Informed Patient Consent.
1. I voluntarily request that Rume Medical Group (provider) treats my medical condition.
2. I have informed my provider of my medical history including any known allergies, medications, past medical history, and social/family history
3. I have the right to be informed of any alternative options, side effects, and the risks and benefits.
4. I understand the mechanism of action of the medication.
5. I understand how it is to be administered.
6. I understand the prescription will come from a compounding pharmacy, which is not FDA approved. I have been told that the manufacturing facility itself is FDA monitored along with third party testing on the medication itself.
7. I understand the potential risks and benefits of the compounded medication and am aware of the alternative treatments.
8. I understand the risks of handling and self injecting the medication.
9. Prices may vary and change. My charge will include my time with the provider (in person and via communication outside of the office), supplies, and medication.
10. The provider may change the pharmacy based on several factors (availability, shipping time, cost). The provider will tell you as this happens.
11. It has been explained to me that this medication could be harmful if taken inappropriately or without advice from the provider
12. I understand the potential risks if I am a female and become pregnant while taking the medication.
13. I understand this medication may cause adverse side effects (see below). I understand this list is not complete and it describes the most common side effects, and that death is also a possibility of taking this medication. I understand symptoms may be worse after there has been a change in my medication dose or when first starting the medication.
Common side effects include, but are not limited to:
Gastrointestinal: Nausea/vomiting, abdominal pain, Diarrhea/constipation, dyspepsia, abdominal distension, eructation, flatulence, gastroenteritis, GERD, gastritis, lipase increase, amylase increase
Neurological: Headache, dizziness
Cardiac: Heart rate increase, Hypotension
Endocrine: Fatigue, hypoglycemia (diabetic patients), alopecia
Ophthalmic: Retinal disorder (diabetic patients)
Skin: redness or pain at injection site
Serious Reactions include, but are not limited to:
Thyroid C-cell tumor (animal studies)
Medullary thyroid cancer
Hypersensitivity reaction
Anaphylaxis
Angioedema
Acute kidney injury
Chronic rena failure exacerbation
Pancreatitis
Cholelithiasis
Cholecystitis
Syncope
B. I understand that I have the following responsibilities:
1. I agree to obtain prescriptions for compounded semaglutide only from Rume Medical Group.
a. If I am looking to transition to a non-compounding pharmacy or seek insurance coverage, I will tell Rume Medical Group in advance.
2. Medical history: I will tell Rume Medical Group’s provider my complete medical history, including: allergies, medications, medical/surgical/social/family history.
a. Rume Medical Group’s Provider, may ask to review, with your permission, your medical history (medications, recent lab results, pertinent imaging results, most recent yearly physical exam).
b. I understand that if I become pregnant or start trying to become pregnant, I must stop this medication.
c. I will be honest to the best of my ability the history he/she needs to know.
d. I will tell my provider any updated health information (medication, allergies, personal medical issues/surgeries/social history, or family history changes).
e. My provider can discuss my treatment plan with any co-treating pharmacist and/or healthcare provider
f. I will always tell other providers about all medications I am taking.
g. Rume Medical Group’s provider may ask for me to seek additional labs while on treatment to ensure its safety.
3. Directions for use: I will take my medications only as prescribed according to the directions, led by Rume Medical Group provider.
a. If I feel my medications are not effective, or are causing undesirable side effects, I will contact my provider for instructions.
b. I will not adjust my medications without prior instruction to do so.
c. I understand that the medication must be either kept frozen or refrigerated.
d. I understand this medication must be self-injected in the subcutaneous tissue once weekly. I will not inject any less than 7 days unless directed by Rume Medical Group provider (example: travel).
e. I will not share needles and dispose of needles safely.
f. If I’m having troubles with the administration of the medication, I will seek help from Rume Medical Group.
g. I am aware the medication expires and will refer and abide by the Beyond Usage Date (BUD).
4. Refills:
a. All refills will require an appointment.
b. I understand, I may need to schedule refill appointments ahead of time to avoid delays in refills.
c. Refills will get ordered by a Rume Medical Group provider.
d. I will not ask for early refills.
