Informed Consent to Telehealth Services and Hormone Optimization Therapy | Solvion Health

Informed Consent to Telehealth Services and Hormone Optimization Therapy

This document explains how Solvion Health and its affiliated medical practices deliver care using telehealth, and it describes the potential risks and benefits of hormone optimization therapy. Please read it carefully and ask any questions before you sign. By signing (within the secure patient portal), you confirm that you understand and voluntarily consent to the services described.

1. Purpose of this document

The purpose of this Informed Consent is to:

Explain how telehealth visits work and how they differ from in person care.
Explain the nature, potential benefits, risks, and alternatives of hormone optimization therapy.
Document your voluntary consent to receive telehealth and hormone optimization services from independent licensed health care professionals who provide care through Solvion Health’s platform.

This consent form supplements, and does not replace, any other informed consent forms you may be asked to sign for specific procedures, tests, or treatments.

2. Solvion Health structure and role of affiliated medical practices

Solvion Health is a management and technology company that provides non clinical administrative, technology, and support services to independent professional entities that employ or contract with licensed health care providers.

Clinical telehealth services and medical decision making are provided exclusively by those independent professional entities and their physicians and other licensed providers. These entities are referred to in this document as “Affiliated Medical Practices” and their clinicians are referred to as “Providers.”

By signing this consent:

You understand that your clinical care and treatment decisions are made by Providers, not by Solvion Health.
You understand that your doctor–patient relationship is with the Provider and Affiliated Medical Practice that treat you.

3. Description of telehealth

Telehealth involves the use of secure electronic communications and information technology to provide health care services when you and your Provider are not in the same physical location. Telehealth may include:

Live audio and video visits.
Secure messaging through a patient portal.
Review and transmission of medical records, images, and test results.
Remote monitoring of certain health data, when applicable.

By signing this consent, you understand and agree that:

Telehealth may be used for evaluation, diagnosis, treatment, follow up, counseling, and education.
Telehealth will follow applicable laws and professional standards, but it is not the same as in person care.
You must be physically located in a state where the Provider is authorized to practice at the time of each telehealth visit.

4. Risks and limitations of telehealth

You understand that telehealth has known and potential risks and limitations, including:

The Provider may not be able to perform a physical examination or may be limited in the examination they can perform.
Information you provide may be incomplete or inaccurate, which can affect clinical decisions.
Technical issues such as poor internet connection, dropped calls, hardware or software failures, or data transmission problems may interrupt or delay care.
In rare cases, security protocols could fail and personal medical information could be accessed by unauthorized persons despite efforts to protect your privacy.
Telehealth may not be appropriate for all conditions. Your Provider may determine that you should be seen in person or referred to another health care facility or provider.

You understand that it is your responsibility to:

Be in a private, safe location for telehealth visits.
Use a device and connection that are as secure as reasonably possible.
Inform your Provider if the audio, video, or connection quality is poor or if you do not understand something.

5. Not for emergencies

Telehealth services provided through Solvion Health are not appropriate for emergency situations.

If you believe you are experiencing a medical or mental health emergency, or if you are in immediate danger, call 911 or go to the nearest emergency department immediately.
Do not delay seeking emergency or in person care based on information or instructions you receive through telehealth.

6. Description of hormone optimization therapy

Hormone optimization therapy may include evaluation and treatment for hormone related symptoms or conditions, which can involve:

Testosterone therapy for men or women.
Estrogen and progesterone therapy for women.
Thyroid hormone therapy.
Other hormone related medications, supplements, or treatment plans that your Provider considers clinically appropriate.

Typical goals of hormone optimization may include improvement in:

Energy, mood, motivation, and sense of well being.
Sexual function and libido.
Body composition, muscle mass, or fat distribution.
Sleep quality and cognitive performance.
Menopausal or andropausal symptoms.

Your specific treatment plan will depend on your medical history, symptoms, goals, physical examination, and laboratory test results. There is no guarantee that you will receive any particular medication or that hormone therapy will be recommended for you.

7. Potential benefits of hormone optimization therapy

Possible benefits of hormone optimization therapy may include:

Reduction in bothersome symptoms such as fatigue, reduced libido, low mood, hot flashes, or sleep disturbance.
Improvement in quality of life, energy, and daily functioning.
Support for healthy body composition and physical performance when combined with appropriate nutrition and exercise.
Improved sexual function and relationship satisfaction.

You understand that not all patients experience these benefits, that benefits may vary, and that it may take time to reach an optimal treatment plan.

8. Risks and possible side effects of hormone optimization therapy

All medical treatments carry risks. The risks of hormone therapy depend on the specific hormones used, the doses, your age, medical history, and other factors. The following lists are not complete but include important potential risks.

General risks of hormone therapy may include, but are not limited to:

Acne, oily skin, or hair changes.
Fluid retention or swelling.
Changes in mood, irritability, or anxiety.
Headaches or changes in sleep.

Potential risks and side effects of testosterone therapy may include, but are not limited to:

Increase in red blood cell count, which may increase the risk of blood clots if not monitored and managed.
Worsening or development of sleep apnea.
Changes in cholesterol, blood pressure, or other cardiovascular risk markers.
Growth or stimulation of existing prostate tissue, which may worsen benign prostatic hyperplasia (BPH) symptoms in men.
Possible influence on the risk of heart attack, stroke, or other cardiovascular events, which is still being studied.
Reduced sperm production, reduced testicular size, reduced fertility, and potential difficulty conceiving children while on therapy.
Local reactions at injection or application sites.

