Informed Consent
BY CLICKING “I AGREE,” CHECKING A RELATED BOX TO SIGNIFY YOUR ACCEPTANCE, USING ANY OTHER ACCEPTANCE PROTOCOL PRESENTED THROUGH THE SERVICE OR OTHERWISE AFFIRMATIVELY ACCEPTING THIS CONSENT, YOU ACKNOWLEDGE THAT YOU HAVE READ, ACCEPTED, AND AGREED TO BE BOUND BY THIS CONSENT. IF YOU DO NOT AGREE TO THIS CONSENT, DO NOT CREATE AN ACCOUNT OR USE THE SERVICE. YOU HEREBY GRANT AGENCY AUTHORITY TO ANY PARTY WHO CLICKS ON THE “I AGREE” BUTTON OR OTHERWISE INDICATES ACCEPTANCE TO THIS CONSENT ON YOUR BEHALF.
IF YOU ARE EXPERIENCING A MEDICAL EMERGENCY OR A LIFE-THREATENING SITUATION CALL 911. PURPOSE The purpose of this consent form (“Consent”) is to provide you with information about telehealth and to obtain your informed consent to the use of telehealth in the delivery of healthcare to you by physicians, physician assistants, or nurse practitioners (“Providers”) using the online platforms owned and operated by Mat Funk, LLC, and/or its subsidiaries (the “Service”). Mat Funk provides certain administrative and management services to various healthcare providers and professional entities and itself does not provide professional medical services.
In this Consent, the terms “you” and “yours” refer to the person using the Service, or in the case of a use of the Service by or on behalf of an individual minor between the ages of thirteen (13) and eighteen (18) or higher age of majority under applicable state law, “you” and “yours” refer to and include (i) the parent or legal guardian who provides consent to the use of the Service by such minor or uses the Service on behalf of such minor, and (ii) the minor for whom consent is being provided or on whose behalf the Service is being utilized.
LIMITED NATURE OF RELATIONSHIP The Provider’s medical relationship with you is explicitly limited to the specified services and is not intended to replace the services of a primary care physician or emergency medical or mental health care. You should expect no services from the Providers outside of the limited scope of the Services. Providers reserve the right to deny care for potential misuse of Services.
YOU UNDERSTAND THAT THE PROVIDERS ARE NOT YOUR GENERAL OR SPECIALIZED PHYSICIANS/HEALTH CARE PROVIDER(S), AND ARE ENGAGED FOR A LIMITED PURPOSE, AND YOU UNDERSTAND THAT YOU SHOULD FOLLOW-UP WITH YOUR PRIMARY CARE PHYSICIAN REGARDING ANY ISSUES THAT MAY ARISE DURING OR IN RELATION TO THE SERVICES.
TO THE EXTENT ALLOWABLE BY LAW, THE SERVICES ARE NOT INTENDED TO CREATE, NOR DO THEY CREATE, ANY PROVIDER-PATIENT RELATIONSHIP WITH THE PROVIDERS, EXCEPT WITH THE PROVIDERS FOR THE LIMITED PURPOSES OF PROVIDING THE SERVICES. YOU EXPRESSLY AGREE THAT THIS IS A LIMITED ENGAGEMENT. YOU EXPRESSLY AGREE THAT THE PROVIDERS DO NOT HAVE AN OBLIGATION TO TREAT YOU OR OTHERWISE COUNSEL YOU REGARDING ANY SECONDARY CONDITIONS THAT MAY BE DISCOVERED OR EVALUATED OR DISCUSSED DURING THE SERVICES.
YOU UNDERSTAND THAT THE PROVIDERS DO NOT GUARANTEE THE ACCURACY, COMPLETENESS, USEFULNESS, OR ADEQUACY OF THE SERVICES FOR ANY TREATMENT, DIAGNOSIS, OR OTHER PURPOSES.
YOU WILL INFORM THE PROVIDERS OF ANY CONDITION(S) THAT WOULD LIMIT YOUR ABILITY TO RECEIVE THE SERVICES OR THAT WOULD BE RELEVANT TO THE SERVICES THEMSELVES.