5. Safety:
a. I understand it is important to keep my medication away from children (<18 years old)
b. I am the only one who will use my medication. I will not give or sell my medication to anyone else.
6. If Rume Medical Group provider seems it appropriate to start weaning my medication or transition to maintenance dosing, I will comply.
a. Discontinuation of medication: I understand that Rume Medical Group may stop prescribing my medications if:
I am having unfavorable side effects or it’s not working to treat my medical condition
I have been untruthful in my medical or family history
I do not follow through with the recommended plan of care set by the Rume Medical Group provider.
I do not follow any parts of “Part B: responsibilities” in this agreement.
By my signature below, I agree that I am of legal age and authorized to provide written informed consent to prescribed compounded medication (semaglutide or any other medications) used for the treatment of medical weight loss. I release the provider of all liability resulting or arising from my receipt of this medication. I have read this form in its entirety. It has been explained to me. I have had the opportunity to ask questions and have all my questions answered. I agree to inform my provider of any medical conditions which may adversely affect my personal health or effectiveness of the medication. I fully understand why I am using the compounded medication, the potential risks and benefits of the compounded medication, the alternative treatment options, and all of the above information. I have received education regarding the potential side effects, when they may occur, when and where to seek treatment, and understand the possible side effects of the medication if I am a female and become pregnant while taking the medication. I agree to take the compounded medication as prescribed and will report any adverse event to my provider. I understand that a copy of my medical records will be stored in a confidential manner. I have no further questions. By signing this form, I voluntarily give my consent for treatment and agree to the risks.
Financial Consent
We are looking forward to providing you with high quality care for your visit. Thank you for trusting us with your care. Please review the following information.
Patient Financial Policy
I understand that if I do not pay as services are rendered, a service charge may be added each month, if there is an outstanding balance. Should this account become delinquent, I understand that I am responsible for any and all legal fees, court costs, and collection fees involved as a result of any collection activity.
I hereby authorize Rume Health/Rume Medical Group to treat and furnish information to insurance carriers concerning the diagnosis and treatment of the patient listed above. I understand that I am responsible for all charges, regardless of insurance coverage. I also understand that payment (co-pays, deductibles, etc) is due at time of service. I understand that charges are NOT final until the chart has been reviewed and the billing process is completed. In the event that the final balance on the account or invoice is a credit, the Practice has 30 days to notify the policyholder, guarantor or other responsible party by US Mail that a credit balance is on the account. In the event of no response to the notification, I authorize the credit to remain on my account and applied to any future services.
I authorize my insurance company to pay benefits directly to Rume Health/Rume Medical Group. I have read, understand, and agree to the Little Spurs Pediatric Urgent Care (The Practice) Patient Financial Policy. I understand that charges not covered by my insurance company, as well as applicable copayments and deductibles, are my responsibility. In the event of my default, or non-payment of my bill, I agree to pay all collection costs, reasonable attorney's fees and court costs that may be added to the account as collection costs, in addition to the amount due for services rendered.
Marketing/Communication Agreement
I authorize Rume Health/Rume Medical Group, to send e-mails to my e-mail address indicated above for business purposes such as surveys, announcements, events, articles, links, general medical information and marketing material. I understand that I can opt out of the e-mail program at any time by following the instructions to 'opt out'. X I hereby give my consent and authorization to The Practice, its' subsidiaries and its' practitioners to provide my medical treatment. If the patient is a minor, I, as custodian of the child, give my consent and authorization to The Practice, its' subsidiaries and its' practitioners to provide treatment for the minor patient.
Notice of Privacy Practices
I hereby authorize Rume Health/Rume Medical Group, and their healthcare providers to release all information necessary to my insurance company both when requested, or to facilitate the payment of my claim(s). I further agree that a photocopy of this agreement shall be as valid as the original. As the person bringing the patient in, (the parent, the guardian and/or the custodian of the patient, or a person as allowed by Law), I agree to be responsible for all services rendered to minor patients. I hold The Practice harmless for attempts to collect regardless of parental, guardian or custodial financial responsibility. I agree to be responsible for payment regardless of any divorce, separation or other outside agreements that may or may not be in effect at the time of service.
