Effective Date: June 1, 2025
IMPORTANT EMERGENCY NOTICE
WE ARE NOT A REPLACEMENT FOR EMERGENCY MEDICAL SERVICES. IF YOU HAVE A MEDICAL EMERGENCY, SEEK EMERGENCY MEDICAL CARE IMMEDIATELY IN-PERSON OR DIAL 911 OR YOUR LOCAL EMERGENCY NUMBER.
We may change these terms at any time, as required by law. This may include changing, adding, or removing terms. We may do this in response to legal, regulatory, business, competitive environment, or other reasons not listed here.
TELEHEALTH INFORMED CONSENT
What is Telehealth?
Telehealth is the delivery of healthcare services that allows patients to access medical care using audio-video technology such as videoconferencing, secure messaging, and digital health platforms. Through Renuvia's platform, you can receive specialized treatments including NAD+ therapy, L-Carnitine injections, Vitamin B12 supplementation, Glutathione therapy, and other wellness treatments.
Technology and Security
Electronic systems used by Renuvia incorporate advanced network and software security protocols to protect the confidentiality of patient identification and medical data. These systems include multiple safeguards to protect your information and ensure data integrity against intentional or unintentional corruption, in full compliance with HIPAA requirements.
Expected Benefits of Telehealth Services
- Improved Access: Receive specialized wellness and therapeutic treatments regardless of your geographic location
- Enhanced Convenience: Access healthcare services from the comfort of your home or preferred location
- Efficient Care Delivery: Streamlined medical evaluation, treatment planning, and ongoing management
- Specialist Expertise: Access to specialized providers experienced in NAD+ therapy, peptide treatments, and wellness medicine
- Continuity of Care: Maintain ongoing relationships with healthcare providers across different locations
- Personalized Treatment: Customized treatment plans based on your individual health needs and goals
Potential Risks and Limitations
As with any medical service, there are potential risks associated with telehealth treatment. These risks include, but are not limited to:
- Technical Limitations: In rare cases, information transmitted may not be sufficient (e.g., poor resolution of images or video) to allow for appropriate medical decision-making by your healthcare provider
- Equipment Failures: Delays in medical evaluation and treatment could occur due to deficiencies or failures of technology equipment or internet connectivity
- Privacy Risks: In very rare instances, security protocols could fail, potentially causing a breach of privacy of personal medical information
- Incomplete Medical Records: Limited access to complete medical records may result in adverse drug interactions, allergic reactions, or other clinical judgment errors
- Physical Examination Limitations: The inability to perform hands-on physical examinations may limit diagnostic capabilities
- Emergency Response: Telehealth providers may not be able to provide immediate emergency response or intervention
Patient Rights and Responsibilities
By consenting to telehealth services through Renuvia, I understand and acknowledge the following:
Privacy and Confidentiality Rights:
- The laws that protect privacy and confidentiality of medical information (including HIPAA) fully apply to telehealth services
- No information obtained through telehealth that identifies me will be disclosed to researchers or other entities without my explicit consent
- All communications and medical records are maintained with the same confidentiality standards as in-person visits
Consent and Withdrawal Rights:
- I have the right to withhold or withdraw my consent to telehealth services at any time, without affecting my right to future care or treatment
- I may request in-person care or referral to local providers at any time
- Withdrawal of consent will not result in any penalty or loss of access to appropriate alternative care
Access to Medical Records:
- I have the right to inspect all information obtained and documented during telehealth interactions
- I may receive copies of my medical information for a reasonable fee as permitted by law
- All records become part of my permanent medical record
Alternative Treatment Options:
- I understand that various alternative methods of healthcare may be available to me
- I may choose one or more alternative treatment options at any time
- My healthcare provider will discuss appropriate alternatives when clinically indicated
Communication and Coordination:
- It is in my best interest to inform my Renuvia healthcare provider of any other healthcare providers involved in my medical care
- I will provide complete and accurate medical history and current medication information
- I will promptly communicate any changes in my health status or concerns about my treatment
Treatment Expectations:
- I may expect the anticipated benefits from telehealth services, but no specific results can be guaranteed or assured
- Treatment outcomes may vary based on individual factors and medical conditions
- I understand the importance of following treatment recommendations and follow-up instructions
Patient Consent to Telehealth Services
I have read and understand the information provided above regarding telehealth services offered by Renuvia. I have discussed this information with my healthcare provider, and all of my questions have been answered to my satisfaction.
