medical treatment,telehealth comes with no guarantee ofsuccessful outcomefor my condition. The providerhas made no guarantees orpromises regardingcure orweight loss results through telehealth care.

 Consent and Acknowledgment: By signing below, Icertify thatI have read and understand the above information. All my questions regarding telehealth have been answered tomysatisfaction. I hereby give my informed consentto receive telehealthservices fromVivid BeautybyAshley. I understandthat this consentis ongoingthroughout my treatment, and Ican revoke itin writing atany time forfuture sessions.

HIPAA Notice of Privacy Practices & Authorization

HIPAA Notice ofPrivacy Practices and Authorization

Notice ofPrivacy Practices: This notice describes how your medical information may be used and disclosed, andhow you can getaccess tothis information, in accordance with the Health Insurance Portabilityand AccountabilityAct (HIPAA). Please review it carefully.

• Our Commitment to Privacy: Vivid Beauty by Ashley is committed to protecting the privacy of your Protected Health Information (PHI). We create a record ofthe care and services you receiveat our clinic to provide you with quality care and to comply with legal requirements. We will notuse ordisclose yourhealth information without yourauthorization,exceptas described in this notice oras permitted by law.

• Uses and Disclosures ofPHI: We mayuse and disclose yourhealthinformation for the following purposes:

o Treatment: To provide,coordinate, or manage yourhealthcare. Forexample, we may share information withour medical sta , pharmacists, or laboratories involved in yourweightloss care.

o Payment: To obtain payment for services we provide. Forinstance, informationabout your diagnosis andtreatments may be used tobill you or yourcredit card onﬁle, orto process claims if you seek reimbursement from an insurer.

o Health Care Operations: Forourinternal operations, such as quality improvement, sta training, andaccreditation. This helps ensure you receive quality care.

o As Required by Law: We will disclose PHI when required to do so by federal, state, orlocal law. Forexample, we mayshare information if required to report communicable diseases orif ordered by a court.

o Public Health and Safety: We maydisclose information topublic health authorities toprevent orcontrol disease, orto avert aserious threatto health orsafety.

o Healthcare Oversight: We mayshare informationwithagencies overseeing healthcare systems orgovernment programs (forexample, for audits, inspections, orlicensure).

o Law Enforcement andLegal Proceedings: Wemay disclose PHI in response to a valid subpoena, courtorder, or as required forlaw enforcement purposes (such as identifying a missingpersonorreportinga crime at the clinic).

o Others Involved in Your Care: Unless you object, we may share relevant informationwith a family member orperson you identify who is involved in yourmedical care, but only as itdirectlyrelates to theirinvolvement (for example, schedulingor pickingup medications). You havethe rightto object to such disclosures.

• Other Uses RequiringAuthorization: Uses and disclosures ofyourPHI for purposes otherthan those listed above will be made only with your written authorization. Forexample, we will notuse yourinformation for marketing purposes, fundraising, orshare anypsychotherapy notes (if any) without your explicit consent. You mayalso speciﬁcally authorize us torelease information to third parties (forinstance, toyourprimary care physician orto afamily member). You have the rightto revoke anyauthorization in writing, except tothe extentwe have already acted based onit.

• Your Health InformationRights: You have several rightsregarding yourhealth information:

o Right to Inspect and Copy: You may request access to review and obtain a copy of your medical records and other health informationthatwe have aboutyou, withlimited exceptions (e.g., psychotherapy notes).We may charge a reasonable fee forcopies.

o Right to Request Amendment: If you feel thathealthinformation we have aboutyou is incorrect orincomplete, you may request in writingthat we amend the information. We will review yourrequest andeither make the amendmentor provide a reasonfordenyingit within the bounds of the law.

o Right to an Accounting ofDisclosures: You have the right to request a list (accounting)of certain disclosures we have made ofyourhealth information, other thanthose fortreatment,payment,orhealthcare operations (and certain otherexceptions).

o Right to Request Restrictions: You may request in writing that we restrict the use ordisclosure of yourPHI fortreatment, payment,orhealthcare operations. While we will considerany reasonable request, we are not legally

required toagree toall restrictions. If we do agree, we will comply with your request except in emergency situations oras required by law.

o Right to Request Conﬁdential Communications: You canrequest that we communicate with you about medical matters in a certain wayor ata certain location (forexample, only at a speciﬁc phone number or by mail).We will accommodate reasonable requests.

o Right to aPaper Copy ofThis Notice: You have the right to a paper copy of ourNotice of PrivacyPractices at any time. You may request a copy from us via email orin person. (This electronic copy is provided foryour convenience.)

• PrivacyContact: If you have questions aboutthis notice orwant more information, you maycontact us at Email: ashley@getvividaesthetics.com or Phone: 248-767-0327. If you believe yourprivacy rightshave been violated, you can ﬁle a complaint with our o ice or with the U.S. Departmentof Health &HumanServices. There will be no retaliation forﬁlinga complaint.

• HIPAA Authorization (Consent to Use/Disclose): By signing below, you authorize Vivid Beauty byAshley to use and disclose yourhealthinformationfor the purposes oftreatment, payment, and healthcare operations as described above. You acknowledge that you have received (or have been o ered) acopy of the Vivid Beautyby Ashley Notice ofPrivacy Practices. You understand thatVivid Beautyby Ashley may communicate with you via the contact information you provided (includingphone, email, ormail) for appointment reminders, follow-up care, and treatmentinformation, and you consentto such communications. If you have any speciﬁcinstructions or restrictions on communications or disclosures (forexample, do not leave voicemails withdetailed info, ordonot email sensitive results), you will inform the clinicin writing.

Acknowledgment: I hereby acknowledge that I have been provided with Vivid Beautyby Ashley’s Notice of Privacy Practices. I have had the chance toreview and consider this information. I understand my rights andhow my health information maybe used. Bysigning below, I consent to the use and disclosure ofmyhealth information as outlined above, and Iacknowledge receipt(oro er) of the Notice ofPrivacyPractices. I understandthatI mayrequest additional restrictionsor revoke this consentin writing at any time, except to the extent that action has alreadybeentakeninreliance on myconsent.