I have read The Practice Policies above regarding: Authorizations, Consents, Medical Records, Billing, Refunds, Guardian, Assignment of Benefits, Message, and email Marketing. I have read, understand and have been offered a copy of the posted Notice of Privacy Practices, the practice policies: 'Patient Financial Policy', 'Notice of Privacy Practices' and the 'Notice to Patients Regarding Credit Balance and Refunds' policies. I certify the information provided is true, correct and accurate.
Telehealth Consent
Rume refers to a network of medical professional organizations affiliated and their employed and contracted health care providers (the “Providers”).
Section II. Telehealth Definition.
Telehealth involves the delivery of health and wellness services using electronic communications, information technology, or other means between a licensed, certified, or registered healthcare professional at one location and a patient in another location about a clinical matter. Telehealth may be used for diagnosis, treatment, follow-up and/or patient education. These telehealth services may involve various modalities, including asynchronous interactions, real-time video and audio encounters and interactive audio with store and forward. This “Telehealth Informed Consent” informs the patient or guardian (“patient,” “you,” or “your”) concerning the treatment methods, risks, and limitations of utilizing telehealth to meet your health and wellness needs.
Section III. Benefits of Telehealth.
It can be easier and more efficient for you to access health and wellness services. You can obtain health and wellness services at times that are convenient for you without the necessity of an in-office appointment, including follow-up care related to your treatment. If you need follow-up care, please contact us through our website https://rumehealth.com/.
Section IV. Risks of Telehealth.
Information transmitted to your health professional may not be sufficient to allow for appropriate health or wellness services to meet your particular need. Some clinical needs may not be appropriate for a telehealth visit and your Provider will make that determination. The technology necessary to interact with your health professional may fail and delay your services. If a technical failure prevents you from communicating with your Providers, you should call the following phone number: (888) 223 - 7863. As all data exchanged is in a digital format, a data breach enables increased access to your health data. In rare events, a lack of access to complete medical records, and/or the quality of transmitted data could result in adverse drug interactions, allergic reactions, and/or other clinical judgment errors. You may stop or decline any on-going Health Care Services provided by Rume, Inc. using telehealth technologies at any time, although you acknowledge that applicable fees may apply if a medical consultation has occurred prior to request to cancel services and Rume, Inc. has no obligation for your on-going care or selection of separate health care services in such circumstances. LABORATORY PRODUCTS AND SERVICES: To facilitate certain Health Care Services provided to you, Providers may require that you complete diagnostic test(s). These diagnostic tests are provided by third-party laboratories, and neither Rume, nor your Provider(s) can guarantee the accuracy or reliability of these tests. These laboratory tests can provide false negative, false positive, or inconclusive results that could impact your Provider(s) ability to correctly diagnose or treat your medical conditions. A failure or defect of these tests could also impact your Provider(s) ability to correctly diagnose or treat your medical conditions.
Section V. Not for Emergencies.
I understand that I should never use Rume telehealth services in a medical or psychiatric emergency. I understand that in an emergency, I should dial 911 or go to the nearest emergency room.
Section VI. Patient Acknowledgement.
By accepting this Telehealth Informed Consent, you acknowledge you understand and consent to the following:
1. I have reviewed this Telehealth Informed Consent carefully, and understand there are risks, limitations, and benefits of utilizing telehealth.
2. I understand that the electronic nature of the telehealth services means that there is a greater risk to the privacy of my health information.
3. In some cases, my Provider may be a nurse practitioner or physician assistant and not a physician. I understand and agree that my Provider is licensed in the state that I reside in and that my provider may not be able to prescribe certain medications for me, and cannot assist me in an emergency situation. My licensed healthcare provider will utilize telemedicine only for the services that are appropriate for my medical condition, and like all medical care, no specific results can be guaranteed or assured.
4. Persons may be present during the telehealth visit other than my Provider in order to operate the telehealth technologies and/or for language translation assistance, if requested. If another person is present during the telehealth visit, I will be informed of the individual’s presence and his/her role.
5. I understand that information I provide as part of any telehealth offering is viewed as accurate, true, and complete. I understand that I may have opportunities to correct any incorrect information.