I hereby give my informed consent for the use of telehealth in my medical care through the Renuvia platform.
I understand that I have been offered a copy of this form for my personal records. My continued use of Renuvia's services constitutes my understanding and acceptance of the above terms, and I hereby authorize the use of telehealth in the course of my diagnosis, treatment, and ongoing medical care.
HIPAA PRIVACY CONSENT
Understanding HIPAA
The Health Insurance Portability and Accountability Act (HIPAA) provides comprehensive safeguards to protect your medical privacy. These protections have been in effect since April 14, 2003, and continue to evolve with new regulations. This form provides a user-friendly explanation of your rights and our responsibilities.
Your Protected Health Information (PHI)
HIPAA establishes rules and restrictions on who may see or be notified of your Protected Health Information (PHI). These restrictions do not include the normal interchange of information necessary to provide you with quality healthcare services. HIPAA provides you with specific rights and protections as a patient, which we balance with our commitment to providing you with exceptional professional service and care.
Renuvia's Privacy Policies
Information Confidentiality:
- Patient information will be kept confidential except as necessary to provide services or ensure that all administrative matters related to your care are handled appropriately
- This includes sharing information with other healthcare providers, laboratories, pharmacies, and health insurance companies as necessary and appropriate for your care
- Information may be shared with our business associates who assist in providing your care, all of whom are required to maintain HIPAA compliance
Record Management:
- Patient files are maintained in secure, HIPAA-compliant systems with appropriate access controls
- Electronic records include security measures and audit trails to track access
- Records may be temporarily accessed by authorized office staff and healthcare providers as part of normal care delivery
- Physical and electronic safeguards are in place to protect against unauthorized access
Communication Preferences:
- We may remind you of appointments through telephone, email, text message, or other convenient means as requested by you
- We may send communications about treatment updates, policy changes, or other information that may be valuable to your care
- You may opt out of non-essential communications at any time while maintaining access to necessary medical communications
Business Associates and Vendors:
- Renuvia works with various HIPAA-compliant vendors and business associates to provide our services
- These entities may have limited access to PHI but must agree to abide by the confidentiality rules of HIPAA through signed Business Associate Agreements
- All vendors are carefully selected and monitored for HIPAA compliance
Regulatory Compliance:
- You understand and agree to inspections of our systems and review of documents (which may include PHI) by government agencies or insurance companies in normal performance of their regulatory duties
- We comply with all applicable state and federal regulations regarding PHI protection
Marketing and Advertising:
- Your confidential information will not be used for marketing or advertising of products, goods, or services without your explicit consent
- We may use de-identified information for quality improvement and research purposes in compliance with HIPAA regulations
Your Rights Under HIPAA
Access to Records:
- We provide patients with access to their medical records in accordance with state and federal laws
- You may request copies of your records and receive them within the timeframes required by law
- Reasonable fees may apply for copying and processing records
Complaints and Concerns:
- Please bring any concerns or complaints regarding privacy to the attention of our Privacy Officer or medical director
- You also have the right to file complaints with the U.S. Department of Health and Human Services
Requesting Restrictions:
- You have the right to request restrictions in the use of your protected health information
- You may request changes in certain policies used within our practice concerning your PHI
- However, we are not obligated to alter internal policies to conform to your request, though we will consider all reasonable requests
Policy Changes:
- We may change, add, delete, or modify any of these provisions to better serve the needs of both our practice and our patients
- Significant changes will be communicated to you in accordance with HIPAA requirements
HIPAA Consent Acknowledgment
My continued use of Renuvia's services constitutes my understanding and acceptance of the above terms set forth in this HIPAA Privacy Consent and any subsequent changes in privacy policies. I understand that this consent shall remain in force from this time forward unless I specifically revoke it in writing.
FINANCIAL CONSENT AND BILLING AUTHORIZATION
Payment Terms and Authorization
I understand and accept that in order to receive services through Renuvia, payment information may be kept on file and that any balances for services rendered shall be paid according to the terms outlined below.
