Onsera Health, Inc. ("Onsera Health") provides a secure platform for working with health providers of Onsera Medical Group, PA (the "Medical Group") in the delivery of healthcare services using electronic communications, information technology, and/or remote means of communication ("Telehealth"). The purpose of this form is to obtain your consent to treat as well as participate in Telehealth visits with one of the Medical Group's health providers via Onsera’s Telehealth platform.
By affirmatively clicking the box saying that "I agree to the . . . Consent to Telehealth," you certify that you are the patient identified and that you are 18 years of age or older or otherwise legally authorized to consent. You further certify that you have carefully read, understood, and agree to the below statements. You understand this informed consent will become a part of your medical record.
1.1 This consent provides the Medical Group with permission to perform reasonable and necessary medical examinations, testing and treatment. I hereby authorize the Medical Group, including affiliated physicians, nursing, and health professional staff, assisted by the employees of Onsera Health, to provide medical treatment to me or the patient identified in connection with this consent.
1.2 I authorize Onsera to assist in my weight-management treatment, which may include:
I understand that anti-obesity medications may be prescribed off-label, at doses higher or lower than listed in FDA labeling, at my clinician’s discretion based on medical judgment and clinical guidelines.
1.3 I agree to diagnostic tests and procedures, including the administration/injection of pharmaceutical products and medication, in addition to the drawing of blood. I understand and authorize the administration of pharmaceutical agents and medications. I understand that certain recommended diagnostic tests and procedures may require me to visit an unaffiliated third-party facility such as a laboratory services provider. I acknowledge that no guarantees or assurances have been made to me concerning the results or findings intended from treatment or examination by the Medical Group.
1.4 I have the right to be informed about my condition and the recommended medical or diagnostic procedure to be used so that I may make the decision whether or not to undergo any suggested treatment or procedure after knowing the risks and hazards involved.
1.5 I have the right at any time to discontinue services. I have the right to discuss my treatment plan with my health care provider including the purpose, potential risks and benefits of any test ordered for me. If I have any concerns regarding any test or treatment recommended by my health care provider, I am encouraged to ask questions. I voluntarily request a physician, and/or mid-level provider (nurse practitioner, physician assistant, or clinical nurse specialist), and other health care providers or designees as deemed necessary, to perform reasonable and necessary medical examination, testing and treatment for the condition which has brought me to seek care at this practice.
I understand that success depends greatly on my participation and lifestyle changes, and that no outcome is guaranteed.
I agree to:
The following clinical criteria must be met in order to be classified as ‘active participant’ and therefore access medication
If participants do not meet the above criteria, they are classified as ‘clinically sunset’ or ‘inactive’ therefore would be removed from the program and unable to access their next prescription.
I understand that common side effects include nausea, vomiting, constipation, diarrhea, abdominal discomfort, fatigue, headache, injection-site irritation. Less common but serious side effects may include pancreatitis, gallbladder disease or gallstones, kidney injury or dehydration, serious allergic reactions, low blood sugar, especially if I have Type 2 Diabetes or take insulin/sulfonylureas, vision changes and increased heart rate.
I understand there are reports of drastically reduced alcohol tolerance while on semaglutide/tirzepatide, and alcohol may also increase nausea or vomiting. I agree to use caution driving or operating machinery after consuming alcohol.
Remaining overweight or obese carries significant risks including hypertension, diabetes, heart disease, joint disease, sleep apnea, and increased mortality. Weight regain is possible even after successful treatment. Long-term lifestyle changes are essential.
I understand alternatives include:
I affirm that I do not have any of the following conditions and if I do, I have disclosed the information to my Onsera provider:
I confirm I am not pregnant or planning to become pregnant in the next two years. I am not breastfeeding or planning to breastfeed in the next two years. I will immediately notify Onsera if my status changes. I am aware that the medications prescribed through Onsera can cause birth defects or fetal harm.
I understand that final eligibility is determined by the clinical judgment of my Onsera provider.
6.1 I consent to treatment involving the use of electronic communications to enable health care providers at different locations to share individual patient medical information for the purpose of improving patient care.
6.2 Providers may include primary care practitioners, specialists and/or subspecialists, nurse practitioners, registered nurses, medical assistants, and other healthcare providers who are part of my clinical care team. In addition to myself and the members of my clinical care team, I may choose to have my family members, caregivers, or other legal representatives or guardians join and participate in the telehealth/telemedicine service, and I agree to share my personal information with such family members, caregivers, legal representatives, or guardians. The information may be used for diagnosis, therapy, follow-up and/or education.