PREGNANCY YOU UNDERSTAND THAT IF YOU ARE PLANNING TO BECOME PREGNANT, ARE CURRENTLY PREGNANT, BECOME PREGNANT, OR ARE BREASTFEEDING, THAT YOU MUST: (A) ADVISE THE PROVIDERS OF THIS; AND (B) ASK YOU OB/GYN OR PEDIATRICIAN IF THE TREATMENTS RECOMMENDED BY THE PROVIDERS ARE ACCEPTABLE DURING THIS PERIOD OF TIME.
USE OF TELEHEALTH Telehealth involves the delivery of healthcare using electronic communications, information technology, or other means between a healthcare provider and a patient who are not in the same physical location. Telehealth may be used for diagnosis, treatment, follow-up, and/or patient education, and may include, but is not limited to, one or more of the following: electronic transmission of medical records, photo images, personal health information or other data between a patient and a provider; interactions between a patient and provider via audio, video and/or data communications (such as messaging or email communications); use of output data from medical devices, sound and video files. Alternative methods of care may be available to you, such as in-person services, and you may choose an alternative at any time. Always discuss alternative options with your Provider. You have the option to withdraw your consent to receive the Services via Telehealth at any time, but doing so will cause the Providers to discontinue care.
ANTICIPATED BENEFITS The use of telehealth may have the following possible benefits: making it easier and more efficient for you to access medical care or other services and treatment for the conditions treated by your Provider(s); allowing you to obtain medical care or other services and treatment by Provider(s) at times that are convenient for you; and enabling you to interact with Provider(s) without the necessity of an in-office appointment.
POTENTIAL RISKS While the use of telehealth in the delivery of care can provide potential benefits for you, there are also potential risks associated with the use of telehealth and other technology. These risks include, but may not be limited to the following: • Because of your specific medical condition, or due to technical problems, a face-to-face consultation still may be necessary after the telemedicine appointment, and the telehealth care Provider may not be able to accurately diagnose or treat my condition due to limitations inherent in using a non-face-to-face encounter; • the quality, accuracy or effectiveness of the services you receive from your Provider could be limited; • technology, including the Service, may contain bugs or other errors, including ones which may limit functionality, produce erroneous results, render part or all of such technology, including the Service, unavailable or inoperable, produce incorrect records, transmissions, data or content, or cause records, transmissions, data or content to be corrupted or lost; • failures of technology may also impact your Provider(s) ability to correctly diagnose or treat your condition; • the inability of your Provider(s) to conduct certain tests or assess vital signs in-person may in some cases prevent the Provider(s) from providing a diagnosis or treatment or from identifying the need for emergency medical care or treatment for you; • your Provider(s) may not able to provide treatment for your particular condition and you may be required to seek alternative healthcare or emergency care services; • delays in medical evaluation/treatment could occur due to unavailability of your Provider(s) or deficiencies or failures of the technology or electronic equipment used; • the electronic systems or other security protocols or safeguards used could fail, causing a breach of privacy of your medical or other information; • data stored and communicated electronically, for example, through email communications, may be more susceptible to unintended disclosure of protected health information to third parties; • given regulatory requirements in certain jurisdictions, your Provider(s) diagnosis and/or treatment options, especially pertaining to certain prescriptions, may be limited; • a lack of access to all of your medical records may result in adverse drug interactions or allergic reactions or other judgment errors.
All health care treatments can have potential adverse side effects and you accept responsibility for these potential adverse outcomes. If you experience adverse side effects, or your condition worsens, it is your responsibility to report any adverse side-effects to the Providers, your local doctor, and to go to the nearest emergency room if you have any reason to suspect I have a medical emergency.
LIFE THREATENING AND OTHER EMERGENCY SITUATIONS; FOLLOW-UP CARE If you are experiencing a life-threatening situation such or medical emergency call 911.
In some situations, telehealth is not an appropriate method of care. If you require immediate or urgent care, you must seek care at an emergency room facility or other provider equipped to deliver urgent or emergent care. Providers may not respond promptly to communications you submit through the Service. If you are not experiencing an emergency or do not require immediate or urgent care, you can communicate with Providers through the secure message service in the Service. If a technical failure prevents you from communicating with your Providers through the Service, you should call the following number: +1 (443) 679-3054 (M-F 9AM – 5PM EST).