Potential risks and side effects of estrogen and progesterone therapy may include, but are not limited to:

Breast tenderness, spotting, or changes in menstrual bleeding.
Nausea, bloating, or fluid retention.
Headache or migraine.
Increased risk of blood clots in the legs or lungs, stroke, or certain cardiovascular events, especially in some populations.
Possible influence on the risk of certain cancers, such as breast or uterine cancer, depending on the type, dose, route, and duration of therapy.

Other important considerations:

Hormone therapy may be used off label, meaning that a medication is used in a manner not specifically listed in its official prescribing information, when a Provider believes it is appropriate and standard of care for your condition.
Pre existing medical conditions such as cardiovascular disease, clotting disorders, liver disease, prostate disease, breast cancer, or strong family history of certain cancers may increase risks and may make hormone therapy inappropriate for you.
Hormone therapy can interact with other medications and supplements.

You understand that:

Your Provider will review your history, lab results, and risk factors before recommending therapy.
Ongoing monitoring with follow up visits and laboratory testing is necessary for safety and dose adjustment.
It is your responsibility to complete recommended labs and follow up visits. If you do not, your Provider may stop or refuse to continue hormone therapy.

9. Alternatives to telehealth and hormone optimization therapy

You understand that alternatives may include:

Receiving care entirely in person from your primary care physician, gynecologist, urologist, endocrinologist, or other specialists.
Using non hormonal treatment options for your symptoms when appropriate.
Choosing not to receive hormone therapy at all.

Your Provider can discuss reasonable alternatives based on your individual situation.

10. Pregnancy, breastfeeding, and fertility

You understand and agree that:

Certain hormone therapies are not appropriate during pregnancy or while breastfeeding.
Some hormone therapies, especially testosterone and certain other medications, can reduce fertility and may make it more difficult to conceive while on treatment.
You must inform your Provider if you are pregnant, may be pregnant, are planning to become pregnant, or are breastfeeding.
You agree to use reliable contraception if recommended by your Provider and to notify your Provider promptly of any change in your pregnancy or fertility plans.

11. Laboratory testing and monitoring

You understand that:

Baseline and periodic laboratory tests are required to assess whether hormone therapy is appropriate and to monitor your response and safety.
Labs may include blood tests, saliva or urine tests, imaging studies, or other diagnostics, as deemed appropriate by your Provider.
Laboratory services are typically provided by independent laboratories. Charges for lab work may be separate from clinical fees and may not be covered by insurance.
Failure to complete recommended lab tests may lead your Provider to modify, pause, or discontinue your treatment.
You authorize the laboratories and diagnostic facilities to release your results to your Providers and Affiliated Medical Practice for use in your care.

12. Medications, pharmacies, and supplements

You understand that:

Prescriptions will be sent to independent pharmacies chosen by you and your Provider.
Solvion Health does not manufacture or dispense prescription medications. Any issues with dispensing, shipping, or pricing should be addressed with the pharmacy.
Some medications or supplements recommended by your Provider may not be covered by your insurance plan.
You should only take medications and supplements exactly as prescribed or recommended.
You must not share your medications or supplements with any other person.
You agree to inform your Provider of all medications, vitamins, and supplements you take, including over the counter products and substances obtained without a prescription.

13. Confidentiality and privacy

Telehealth visits and your medical information are protected by privacy laws such as the Health Insurance Portability and Accountability Act (HIPAA) and applicable state laws.

You understand that:

Electronic systems used for telehealth visits will include security measures designed to protect your privacy.
There are still potential risks to privacy whenever information is transmitted or stored electronically.
Solvion Health’s Privacy Policy and Notice of Privacy Practices explain how your information may be used and disclosed, and you have received or had access to these documents.
You consent to the use and disclosure of your health information as described in those documents, including the sharing of information among Solvion Health, Affiliated Medical Practices, Providers, laboratories, and pharmacies as needed for your care, payment, and health care operations, consistent with applicable law.

14. Financial responsibility

You understand and agree that:

Some or all of the services provided through Solvion Health and Affiliated Medical Practices may be self pay and may not be billed to, or reimbursed by, your health insurance plan.
You are financially responsible for fees associated with memberships, visits, laboratory testing, medications, supplements, and other services, as explained at the time of purchase or enrollment.
You are responsible for understanding which services are or are not covered by your insurance and for any amounts not covered.

15. No guarantee of results

You understand that:

Medical care and hormone therapy outcomes vary between individuals.
No Provider, Affiliated Medical Practice, or Solvion Health can guarantee a specific outcome, improvement, or result from telehealth or hormone optimization therapy.

16. Right to withdraw consent

You understand that:

You may withdraw your consent to telehealth or hormone therapy at any time, without affecting your right to future care or treatment.
If you withdraw consent, you should notify your Provider and discontinue scheduling telehealth visits and taking prescribed medications, as directed by your Provider.
If you stop treatment or fail to complete recommended monitoring, you may experience return or worsening of symptoms, and you should discuss a safe discontinuation plan with your Provider.

17. Patient acknowledgments and consent

By signing (within the Solvion Health patient portal), you acknowledge that:

You have read and understand this Informed Consent to Telehealth Services and Hormone Optimization Therapy.
You have had the opportunity to ask questions, and your questions have been answered to your satisfaction.
You understand the potential benefits, risks, and alternatives associated with telehealth and hormone optimization therapy.
You understand that no guarantees have been made regarding outcomes or results.
You voluntarily consent to receive telehealth services and, when recommended by your Provider, hormone optimization therapy from the Affiliated Medical Practices and Providers who work through the Solvion Health platform.

If you do not understand any part of this document, please discuss it with your Provider before signing.

Note: The legally binding version of this consent is presented for electronic signature inside the secure Solvion Health onboarding and patient portal.

Important notice

This page is provided for general informational purposes only and does not constitute legal advice. The consent language used in Solvion Health’s secure onboarding and patient portal has been reviewed and approved for actual clinical use.

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