Consent to Care
I consent to the treatment and any procedures that may be provided by AC Wellness and its affiliated professional entities identified in Appendix A (collectively, “AC Wellness”), including laboratory procedures, x-ray examinations, emergency treatment, medical treatment or procedures, anesthesia, or other services provided to me at a Wellness Center location or via telehealth technologies (as further described below). I consent to my providers taking photographs of me for treatment and clinical education purposes, and to the electronic delivery (via app or portal) of test results or other records where appropriate. I understand that AC Wellness, by providing care to me and others, may develop new discoveries in healthcare that may be used to inform future products and services for AC Wellness and in certain circumstances, Apple Inc. I understand that my personal health information will not be shared beyond AC Wellness other than as set forth in the Notice of Privacy Practices or with my consent.
Telehealth Services
AC Wellness offers treatment by physicians, nurses, and other licensed healthcare professionals via telecommunications technology (also referred to as “telehealth”). The services provided may also include chart review, remote prescribing, appointment scheduling, refill reminders, health information sharing, and non-clinical services, such as patient education. The electronic communication systems used by AC Wellness incorporate network and software security protocols and other safeguards to protect the confidentiality, security, and integrity of patient data. There are various benefits associated with telehealth services, including improved access to care by enabling patients to remain in their homes while the provider consults with them, more efficient care evaluation and management, and obtaining expertise of a specialist as appropriate. Possible risks include delays in evaluation and treatment due to deficiencies or failures of the equipment and technologies; in rare events, the AC Wellness provider may determine that the transmitted information is of inadequate quality, thus necessitating a rescheduled telehealth consult or a visit with a local primary care doctor.
I hereby consent to receive AC Wellness services via telehealth technologies (in accordance with the License Agreement for such use), and acknowledge that I further understand and agree with the following:
• I understand that AC Wellness and its providers offer telehealth-based medical services, but that these services do not replace the relationship between me and my primary care doctor. I also understand it is up to the AC Wellness provider to determine whether or not my specific clinical needs are appropriate for a telehealth encounter.
• I will be given an opportunity to review the credentials of the AC Wellness provider prior to the telehealth consult.
• I understand that federal and state law requires healthcare providers to protect the privacy and the security of health information. I understand that AC Wellness will take steps to make sure that my health information is not seen by anyone who should not see it (as set forth in the Notice of Privacy Practices). I understand that telehealth may involve electronic communication of my personal medical information to other health practitioners who may be located in other areas, including out of state, and that healthcare information may be shared with other individuals for scheduling and billing purposes.
• I understand there is a risk of technical failures during the telehealth encounter beyond the control of AC Wellness, and I agree to hold AC Wellness harmless for delays in evaluation or for information lost due to such technical failures.
• I understand that I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time, without affecting my right to future care or treatment. I understand that I may suspend or terminate use of the telehealth services at any time for any reason or for no reason. I understand that if I am experiencing a medical emergency, I will be directed to dial 9-1-1 immediately and that AC Wellness providers are not able to connect me directly to any local emergency services.
• I understand that alternatives to telehealth consultation, such as in-person services, are available to me, and in choosing to participate in a telehealth consultation, I understand that some parts of the services involving tests may be conducted by individuals at my location, or at a testing facility, at the direction of the AC Wellness provider (e.g., labs or bloodwork).
• I understand that I may expect the anticipated benefits from the use of telehealth in my care, but that no results can be guaranteed or assured.
• I understand that I will not be prescribed any narcotics, nor is there any guarantee that I will be given a prescription at all.
• I understand that if I participate in a consultation, I have the right to request a copy of my medical records.
• I have read and understand the State-Specific Disclosures for the state in which I am located at the time of my telehealth encounter.
Patient Rights and Responsibilites
I acknowledge that as a recipient of Wellness Center services I have certain rights and responsibilities, which are summarized below. I acknowledge and agree that I have reviewed and understand the full description of my rights and responsibilities, which is available here.
• I have the right to considerate and respectful care in a safe setting, confidential treatment of my communications and records, to receive information about and participate in my plan of care, receive reasonable continuity and appropriate coordination of care, and to be advised of any conflicts of interest my provider may have relating to my care.
• I must provide, to the best of my knowledge, complete and accurate information about my health and medications to my providers.
• I must demonstrate respectful behavior, comply with all applicable Apple policies (if I am an Apple employee) and all Wellness Center rules and policies, and maintain professional boundaries in the patient-provider relationship.
• I must keep scheduled appointments or notify the Wellness Center as soon as possible in accordance with the cancellation and no-show policy, as well as timely meet my financial responsibilities.
Open Payments Disclosure
The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. It can be found at https://openpaymentsdata.cms.gov.
Coaching Services
I acknowledge that AC Wellness may also offer to connect me with coaching services intended to support behavioral modification in various domains of health and wellness (“Coaching Services”). I understand that the Coaching Services are not licensed by any state regulatory agency, and are provided by health coaches who are not licensed physicians. Rather, the Coaching Services are intended to be complementary to the practice of medicine and other healing arts services licensed by the state.
I acknowledge I have been provided information regarding the nature of the Coaching Services, the theory of treatment upon which they are based, and the educational, experience, and other qualifications of the health coaches. A copy of such information is available here.
Appendix A
When using the services described in this Consent, you will be treated by and will enter into a patient-provider relationship with a licensed healthcare provider employed or contracted by one or more of the entities identified below, based on your location at the time of the encounter.
If you are located in California, your healthcare provider will be employed by or contracted with AC Wellness, a California professional corporation.
If you are located in one of the following states, your healthcare provider will be employed by or contracted with AC Wellness On Demand Medical, PLLC, an Arizona professional limited liability company.
• Alabama
• Alaska
• Arizona
• Arkansas
• Colorado
• Connecticut
• Delaware
• Florida
• Georgia
• Hawaii
• Idaho
• Illinois
• Indiana
• Iowa
• Kentucky
• Louisiana
• Maine
• Maryland
• Massachusetts
• Michigan
• Minnesota
• Mississippi
• Missouri
• Montana
• Nebraska
• Nevada
• New Hampshire
• New Mexico
• North Carolina
• North Dakota
• Ohio
• Oklahoma
• Oregon
• Pennsylvania
• Rhode Island
• South Carolina
• South Dakota
• Tennessee
• Texas
• Utah
• Vermont
• Virginia
• Washington
• Washington, D.C.
• West Virginia
• Wisconsin
• Wyoming
If you are located in Kansas, your healthcare provider will be employed by or contracted with AC Wellness On Demand Medical of Kansas, P.A., a Kansas professional entity.
If you are located in New Jersey, your healthcare provider will be employed by or contracted with AC Wellness On Demand Medical of NJ, LLC, a New Jersey limited liability company.
If you are located in New York, your healthcare provider will be employed by or contracted with Primary+ Medical, PLLC, a New York professional limited liability company.