Consents_and_Communications.pdf - Your Wellness MD

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Consents and Communication Name___________________________________________Date__________________________ Pharmacy Please list your pharmacy, and it’s cross streets: Communication Persons authorized to be included in issues regarding your health: Name_________________________________Relationship_______________Phone__________ Name_________________________________Relationship_______________Phone__________ Telehealth Telehealth involves the delivery of healthcare services using electronic communications such as phone, texting, email, and video. Telehealth may be used for diagnosis, treatment, follow-up and/or patient and education. The electronic systems used in our Service will incorporate network and software security protocols to protect the privacy and security of health information, and will include measures to safeguard the data to ensure its integrity. I understand that I am advised to use the confidential systems established by Your Wellness MD, but that if I initiate communication with my health care provider through another means I will accept a response with that means of communication. Signature______________________________________________________________________ Privacy Practices I have read the Notice of Privacy Practices provided to me on the website of Your Wellness MD, and I understand that my medical information is subject to all applicable laws regarding the confidentiality of healthcare information. Signature______________________________________________________________________ Membership Agreement I have read and understood the Membership Agreement/Direct Primary Care Patient Agreement provided to me on the website of Your Wellness MD, have had my questions answered, and agree to its terms. Signature______________________________________________________________________