DATA PRIVACY AND PROTECTION The electronic systems used in the Service will incorporate network and software security protocols to protect the privacy and security of your information and will include measures to safeguard data against intentional or unintentional corruption. Personal information that identifies you or contains protected health information will not be disclosed to any third party without your consent, except as authorized by law for the purposes of consultation, treatment, payment/billing, certain administrative purposes, or as otherwise set forth in your Provider’s Notice of Privacy Practices. Use of the Service may include email communications to and from you that may include your protected health information. You understand that Mat Funk and its subsidiaries/affiliates (collectively, “Mat Funk”) does not and cannot guarantee the security or privacy of the services you use to receive communications, including for example your email service provider.
PRESCRIPTIONS. Many participants choose to utilize medication to help them achieve their health goals. If a Provider chooses to prescribe medication (not guaranteed), you are directly responsible for related costs (including copayments, and deductibles) for any prescriptions that are not explicitly included as part of the Service. • Prescription medications have risks. It is your responsibility to read the risks, side-effect profile, and adverse drug interaction information provided with medication and to consult with your Provider, local doctor, and/or pharmacist to determine if the risks are acceptable. • If you experience adverse side effects from prescriptions, you should immediately report them to the Providers, and/or a local doctor. If you suspect you have a medical emergency, you will immediately seek urgent/emergency care.
LABORATORY PRODUCTS AND SERVICES Certain healthcare services provided to you by Providers via the Service may require that you complete an at-home diagnostic test. These diagnostic tests are provided by third-party laboratories, and neither Mat Funk 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.
OPEN PAYMENTS NOTICE For informational purposes only, a link to the federal Centers for Medicare and Medicaid Services Open Payments web page is provided here. The federal Physician Payments Sunshine Act requires that detailed information about payment and other payments of value worth over ten dollars ($10) from manufacturers of drugs, medical device, and biologics to physicians and teaching hospitals be made available to the public. 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.
ACKNOWLEDGMENTS By clicking “I Agree”, checking a related box to signify your acceptance, using any other acceptance protocol presented through the Service or otherwise affirmatively accepting this consent, you are agreeing and providing your consent with respect to the following: • Healthcare services provided to you by Providers via the Service will be provided by telehealth. In some cases, your treating Provider may be a nurse practitioner or physician assistant and not a physician, and you agree to be treated by non-physician providers, if applicable, by using the Service. • Certain technology, including the Service, may be used while still in a beta testing and development phase, and before such technology is a final and finished product. Technology used to deliver care, including the Service, may contain bugs or other errors, including ones which may limit functionality, produce erroneous results, render part or all of such technology unavailable or inoperable, produce incorrect records, transmissions, data or content, or cause records, transmissions, data or content to be corrupted or lost, any or all of which could limit or otherwise impact the quality, accuracy and/or effectiveness of the medical care or other services that you receive from your Provider(s). • Certain diagnostic testing services, including laboratory products and services offered through the Service, 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 you receive from your Provider(s). • The delivery of healthcare services via telehealth is an evolving field and the use of telehealth or other technology in your medical care and treatment from Provider(s) may include uses of technology different from those described in this Consent or not specifically described in this Consent. • No potential benefits from the use of telehealth or other technology or specific results can be guaranteed, including any laboratory testing results or related diagnosis or treatment by your Provider(s). • Your condition may not be cured or improved, and in some cases, may get worse. • There are limitations in the provision of medical care or other services and treatment via telehealth and technology, including the Service, and you may not be able to receive diagnosis and/or treatment through telehealth for every condition for which you seek diagnosis and/or treatment. • There are potential risks to the use of telehealth and other technology, including but not limited to the risks described in this Consent. • You have the opportunity to discuss the use of telehealth, including the Service, with your Provider(s), including the benefits and risks of such use and the alternatives to the use of telehealth. • You understand that there will be no recording of any online treatment sessions by your Provider(s) or you. • Your Provider(s) will assess your medical condition and, in their sole discretion, may determine it is medically appropriate to diagnose and/or treat your condition via telehealth and whether you maintain sufficient knowledge and skills in the use of technology appropriate to diagnosing and/or treating your condition via telehealth. • By continuing to use the Service, you concur with your Provider’s medical assessment and agree to receive a diagnosis and/or treatment via telehealth technology. • You have the right to withdraw your consent to the use of telehealth in the course of your care, without prejudice to any future care or treatment