HRT clinics in Indiana

Client Agreement and Consent

CLIENT AGREEMENT

I, the undersigned, wish to become a client of Prometheuz HRT (the "Company") and receive treatment from the Company's qualified healthcare professionals (referred to as the Professional Staff, comprising individuals in healthcare-related professions whose primary responsibilities include delivering healthcare services to clients, necessitating the use of medical judgment and discretion).

1. LIABILITY AND WAIVER OF LIABILITY

I acknowledge that I will be self-administering all over-the-counter medications and prescriptions recommended and prescribed by the Professional Staff. These may include various forms such as pills, injections, troches, patches, or nasal sprays. I understand that I will receive guidance on how to self-administer these medications and prescriptions. If I choose not to self-administer, I may visit the Company's facility for assistance, though additional fees may apply. I recognize that self-administration is done at my own risk, and neither the Company nor the Professional Staff shall be liable for any injuries or damages resulting from this, nor subject to any claims, demands, actions, causes of actions, or damages. I, along with my personal representatives, heirs, administrators, assigns, and successors, hereby release and forever discharge the Company, its successors, officers, agents, and employees from all such claims, demands, actions, causes of actions, or damages.

2. THERAPY

Before beginning any therapy offered by the Company, clients are required to undergo bloodwork. Upon receiving results, the Professional Staff will review them to create a personalized health optimization plan using recommended therapies. These therapies are based solely on the client's bloodwork, not personal opinions. It is important to note that these therapies are not guaranteed to be 100% effective, and the Company and Professional Staff are not liable for any side effects, outcomes, diseases, or even death potentially associated with these therapies.

3. FEES

Fees vary based on the lab package chosen and the medications prescribed by the Professional Staff. Prometheuz HRT offers several package options, details of which are available at https://prometheuzhrt.com/. These packages include options tailored to different needs and budgets.

• Bronze ($155.00), Silver ($305.00), and (3) Gold ($405.00). I understand the medications prescribed vary in price and may be prescribed on a subscription basis.
• I agree that all services provided by the Professional Staff and/or the Company will be billed directly to me. I am personally responsible for the full payment of these services. I understand that if I suspend or terminate treatment, any fees for professional services rendered up to that point will be due immediately. Payment in full is required at the time of each session, consultation or upon ordering any product.
• I acknowledge that Prometheuz HRT reserves the right to charge a no-show/cancellation fee if I fail to attend or cancel a scheduled appointment without providing 24-hour prior notice. Furthermore, I understand that Prometheuz HRT may reschedule my appointment if I am over 15 minutes late.

5. SUSPENSION/TERMINATION OF CLIENT/COMPANY RELATIONSHIP

Prometheuz HRT reserves the right to suspend or terminate my client relationship for reasons including non-payment of sessions, consultations, prescription orders, inappropriate behavior towards staff, non-compliance with treatment plans, or any other reason deemed sufficient at the Company's discretion.

6. CANCELLATION, REFUNDS

Prometheuz HRT maintains a strict no-refund policy. By purchasing services and/or products, I authorize the Professional Staff and/or Company to order products for my treatment, including prescriptions, in advance. I understand these products may have short shelf lives and require timed ordering. If I choose to cancel any purchased product(s), the Company may approve the cancellation, but I will remain responsible for the full cost of the already ordered product(s), and I understand that refunds are not provided in such cases.

7. ENTIRE AGREEMENT

This agreement represents the complete and exclusive understanding between Prometheuz HRT and me. Any promise, representation, understanding, oral or written, not included herein, is waived.

CLIENT CONSENT TO EVALUATION AND TREATMENT

• I, the undersigned, hereby request and consent to evaluations and treatments by Prometheuz HRT's Professional Staff, defined as individuals retained by the Company, qualified in healthcare-related professions, whose primary responsibilities include delivering healthcare services requiring medical judgment and discretion.
• I acknowledge that at this stage, no specific treatment plan has been recommended. A personalized treatment plan will be formulated by the Professional Staff at Prometheuz HRT after evaluating my individual needs. This consent authorizes the Professional Staff to conduct necessary medical evaluations, testing, and treatments. I understand my right to be informed about my diagnosis, treatment options, and to make informed decisions about undergoing any recommended treatment, understanding its potential benefits and risks.
• I am aware that the Professional Staff at Prometheuz HRT offers a range of treatments and services, including medical treatment, health and wellness advice, and prescription services. I trust the Professional Staff to act in my best interest throughout my treatment. I will inform them of any sensitive conditions or adverse reactions I have experienced before, during, or after treatment. I understand that I can address any questions regarding potential side effects, complications, or specific treatment areas to the Professional Staff during my evaluation and treatment.
• I recognize that the practice of medicine is not an exact science and agree that the fees paid are for the performance of medical services, not for guaranteed results. While expecting a favorable outcome and understanding that realistic expectations have been established, I acknowledge that there can be no warranty, either expressed or implied, regarding the results that may be achieved.
• This consent is intended to cover the full course of treatment and will remain effective until revoked in writing. To revoke consent, I must contact Prometheuz HRT via email or mail, as detailed in their Notice of Privacy Practices.
• In case of a medical emergency during my treatment at Prometheuz HRT, I consent to be transported by the Professional Staff, the Company, or emergency medical services to a hospital or emergency medical facility.