6.3 Telehealth/Telemedicine requires transmission, via Internet or telecommunication device, of health information, which may include:
6.4 The laws that protect the privacy and confidentiality of health and care information also apply to telehealth/telemedicine. Information obtained during telehealth/telemedicine that identifies me will not be given to anyone without my consent except as described in the Notice of Privacy Practices. By agreeing to use the telehealth/telemedicine services, I am consenting to the Medical Group sharing of my protected health information with certain third parties as more fully described in the Notice of Privacy Practices. I understand, agree, and expressly consent to the Medical Group obtaining, using, storing, and disseminating to necessary third parties, information about me, including my image, as necessary to provide the telehealth/telemedicine services.
6.5 As with any Internet-based communication, I understand there is a risk of security breach. Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.
6.6 Individuals other than my clinical care team or consulting providers may also be present and have access to my information for the telehealth/telemedicine session. This is so they can operate or repair the video or audio equipment used. These people will adhere to applicable privacy and security policies.
6.7 Telehealth/telemedicine sessions may not always be possible. Disruptions of signals or problems with the Internet's infrastructure may cause broadcast and reception problems (e.g., poor picture or sound quality, dropped connections, audio interference) that prevent effective interaction between consulting clinician(s), participant, patient, or care team. I hereby release and hold harmless the Medical Group, Onsera Health, and all members of my care team from any loss of data or information due to technical failures associated with the telehealth/telemedicine service.
6.8 I understand and agree the health information I provide at the time of my telehealth/telemedicine service may be the only source of health information used by the medical professionals during my evaluation and treatment at the time of my telehealth/telemedicine visit, and such professionals may not have access to my full medical record or information held by the Medical Group or Onsera Health.
6.9 I understand I will be given information about proposed test(s), treatments(s) and procedures(s), as applicable, including the benefits, risks, possible problems or complications, and alternate choices for my medical care through the telehealth/telemedicine visit.
6.10 I have the right to withhold or withdraw consent to the use of telehealth/telemedicine services at any time, however I understand if I withdraw my consent for telehealth/telemedicine, I will be unable to receive care via the Medical Group, which has no physical location.
In addition to the risks described above, I acknowledge that in some instances treatment with Telehealth technology may present certain risks and limitations, which include, but are not limited to, the following:
7.1 Information transmitted to my health provider via Telehealth may not in every case be sufficient to allow for appropriate medical decision-making by the health provider.
7.2 The inability of my health provider to conduct certain tests or assess vital signs in-person may, in certain cases, prevent the health provider from making accurate diagnoses, providing appropriate treatments, or identifying the need for emergency medical care or treatment.
7.3 My health provider may not be able to provide all of the necessary medical treatment for my particular condition via the Telehealth visit, in which case I will need to rely on alternative and/or specialized medical care.
7.4 Delays in medical evaluation/treatment may occur due to unexpected failures in technology associated with providing Telehealth.
7.5 My health provider's treatment options may be limited by regulatory requirements in certain states.
7.6 I have the right to ask my health provider about their identity, professional credentials, and the location from which they are providing telehealth services to me. If I have questions about whether telehealth is appropriate for my medical condition, the associated risks, or the provider's credentials and professional background, I may ask my provider at any time before or during my visit.
I acknowledge receipt of the Notice of Privacy Practices, which outlines how health information about me may be used or disclosed by Onsera Health and/or the Medical Group, and how I may obtain access to and control this information. To the extent permitted by law, I consent to the use and disclosure of my information for the purposes described in the Notice of Privacy Practices.
I may give permission for my Protected Health Information to be disclosed for purposes of communicating results, findings and care decisions to the family members and others. When I give such permission I will communicate the Name, Relationship, and contact information to the clinical team to ensure it is documented.
I consent to photographs, digital or audio recordings, and/or images of me being recorded for patient care, security purposes and/or the Medical Group's health care operations purposes (e.g., quality improvement activities). I understand that the Medical Group and/or Onsera Health retains the ownership rights to the images and/or recordings. I understand that these images and/or recordings will be securely stored and protected. Images and/or recordings in which I am identified will not be released and/or used outside the facility without a specific written authorization from me or my legal representative unless otherwise permitted or required by law.
If at any time I provide an email address or cellphone number at which I may be contacted, I consent to receiving unsecure instructions and other healthcare communications at the email or phone number (including text message and voicemail) I have provided. These communications may include, but are not limited to: follow-up instructions, check-ins by your provider, educational information, and prescription information. Other healthcare communications may include, but are not limited to, communications to family or designated representatives regarding my treatment or condition, or reminder messages to me regarding appointments for medical care.
I hereby authorize the Medical Group and the physicians or other health professionals involved in my care to release healthcare information as is necessary for purposes of treatment, payment, or healthcare operations. I also acknowledge that healthcare information regarding a prior service(s) with other Medical Group providers may be made available to subsequent Medical Group providers to coordinate care.