and without risking the loss or withdrawal of any health benefits to which your entitled, but you understand that the Providers who utilize the Service do not offer in-person treatment. Any withdrawal of your consent will be effective upon receipt of written notice to your Providers, except that such withdrawal will not have any effect on any action taken by Mat Funk or your Provider(s) in reliance on this Consent before it received your written notice of withdrawal. Any withdrawal of your consent will not affect any other provision of this Consent, and you will continue to be bound by this Consent. • You understand that the use of the Service involves electronic communication to and from you of your personal medical information in connection with the provision of telehealth services, including through email and text messages. We are advising you in this Consent that these are unsecure mediums for transmitting information and that there is some risk to using these mediums. Information transmitted these ways is more likely to be intercepted by unauthorized third parties than more secure transmission channels. If you want to communicate with us in these mediums, you are accepting the risks we have notified you of, and you agree that we are not responsible for unauthorized access of such medical information while it is in transmission to you based on your request, or when the information is delivered to you. • You understand that it is your duty to provide Mat Funk and your Provider(s) truthful, accurate, and complete information, including all relevant information regarding care that you may have received or may be receiving from healthcare providers including emergency contact information for your local healthcare providers. • You understand that if you are not clinically appropriate for treatment you may be directed to a more appropriate treatment venue at any time. • While receiving Services, you agree to provide your Provider with timely, complete updates, particularly with respect to changes in medical or mental health. • You agree to the entry of your medical records into the Provider’s computer database and understand that all reasonable measures have been taken to safeguard your medical information. • You understand that each of your Provider(s) will assess your medical condition and, in their sole discretion, may determine it is medically appropriate to diagnose and/or treat your condition using telehealth technology, including the Service. By continuing to use the Service, you concur with your Provider’s medical assessment and agree to receive a diagnosis and/or treatment via telehealth technology. You understand that each of your Provider(s) may determine in their sole discretion that your condition is not suitable for diagnosis and/or treatment using telehealth technology, including the Service, and that you may need to seek care and treatment from a specialist or other healthcare provider, outside of such telehealth technology. • Mat Funk has a commercial relationship with the following “Pharmacies”: CURRENTLY N/A. Mat Funk has a commercial relationship with the following “Laboratories”: CURRENTLY N/A. • Mat Funk has a commercial relationship with the entity that employs or contracts with your Provider. • Mat Funk has a commercial relationship with its “Affiliates,” and gyms and influencers that promote its services. • You are free to obtain your medical examination from another healthcare provider that is not associated with Mat Funk. Mat Funk may offer for you to use its Pharmacy partners to fulfill your order directly to your door. You are free to obtain your prescription from any pharmacy of your choice by contacting our support team. Prescriptions may be filled by and transferred between any Pharmacy partners on your behalf. • You must pay the full amount of the costs associated with use of the Service, including any prescription you may receive, and you will not attempt to submit a claim to Medicare, any other federal payor, or any state or private insurer.
If you have a concern about a medical professional, you may contact the Medical Board in your state regarding your concerns. For applicable contact information see the list available here.
Location of Services You have provided information regarding my residence to Providers, and Providers have, to the extent required by licensure laws, matched me with a Provider for providing services who is licensed where I am physically located. In any event, if my physical location changes I will immediately notify Provider. By seeking to receive the Services, you are: (i) virtually travelling to the state where the Provider is licensed, and for convenience and other purposes availing yourself to the Services in said State in the same manner as if you were physically present in the same State to receive the Services in person; (ii) irrevocably agreeing that the Services and this Informed Consent are provided, and entered into, in the State where the Professional is licensed, and not in the state, territory or country where you are physically located. Further, you agree that you will not bring any action or complaints in the State where you are physically located, it being acknowledged that sole jurisdiction and venue are within the State of Texas and are governed by the Terms and Conditions, and that I have no rights vis-à-vis Mat Funk or the Providers in my state, territory, or country (provided that such State is not Texas). To the extent that the state where I am physically located attempts to assert jurisdiction over Mat Funk or the Providers, whether through its courts, state professional licensing board(s) or otherwise, I agree to cooperate with Mat Funk and the Providers, and otherwise use my best efforts, with respect to asserting the matters agreed to in this Section.
Special Notice to California Clients. Physicians and midwifes and other practitioners are licensed and regulated by the Medical Board of California. To confirm a license or file a complaint, go to www.mbc.ca.gov or call (800) 633-2322.