INFORMED CONSENT FOR OFF-LABEL DRUG USE

I, the undersigned, acknowledge and agree as follows:

When a medication or device is authorized for medical use by the Food and Drug Administration (FDA), its manufacturer provides a label detailing its intended use. Once approved, physicians may use these products "off-label" for other purposes, provided they are well-informed about the product, base its use on sound scientific methods and medical evidence, and maintain records of use and effects.

The Professional Staff at Prometheuz HRT, defined as qualified healthcare professionals with responsibilities including delivering healthcare services, may use certain drugs off-label, particularly in obesity management. These may include Human chorionic gonadotropin (hCG) and other peptides. While not FDA approved for long-term obesity management, there are studies demonstrating the safety and efficacy of these medications in this context, with no long-term cardiovascular risks or withdrawal issues. These studies are available upon request.

Purpose of Off-Label Drug Use:

The intention of using specific drugs off-label is to treat my medical conditions and enhance my quality of life. The Professional Staff may prescribe medications for various conditions, including but not limited to Andropause, Male hypogonadism, low testosterone, erectile dysfunction (ED), anxiety, stress, anger, depression, sleep disturbances, weight loss, among others.

No Guarantees or Assurances Regarding Results from Treatment

Neither the Professional Staff nor Prometheuz HRT provides any guarantees or assurances about specific results from treatments and medications.

Adverse Reactions

Treatments and medications may cause side effects, which can vary in intensity among individuals.

Potential side effects of Human Chorionic Gonadotropin (hCG) and other peptides might include acne, enlargement of penis and testes, headache, restlessness or irritability, growth of pubic hair, mild swelling or water weight gain, depression, and breast tenderness or swelling.

Client's Responsibility in Case of Adverse Reactions

I am responsible for reporting any significant adverse reactions from medications or treatments to the Professional Staff and/or Prometheuz HRT. These should be reported during normal business hours. However, if the reaction is severe, I should seek immediate medical attention.

In case of experiencing significant adverse reactions from medications or treatments outside business hours, I agree to IMMEDIATELY contact the emergency department of my local hospital or call 911.

Treatment

Treatment and medications will only be provided if a clinical need is established. This determination is based on one or more factors: physician consultation, physical examination, and current medical history.

CLIENT CONSENT TO PHOTOGRAPHY AND AUTHORIZATION TO RELEASE AND DISCLOSE PHOTOGRAPHS

PLEASE READ EACH SECTION CAREFULLY. YOU MAY REQUEST A COPY OF THIS FORM FOR YOUR RECORDS.

• I consent to the capture of photographs, videotapes, digital or audio recordings, and other methods of reproducing or editing my likeness or image (collectively, "Photography") by Prometheuz HRT and its staff. These will be used to document and assist with my care, as well as aid the Company's health care operations.
• Prometheuz HRT intends to use the Photography for professional publications, training, education, clinical evaluation, and on social media, including but not limited to the Company's website and social media platforms ("Social Media"). This includes use in email marketing campaigns, resulting in the publication and distribution of protected health information to the general public. The Company does NOT receive direct or indirect remuneration from third parties in connection with the use/disclosure of this protected health information.
• I understand the Photography will be used on Prometheuz HRT's website, social media, and in email marketing, as part of my participation as a client. I acknowledge that the use of Photography in social media and marketing may incidentally disclose additional protected health information related to my treatment, condition, procedure, or other associated health information, and I authorize such disclosure.
• I retain the right to revoke this authorization in writing at any time by sending such written notification to Prometheuz HRT at the email or address listed in their Notice of Privacy Practices. I understand that a revocation is not effective to the extent the Company has relied on the use or disclosure of my protected health information.
• This authorization remains valid until one of the following occurs: my death, reaching the age of majority, or withdrawal of permission.
• Except as otherwise noted in this authorization, Prometheuz HRT may use or disclose my protected health information in line with their Notice of Privacy Practices. I am aware that information disclosed under this authorization may be redisclosed by the recipient and might no longer be protected under the Health Insurance Portability and Accountability Act of 1996 ("HIPAA") or other applicable laws.
• I agree that Prometheuz HRT has the right to interview, consult with, and examine me as they reasonably request before, during, and after my treatments. I understand that these activities might be used on social media and may result in public disclosure.
• I understand that my treatment or payment is not contingent upon signing this form. I also acknowledge that I will not receive any payment or remuneration from Prometheuz HRT for the use of Photography.
• I release and hold harmless Prometheuz HRT, its officers, staff, and employees from any claims or actions that might arise from the use or disclosure of Photography. I understand that my treatment or payment is not conditioned on my authorization for the requested use.