6. I understand that in certain instances, and in compliance with applicable law, my Rume Providers may determine that it is appropriate to provide my Health Care Services asynchronously via store-and-forward technology. In such instances, my Provider and I will communicate electronically through the Rume/Elation (Passport) Platform and not via telephone or video. I agree that if my provider makes that determination, I would like to receive Health Care Services in this manner.
7. I understand that there is no guarantee that I will be given a prescription and that the decision of whether a prescription is appropriate will be made in the professional judgment of my Provider. I understand that while the use of telehealth may provide benefits to me, no such benefits or specific results can be guaranteed and my condition may not improve.
8. I understand there is a risk of technical failures during the telehealth encounter beyond the control of Rume, Inc. and my Provider(s). I AGREE TO HOLD HARMLESS Rume, INC. AND ITS EMPLOYEES, CONTRACTORS, AGENTS, DIRECTORS, MEMBERS, MANAGERS, SHAREHOLDERS, OFFICERS, REPRESENTATIVES, ASSIGNS, PREDECESSORS, AND SUCCESSORS, INCLUDING NURX AND ITS EMPLOYEES, CONTRACTORS, AGENTS, DIRECTORS, MEMBERS, MANAGERS, SHAREHOLDERS, OFFICERS, REPRESENTATIVES, ASSIGNS, PARENTS, PREDECESSORS, AND SUCCESSORS FOR DELAYS IN EVALUATION OR FOR INFORMATION LOST DUE TO SUCH TECHNICAL FAILURES.
9. I understand that certain diagnostic testing services, including laboratory products and services offered through Rume, Inc. to support the Health Care Services of Providers, may contain defects, including ones which may limit functionality or produce erroneous results, any or all of which could limit or otherwise impact the quality, accuracy and/or effectiveness of the medical care or other services that I receive from my Provider(s). Upon being recommended for such diagnostic lab tests I am under no obligation to complete such tests, or to complete them with Rume and its affiliates, and I understand that I may have the tests done by another lab of my choosing.
10. I understand Rume, Inc. makes available a specific set of services and I may need to seek other resources for my other health needs. There is no guarantee that I will be treated by a Provider. My Provider reserves the right to deny care for any reason if, in the professional judgment of my Provider, the provision of the services, including when provided via telehealth is not medically or ethically appropriate. I understand that the Providers, and not Rume, Inc., are responsible for the quality and appropriateness of the care they render to me and make all decisions regarding clinical care in their independent discretion without the influence of Rume, Inc. I agree to only seek relief against the Provider for any liabilities pertaining to medical or clinical issues arising as a direct result of medical or clinical services accessed through Rume, Inc.
11. I understand that by using the Rume Platform I am not always speaking or messaging with my Provider in real-time, and there may be a delay before my messages or information is reviewed. I understand that I must check the Rume Platform for messages because this is the way that my Provider will communicate important information to me. I understand that if I do not check the Rume Platform regularly, then my services may be delayed.
12. I understand that I have the opportunity to discuss the use of telehealth, including the Health Care Services, with my Provider(s), including the benefits and risks of such use and the alternatives to the use of telehealth. I have the right to withdraw my consent to the use of telehealth in the course of my care, without prejudice to any future care or treatment and without risking the loss or withdrawal of any health benefits to which I am entitled, but I understand that the Providers who provide Health Care Services via the Rume Platform do not offer in-person treatment.
13. I understand that I have access to my medical record pertaining to the Health Care Services of Providers utilizing the Rume Platform in accordance with applicable laws and regulations and that my primary care provider, or another treating provider, may obtain copies of my health and wellness information with my consent.
14. I understand that while the Rume Platform may make available access to pharmacy or diagnostic lab services that are coordinated with the Health Care Services, I am able to request any pharmacy or lab of my preference.
15. I agree that Rume is a third-party beneficiary of the Telehealth Patient Consent and has the right to enforce it against you.
16. In giving the consent hereunder, I, as patient, am relying on the judgment of the clinical professional evaluating me and administering the treatments. I have had the meaningful chance to ask questions and have received satisfactory answers to my questions. The risks and potential benefits of the treatment I am consenting to have been explained to me. Alternatives to the treatments I am consenting to have also been discussed with me.