Consent. This consent and acknowledgment (“Consent”) is governed in all respects, including as substantive effect and enforceability, by the internal laws of the State of Texas. If any provision of this Consent is held to be unenforceable, the remainder of the Consent will remain in full force. You are digitally receiving a copy of this Consent (you have the ability to print, PDF, copy/paste, or screenshot a copy of this Consent).
THIS FORM MUST BE PLACED IN THE MEDICAL RECORD. A COPY OF THIS DOCUMENT CAN BE ACCESSED BY EMAILING [email protected] OR BY GOING TO WWW.MATFUNK.COM/INFORMEDCONSENT.
IF YOU ARE EXPERIENCING A MEDICAL EMERGENCY OR A LIFE-THREATENING SITUATION CALL 911. PURPOSE The purpose of this consent form (“Consent”) is to provide you with information about telehealth and to obtain your informed consent to the use of telehealth in the delivery of healthcare to you by physicians, physician assistants, or nurse practitioners (“Providers”) using the online platforms owned and operated by Mat Funk, LLC, and/or its subsidiaries (the “Service”). Mat Funk provides certain administrative and management services to various healthcare providers and professional entities and itself does not provide professional medical services.
In this Consent, the terms “you” and “yours” refer to the person using the Service, or in the case of a use of the Service by or on behalf of an individual minor between the ages of thirteen (13) and eighteen (18) or higher age of majority under applicable state law, “you” and “yours” refer to and include (i) the parent or legal guardian who provides consent to the use of the Service by such minor or uses the Service on behalf of such minor, and (ii) the minor for whom consent is being provided or on whose behalf the Service is being utilized.
LIMITED NATURE OF RELATIONSHIP The Provider’s medical relationship with you is explicitly limited to the specified services and is not intended to replace the services of a primary care physician or emergency medical or mental health care. You should expect no services from the Providers outside of the limited scope of the Services. Providers reserve the right to deny care for potential misuse of Services.
YOU UNDERSTAND THAT THE PROVIDERS ARE NOT YOUR GENERAL OR SPECIALIZED PHYSICIANS/HEALTH CARE PROVIDER(S), AND ARE ENGAGED FOR A LIMITED PURPOSE, AND YOU UNDERSTAND THAT YOU SHOULD FOLLOW-UP WITH YOUR PRIMARY CARE PHYSICIAN REGARDING ANY ISSUES THAT MAY ARISE DURING OR IN RELATION TO THE SERVICES.
TO THE EXTENT ALLOWABLE BY LAW, THE SERVICES ARE NOT INTENDED TO CREATE, NOR DO THEY CREATE, ANY PROVIDER-PATIENT RELATIONSHIP WITH THE PROVIDERS, EXCEPT WITH THE PROVIDERS FOR THE LIMITED PURPOSES OF PROVIDING THE SERVICES. YOU EXPRESSLY AGREE THAT THIS IS A LIMITED ENGAGEMENT. YOU EXPRESSLY AGREE THAT THE PROVIDERS DO NOT HAVE AN OBLIGATION TO TREAT YOU OR OTHERWISE COUNSEL YOU REGARDING ANY SECONDARY CONDITIONS THAT MAY BE DISCOVERED OR EVALUATED OR DISCUSSED DURING THE SERVICES.
YOU UNDERSTAND THAT THE PROVIDERS DO NOT GUARANTEE THE ACCURACY, COMPLETENESS, USEFULNESS, OR ADEQUACY OF THE SERVICES FOR ANY TREATMENT, DIAGNOSIS, OR OTHER PURPOSES.
YOU WILL INFORM THE PROVIDERS OF ANY CONDITION(S) THAT WOULD LIMIT YOUR ABILITY TO RECEIVE THE SERVICES OR THAT WOULD BE RELEVANT TO THE SERVICES THEMSELVES.
PREGNANCY YOU UNDERSTAND THAT IF YOU ARE PLANNING TO BECOME PREGNANT, ARE CURRENTLY PREGNANT, BECOME PREGNANT, OR ARE BREASTFEEDING, THAT YOU MUST: (A) ADVISE THE PROVIDERS OF THIS; AND (B) ASK YOU OB/GYN OR PEDIATRICIAN IF THE TREATMENTS RECOMMENDED BY THE PROVIDERS ARE ACCEPTABLE DURING THIS PERIOD OF TIME.