I acknowledge that Onsera Health and/or the Medical Group may use the services of a third-party business associate or affiliated entity as an extended business office for medical account billing and servicing.
The following state-specific consents and disclosures apply to patients receiving telehealth services in the states listed below. These disclosures are required by applicable state law and are incorporated into this Consent. Where a legal representative is signing on behalf of the patient, these disclosures apply on the patient's behalf.
Alaska: I understand that my primary care provider may obtain a copy of records from the telehealth encounter. I have been informed that to register a formal complaint about a provider, I should visit the medical board's website at https://www.commerce.alaska.gov/web/cbpl/ComplaintFAQs.aspx.
Arizona: I understand the patient is entitled to all existing confidentiality protections pursuant to A.R.S. § 12-2292. All medical reports resulting from telehealth services are part of the patient's medical record as defined in A.R.S. § 12-2291. Dissemination of any images or information identifiable to the patient for research or educational purposes shall not occur without consent, unless authorized by state or federal law.
California: I understand that some or all services may be provided using telehealth technologies. I consent to the sharing of my health information among the Medical Group's affiliated entities and care team members for the purpose of coordinating care, consistent with the California Confidentiality of Medical Information Act (CMIA).
Colorado: I consent to the use of telehealth. I understand I will not be charged separately for the use of telehealth technology and that my privacy will be protected under Colorado law.
Connecticut: I understand that my primary care provider may obtain a copy of records from the telehealth encounter.
Florida: To view patient rights under Florida's Patient Bill of Rights and Responsibilities, visit the Florida Agency for Health Care Administration website at https://www.flsenate.gov/laws/statutes/2011/381.026. I understand the provider may not be physically located in Florida when telehealth services are provided. I consent to receive these services under Florida's Telehealth Practice Act.
Georgia: I have been given clear, appropriate, and accurate instructions on follow-up in the event of needed emergent care related to the telehealth services.
Hawaii: I consent to the use of telehealth as permitted by Hawaii law. I understand that privacy will be protected under state and federal law and that consent may be withdrawn at any time.
Idaho: I have been informed that to register a formal complaint about a provider, I should visit the medical board's website at https://dopl.idaho.gov/bom/.
Illinois: I understand that telehealth may be used for parts of my care. Participation is voluntary, and in-person visits may be chosen when available. I consent to telehealth consistent with Illinois law, including the Telehealth Act (225 ILCS 150).
Kansas: I understand that if I have a primary care provider or other treating physician, the person providing telemedicine services must send a report to such primary care or other treating physician of the treatment and services rendered within three days of this consent being provided.
New Hampshire: I understand that my primary care provider or treating provider may obtain a copy of records from the telehealth encounter.
New Jersey: I understand I have the right to request a copy of my medical information, and that medical information may be forwarded to my primary care provider or healthcare provider of record, or upon request, to other healthcare providers. I have been informed of the provider's identity, credentials, and location, and I consent to receive telehealth services consistent with New Jersey law.
New York: I consent to receive telehealth services. I understand that all communications will be secure and that information will remain confidential under New York law, including New York Public Health Law Article 27-F.
Ohio: I understand that my primary care provider may obtain a copy of records from the telehealth encounter.
Oklahoma: I have been informed that to register a formal complaint about a provider, I should visit the medical board's website at http://www.okmedicalboard.org/complaint or the Oklahoma Board of Osteopathic Examiners' website at https://osboe.portalus.thentiacloud.net/webs/portal/register/#/complaint.
Oregon: I consent to receive telehealth services under Oregon law.
Rhode Island: If email or text-based technology is used to communicate with the provider, I understand the types of transmissions permitted and the circumstances when alternate forms of communication should be utilized. I have been informed about security measures, such as encryption of data, password-protected screen savers and data files, or other reliable authentication techniques, as well as potential risks to privacy. I have been informed that to register a formal complaint about a provider, I should visit the medical board's website at https://health.ri.gov/complaints/.
South Carolina: I understand that my medical records may be distributed only with consent and in accordance with applicable laws and regulations to other treating healthcare practitioners.
South Dakota: I have received disclosures regarding telehealth services and their limitations.
Texas: I understand that with consent, medical records related to my services may be sent to my primary care physician within 72 hours after receiving services. I consent to the use of telecommunication technology, including telephone or electronic communications, as part of my care. These services will comply with Texas Medical Board telemedicine standards, and telehealth may be declined at any time. NOTICE CONCERNING COMPLAINTS – Complaints about physicians, as well as other licensees and registrants of the Texas Medical Board, including physician assistants, acupuncturists, and surgical assistants, may be reported for investigation at: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018. Assistance in filing a complaint is available by calling 1-800-201-9353. For more information, visit https://www.tmb.state.tx.us/.
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