NOTICE OF PRIVACY PRACTICES

THIS NOTICE EXPLAINS HOW YOUR MEDICAL INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN ACCESS THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Understanding Your Health Record/Information

This notice outlines the practices of Prometheuz HRT and its staff regarding your protected health information while you are a client. All staff members with access to your records are bound by this notice. Additionally, Prometheuz HRT and the Professional Staff may share medical information for treatment, payment, or healthcare operations as described in this notice.

We maintain a record of the care and services you receive at Prometheuz HRT. We recognize that your medical information is personal and are committed to protecting it.

This notice details the ways in which we may use and disclose medical information about you, and describes your rights and our obligations regarding the use and disclosure of your medical information.

YOUR HEALTH INFORMATION RIGHTS

While your health record is physically held by Prometheuz HRT, the information it contains belongs to you. You have the right to:

• Request restrictions on certain uses and disclosures of your information for treatment, payment, and healthcare operations. This includes disclosures to persons involved in your care, as permitted by law. However, we are not obligated to agree to requested restrictions unless it involves a restriction on disclosures to your health insurer for services you have paid for out-of-pocket in full.
• Obtain a paper copy of this notice of information practices.
• Inspect and request a copy of your health record as allowed by law.
• Request that we amend your health record as permitted by law. We will notify you if we are unable to grant your request for amendment.
• Obtain an accounting of disclosures of your health information as provided by law.
• Request communication of your health information by alternative means or at alternative locations. We will accommodate reasonable requests.
• To exercise your rights, please provide a written request to Prometheuz HRT using the contact information provided in our Notice of Privacy Practices.

Prometheuz HRT'S RESPONSIBILITIES

In addition to the above, Prometheuz HRT is also required to:

• Maintain the privacy of your health information.
• Subject to certain exceptions under the law, notify you of any unauthorized acquisition, access, use, or disclosure of your protected health information that was not properly secured.
• Provide you with a notice outlining our legal duties and privacy practices with respect to your health information.
• We will abide by the terms of this notice.
• We will notify you if we are unable to agree to a requested restriction on certain uses and disclosures.
• Prometheuz HRT reserves the right to change our practices and to make new provisions effective immediately for all protected health information we maintain, including information created or received before the change. Should our information practices change, we are not required to notify you, but the revised notice will be available upon request. We will also display the updated notice at each practice location.

USES AND DISCLOSURES OF MEDICAL INFORMATION THAT DO NOT REQUIRE YOUR AUTHORIZATION

The following categories detail how we may use and disclose medical information about you without your authorization. Not every use or disclosure in a category will be listed, but all permitted uses and disclosures should fall within one of these categories:

• For Treatment: We may use and disclose medical information about you to doctors, nurses, technicians, medical students, or other personnel involved in your care. This includes sharing information to coordinate different treatments like prescriptions, lab work, and x-rays. We may also provide your physician or a subsequent healthcare provider with reports to assist in your treatment after you are discharged from our care.
• For Payment: We may send bills to you or a third-party payer. The information on or accompanying the bill may include details that identify you, along with your diagnosis, procedures, and supplies used.
• For Regular Health Care Operations: We use your health information for standard operations in healthcare service and management.
• We may utilize your health information to evaluate and improve the care and outcomes in your case and others. This effort is aimed at continually enhancing the quality and effectiveness of the healthcare and services provided by Prometheuz HRT.

ADDITIONAL ALLOWED USES AND DISCLOSURES OF YOUR HEALTH INFORMATION

• Business Associates: For certain services, we collaborate with business associates, like answering services and copy services. To protect your health information, we require these associates to safeguard your data appropriately.
• Notification: Unless you object, we may use or disclose information to notify or assist in notifying a family member, personal representative, or someone responsible for your care regarding your location and general condition.
• Individuals Involved in Your Care: Unless you object, we may disclose health information to individuals you identify as being involved in your healthcare or its payment. If you’re unable to agree or object, we may disclose information if we deem it in your best interest based on our professional judgment.
• Disaster Relief: In a disaster, we may disclose your health information to public or private organizations to coordinate care or inform your family or friends of your location or condition. We'll offer you the opportunity to agree or object to these disclosures when practical.
• Research: We may disclose information to researchers when their research has been approved by an institutional review board, which ensures protocols to protect your privacy.
• Communications About Treatment Alternatives and Appointment Reminders: We may contact you with appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