USE OF TELEHEALTH Telehealth involves the delivery of healthcare using electronic communications, information technology, or other means between a healthcare provider and a patient who are not in the same physical location. Telehealth may be used for diagnosis, treatment, follow-up, and/or patient education, and may include, but is not limited to, one or more of the following: electronic transmission of medical records, photo images, personal health information or other data between a patient and a provider; interactions between a patient and provider via audio, video and/or data communications (such as messaging or email communications); use of output data from medical devices, sound and video files. Alternative methods of care may be available to you, such as in-person services, and you may choose an alternative at any time. Always discuss alternative options with your Provider. You have the option to withdraw your consent to receive the Services via Telehealth at any time, but doing so will cause the Providers to discontinue care.
ANTICIPATED BENEFITS The use of telehealth may have the following possible benefits: making it easier and more efficient for you to access medical care or other services and treatment for the conditions treated by your Provider(s); allowing you to obtain medical care or other services and treatment by Provider(s) at times that are convenient for you; and enabling you to interact with Provider(s) without the necessity of an in-office appointment.
POTENTIAL RISKS While the use of telehealth in the delivery of care can provide potential benefits for you, there are also potential risks associated with the use of telehealth and other technology. These risks include, but may not be limited to the following: • Because of your specific medical condition, or due to technical problems, a face-to-face consultation still may be necessary after the telemedicine appointment, and the telehealth care Provider may not be able to accurately diagnose or treat my condition due to limitations inherent in using a non-face-to-face encounter; • the quality, accuracy or effectiveness of the services you receive from your Provider could be limited; • technology, including the Service, may contain bugs or other errors, including ones which may limit functionality, produce erroneous results, render part or all of such technology, including the Service, unavailable or inoperable, produce incorrect records, transmissions, data or content, or cause records, transmissions, data or content to be corrupted or lost; • failures of technology may also impact your Provider(s) ability to correctly diagnose or treat your condition; • the inability of your Provider(s) to conduct certain tests or assess vital signs in-person may in some cases prevent the Provider(s) from providing a diagnosis or treatment or from identifying the need for emergency medical care or treatment for you; • your Provider(s) may not able to provide treatment for your particular condition and you may be required to seek alternative healthcare or emergency care services; • delays in medical evaluation/treatment could occur due to unavailability of your Provider(s) or deficiencies or failures of the technology or electronic equipment used; • the electronic systems or other security protocols or safeguards used could fail, causing a breach of privacy of your medical or other information; • data stored and communicated electronically, for example, through email communications, may be more susceptible to unintended disclosure of protected health information to third parties; • given regulatory requirements in certain jurisdictions, your Provider(s) diagnosis and/or treatment options, especially pertaining to certain prescriptions, may be limited; • a lack of access to all of your medical records may result in adverse drug interactions or allergic reactions or other judgment errors.
All health care treatments can have potential adverse side effects and you accept responsibility for these potential adverse outcomes. If you experience adverse side effects, or your condition worsens, it is your responsibility to report any adverse side-effects to the Providers, your local doctor, and to go to the nearest emergency room if you have any reason to suspect I have a medical emergency.
LIFE THREATENING AND OTHER EMERGENCY SITUATIONS; FOLLOW-UP CARE If you are experiencing a life-threatening situation such or medical emergency call 911.
In some situations, telehealth is not an appropriate method of care. If you require immediate or urgent care, you must seek care at an emergency room facility or other provider equipped to deliver urgent or emergent care. Providers may not respond promptly to communications you submit through the Service. If you are not experiencing an emergency or do not require immediate or urgent care, you can communicate with Providers through the secure message service in the Service. If a technical failure prevents you from communicating with your Providers through the Service, you should call the following number: +1 (443) 679-3054 (M-F 9AM – 5PM EST).
DATA PRIVACY AND PROTECTION The electronic systems used in the Service will incorporate network and software security protocols to protect the privacy and security of your information and will include measures to safeguard data against intentional or unintentional corruption. Personal information that identifies you or contains protected health information will not be disclosed to any third party without your consent, except as authorized by law for the purposes of consultation, treatment, payment/billing, certain administrative purposes, or as otherwise set forth in your Provider’s Notice of Privacy Practices. Use of the Service may include email communications to and from you that may include your protected health information. You understand that Mat Funk and its subsidiaries/affiliates (collectively, “Mat Funk”) does not and cannot guarantee the security or privacy of the services you use to receive communications, including for example your email service provider.