Payment Authorization:
- I authorize Renuvia to charge payment methods on file for services rendered, including consultations, treatments, medications, and related healthcare services
- I understand that payment is due at the time services are provided unless other arrangements have been made in writing
- I authorize Renuvia to submit claims on my behalf and authorize the release of any medical records or other information necessary to process insurance claims or payment
Billing and Account Management:
- I authorize Renuvia to make necessary billing adjustments and charge my account for orders placed, goods received, and/or services rendered
- I authorize charges for any unpaid balances due according to the payment terms provided at the time of service
- Fee schedules and receipts for all professional services are available upon request
Subscription and Auto-Renewal Services:
- I understand that certain programs and services may be offered on a subscription basis with automatic renewal
- I consent to be automatically charged for any subscription program I choose to participate in unless I explicitly request cancellation before the next payment is processed
- I understand the cancellation policy and procedures for each service, which will be clearly communicated at the time of enrollment
Credit Card Authorization:
- I certify that I am an authorized user of any credit card or payment method provided
- I understand my responsibility to maintain current and valid payment information
- I agree not to dispute legitimate charges with my credit card company or financial institution
Refund and Exchange Policy:
- I understand Renuvia's refund and exchange policy as communicated at the time of service
- Refunds may be available in certain circumstances as outlined in our Terms of Service
- Each situation will be evaluated on a case-by-case basis in accordance with applicable laws and regulations
Financial Responsibility Acknowledgment
My continued use of Renuvia's services constitutes my understanding and acceptance of these financial terms and my agreement to pay for all services received according to the terms outlined above.
PRESCRIPTION AND SHIPPING AUTHORIZATION
Prescription Dispensing
All prescription medications provided through Renuvia are:
- Dispensed according to state and federal law with the approval of licensed pharmacists
- Provided in compliance with all applicable laws from relevant Medical Boards and State Boards of Pharmacy
- Subject to clinical review and approval by licensed healthcare providers
- Dispensed only upon receipt of valid prescriptions from authorized providers
Shipping Terms and Conditions
Shipping Authorization:
- I authorize Renuvia and its pharmacy partners to ship prescription medications and medical supplies to the address provided in my intake form or any other address I specifically provide to the company
- I understand that shipping addresses must be verified and may be subject to certain restrictions based on state regulations
Delivery and Completion:
- I understand that medications are considered dispensed and orders completed when they are processed and released for shipping, not when they arrive at the delivery address
- I acknowledge that delivery times may vary based on shipping method, location, and other factors beyond Renuvia's control
Shipping Risks and Liability:
- I understand and accept the risks associated with shipping prescription medications
- I agree to hold harmless Renuvia and its shipping partners for any delays, damages, or errors that may occur during the shipping process, except in cases of gross negligence or willful misconduct
- I understand my responsibility to be available to receive shipments and to store medications properly upon receipt
Delivery Confirmation:
- I may be required to provide delivery confirmation or signature upon receipt of certain medications
- I agree to promptly notify Renuvia of any shipping problems or issues with received medications
- I understand the importance of proper medication storage and handling
Prescription and Shipping Acknowledgment
My continued use of Renuvia's services constitutes my understanding and acceptance of the above prescription and shipping terms. I give permission for Renuvia and its authorized partners to ship medications and medical supplies to me at authorized addresses and agree to all conditions listed above.
COMPREHENSIVE CONSENT ACKNOWLEDGMENT
By signing below or by continuing to use Renuvia's services, I acknowledge that:
- I have read, understood, and agree to all terms outlined in this Medical Consent document
- I have had the opportunity to ask questions about these terms and have received satisfactory answers
- I understand my rights and responsibilities as a patient receiving telehealth services
- I consent to the collection, use, and disclosure of my health information as outlined in these forms and Renuvia's Privacy Policy
- I understand that I may revoke any of these consents at any time by providing written notice to Renuvia
CONTACT INFORMATION
For questions about this Medical Consent or to revoke any consents:
Renuvia Patient Services
For Medical Emergencies: Call 911 or go to your nearest emergency room immediately.