PRESCRIPTIONS. Many participants choose to utilize medication to help them achieve their health goals. If a Provider chooses to prescribe medication (not guaranteed), you are directly responsible for related costs (including copayments, and deductibles) for any prescriptions that are not explicitly included as part of the Service. • Prescription medications have risks. It is your responsibility to read the risks, side-effect profile, and adverse drug interaction information provided with medication and to consult with your Provider, local doctor, and/or pharmacist to determine if the risks are acceptable. • If you experience adverse side effects from prescriptions, you should immediately report them to the Providers, and/or a local doctor. If you suspect you have a medical emergency, you will immediately seek urgent/emergency care.
LABORATORY PRODUCTS AND SERVICES Certain healthcare services provided to you by Providers via the Service may require that you complete an at-home diagnostic test. These diagnostic tests are provided by third-party laboratories, and neither Mat Funk 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.
OPEN PAYMENTS NOTICE For informational purposes only, a link to the federal Centers for Medicare and Medicaid Services Open Payments web page is provided here. The federal Physician Payments Sunshine Act requires that detailed information about payment and other payments of value worth over ten dollars ($10) from manufacturers of drugs, medical device, and biologics to physicians and teaching hospitals be made available to the public. 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.
ACKNOWLEDGMENTS By clicking “I Agree”, checking a related box to signify your acceptance, using any other acceptance protocol presented through the Service or otherwise affirmatively accepting this consent, you are agreeing and providing your consent with respect to the following: • Healthcare services provided to you by Providers via the Service will be provided by telehealth. In some cases, your treating Provider may be a nurse practitioner or physician assistant and not a physician, and you agree to be treated by non-physician providers, if applicable, by using the Service. • Certain technology, including the Service, may be used while still in a beta testing and development phase, and before such technology is a final and finished product. Technology used to deliver care, including the Service, may contain bugs or other errors, including ones which may limit functionality, produce erroneous results, render part or all of such technology unavailable or inoperable, produce incorrect records, transmissions, data or content, or cause records, transmissions, data or content to be corrupted or lost, any or all of which could limit or otherwise impact the quality, accuracy and/or effectiveness of the medical care or other services that you receive from your Provider(s). • Certain diagnostic testing services, including laboratory products and services offered through the Service, 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 you receive from your Provider(s). • The delivery of healthcare services via telehealth is an evolving field and the use of telehealth or other technology in your medical care and treatment from Provider(s) may include uses of technology different from those described in this Consent or not specifically described in this Consent. • No potential benefits from the use of telehealth or other technology or specific results can be guaranteed, including any laboratory testing results or related diagnosis or treatment by your Provider(s). • Your condition may not be cured or improved, and in some cases, may get worse. • There are limitations in the provision of medical care or other services and treatment via telehealth and technology, including the Service, and you may not be able to receive diagnosis and/or treatment through telehealth for every condition for which you seek diagnosis and/or treatment. • There are potential risks to the use of telehealth and other technology, including but not limited to the risks described in this Consent. • You have the opportunity to discuss the use of telehealth, including the Service, with your Provider(s), including the benefits and risks of such use and the alternatives to the use of telehealth. • You understand that there will be no recording of any online treatment sessions by your Provider(s) or you. • Your Provider(s) will assess your medical condition and, in their sole discretion, may determine it is medically appropriate to diagnose and/or treat your condition via telehealth and whether you maintain sufficient knowledge and skills in the use of technology appropriate to diagnosing and/or treating your condition via telehealth. • By continuing to use the Service, you concur with your Provider’s medical assessment and agree to receive a diagnosis and/or treatment via telehealth technology. • You have the right to withdraw your consent to the use of telehealth in the course of your care, without prejudice to any future care or treatment and without risking the loss or withdrawal of any health benefits to which your entitled, but you understand that the Providers who utilize the Service do not offer in-person treatment. Any withdrawal of your consent will be effective upon receipt of written notice to your Providers, except that such withdrawal will not have any effect on any action taken by Mat Funk or your Provider(s) in reliance on this Consent before it received your written notice of withdrawal. Any withdrawal of your consent will not affect any other provision of this Consent, and you will continue to be bound by this Consent. • You understand that the use of the Service involves electronic communication to and from you of your personal medical information in connection with the provision of telehealth services, including through email and text messages. We are advising you in this Consent that these are unsecure mediums for transmitting information and that there is some risk to using these mediums. Information transmitted these ways is more likely to be intercepted by unauthorized third parties than more secure transmission channels. If you want to communicate with us in these mediums, you are accepting the risks we have notified you of, and you agree that we are not responsible for unauthorized access of such medical information while it is in transmission to you based on your request, or when the information is delivered to you. • You understand that it is your duty to provide Mat Funk and your Provider(s) truthful, accurate, and complete information, including all relevant information regarding care that you may have received or may be receiving from healthcare providers including emergency contact information for your local healthcare providers. • You understand that if you are not clinically appropriate for treatment you may be directed to a more appropriate treatment venue at any time. • While receiving Services, you agree to provide your Provider with timely, complete updates, particularly with respect to changes in medical or mental health. • You agree to the entry of your medical records into the Provider’s computer database and understand that all reasonable measures have been taken to safeguard your medical information. • You understand that each of your Provider(s) will assess your medical condition and, in their sole discretion, may determine it is medically appropriate to diagnose and/or treat your condition using telehealth technology, including the Service. By continuing to use the Service, you concur with your Provider’s medical assessment and agree to receive a diagnosis and/or treatment via telehealth technology. You understand that each of your Provider(s) may determine in their sole discretion that your condition is not suitable for diagnosis and/or treatment using telehealth technology, including the Service, and that you may need to seek care and treatment from a specialist or other healthcare provider, outside of such telehealth technology. • Mat Funk has a commercial relationship with the following “Pharmacies”: CURRENTLY N/A. Mat Funk has a commercial relationship with the following “Laboratories”: CURRENTLY N/A. • Mat Funk has a commercial relationship with the entity that employs or contracts with your Provider. • Mat Funk has a commercial relationship with its “Affiliates,” and gyms and influencers that promote its services. • You are free to obtain your medical examination from another healthcare provider that is not associated with Mat Funk. Mat Funk may offer for you to use its Pharmacy partners to fulfill your order directly to your door. You are free to obtain your prescription from any pharmacy of your choice by contacting our support team. Prescriptions may be filled by and transferred between any Pharmacy partners on your behalf. • You must pay the full amount of the costs associated with use of the Service, including any prescription you may receive, and you will not attempt to submit a claim to Medicare, any other federal payor, or any state or private insurer.
If you have a concern about a medical professional, you may contact the Medical Board in your state regarding your concerns. For applicable contact information see the list available here.
Location of Services You have provided information regarding my residence to Providers, and Providers have, to the extent required by licensure laws, matched me with a Provider for providing services who is licensed where I am physically located. In any event, if my physical location changes I will immediately notify Provider. By seeking to receive the Services, you are: (i) virtually travelling to the state where the Provider is licensed, and for convenience and other purposes availing yourself to the Services in said State in the same manner as if you were physically present in the same State to receive the Services in person; (ii) irrevocably agreeing that the Services and this Informed Consent are provided, and entered into, in the State where the Professional is licensed, and not in the state, territory or country where you are physically located. Further, you agree that you will not bring any action or complaints in the State where you are physically located, it being acknowledged that sole jurisdiction and venue are within the State of Texas and are governed by the Terms and Conditions, and that I have no rights vis-à-vis Mat Funk or the Providers in my state, territory, or country (provided that such State is not Texas). To the extent that the state where I am physically located attempts to assert jurisdiction over Mat Funk or the Providers, whether through its courts, state professional licensing board(s) or otherwise, I agree to cooperate with Mat Funk and the Providers, and otherwise use my best efforts, with respect to asserting the matters agreed to in this Section.
Special Notice to California Clients. Physicians and midwifes and other practitioners are licensed and regulated by the Medical Board of California. To confirm a license or file a complaint, go to www.mbc.ca.gov or call (800) 633-2322.
Consent. This consent and acknowledgment (“Consent”) is governed in all respects, including as substantive effect and enforceability, by the internal laws of the State of Texas. If any provision of this Consent is held to be unenforceable, the remainder of the Consent will remain in full force. You are digitally receiving a copy of this Consent (you have the ability to print, PDF, copy/paste, or screenshot a copy of this Consent).
THIS FORM MUST BE PLACED IN THE MEDICAL RECORD. A COPY OF THIS DOCUMENT CAN BE ACCESSED BY EMAILING [email protected] OR BY GOING TO WWW.MATFUNK.COM/INFORMEDCONSENT.