ADDITIONAL USES AND DISCLOSURES OF HEALTH INFORMATION

• FDA Reporting: We may disclose health information to the Food and Drug Administration (FDA) related to adverse events concerning food, medications, devices, supplements, and products, or for post-marketing surveillance to enable product recalls, repairs, or replacement.
• Worker's Compensation: We may disclose health information as authorized by and necessary to comply with worker's compensation laws or similar programs.
• Public Health: As required by law, we may disclose your health information to public health or legal authorities responsible for preventing or controlling disease, injury, or disability.
• Abuse, Neglect, or Domestic Violence: We may disclose health information to authorities legally authorized to receive reports of abuse, neglect, or domestic violence, as required by law.
• Judicial, Administrative, and Law Enforcement Purposes: We may disclose health information for judicial, administrative, and law enforcement purposes, as allowed by law.
• Health Oversight Activities: We may disclose health information for oversight activities authorized by law, such as audits, investigations, inspections, and licensure.
• Threats to Health or Safety: In good faith and as permitted by law, we may disclose health information to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.
• Special Government Functions: We may disclose health information to authorized federal officials for national security activities, intelligence, counterintelligence, and protective services for government officials. For military members, we may disclose health information to military authorities. For inmates, we may disclose necessary health information for their health and the safety of others.
• Required or Allowed by Law: We will disclose medical information when required or allowed by federal, state, or local law.
• Electronic Health Information Exchange: Prometheuz HRT uses a third-party vendor for our electronic medical records (EMR). Your electronic health information is stored in the EMR, and we monitor access to your EMR.

WHEN WE NEED YOUR WRITTEN AUTHORIZATION

We will not use or disclose your health information without your written authorization, except as described in this notice. Additional circumstances may also require your written authorization.

ADDITIONAL INFORMATION AND PRIVACY RIGHTS VIOLATIONS

Instances requiring your additional written authorization, such as disclosures for marketing purposes, are uncommon but may occur.

For more information or to report a problem, you may contact Prometheuz HRT using the contact information provided in our Notice of Privacy Practices.

If you believe your privacy rights have been violated, you can file a complaint with Prometheuz HRT or with the Secretary of Health and Human Services. Filing a complaint will not result in retaliation.

This notice is effective as of January 1, 2022.

NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT

I acknowledge that under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain privacy rights regarding my protected health information. I understand that this information will be used to:

• Conduct, plan, and direct my treatment and follow-up among multiple healthcare providers involved in my treatment, both directly and indirectly.
• Obtain payment from third-party payers.
• Conduct standard healthcare operations, such as quality assessments and physician certifications.
• I confirm that I have received the Notice of Privacy Practices, which provides a detailed description of the uses and disclosures of my health information. I understand that Prometheuz HRT may change its Notice of Privacy Practices and that I can obtain a current copy at any time by contacting the organization as provided in the Notice.
• I understand that I may request in writing that Prometheuz HRT restrict how my medical information/records are used or disclosed for treatment, payment, or healthcare operations. I also understand that while Prometheuz HRT is not required to agree to my requested restrictions, if it does, it is bound to abide by them.

INFORMED CONSENT FOR TELEMEDICINE SERVICES

INTRODUCTION

Telemedicine at Prometheuz HRT involves using electronic communications to enable healthcare providers at different locations to exchange patient medical information to improve care. This includes primary care practitioners, specialists, and subspecialists.

The information used in telemedicine may include:

• Patient medical records
• Medical images
• Live two-way audio and video
• Data from medical devices, sound, and video files

We use electronic systems with network and software security protocols to protect the confidentiality of patient identification and imaging data, and include measures to safeguard the data against corruption.

EXPECTED BENEFITS

• Improved access to medical care, allowing patients to remain in their own office or at a remote site while physicians obtain test results and consultations from healthcare practitioners at other locations.
• More efficient medical evaluation and management.
• Access to the expertise of distant specialists.

POSSIBLE RISKS

As with any medical procedure, telemedicine carries potential risks. These include, but are not limited to:

• In rare cases, the transmitted information may not be sufficient (e.g., poor resolution of images) to allow for appropriate medical decision-making.
• Delays in medical evaluation and treatment could result from equipment deficiencies or failures.
• In very rare instances, security protocols might fail, leading to a breach of privacy concerning personal medical information.
• A lack of access to complete medical records may, in rare cases, lead to adverse drug interactions, allergic reactions, or judgment errors.

BY SIGNING THIS FORM, I ACKNOWLEDGE THE FOLLOWING:

1. I understand that privacy and confidentiality laws applicable to medical information also extend to telemedicine, and no identifying information obtained through telemedicine will be disclosed without my consent.
2. I reserve the right to withhold or withdraw consent to telemedicine at any time, without impacting my right to future care or treatment.
3. I have the right to inspect and obtain copies of information recorded during telemedicine interactions, subject to a reasonable fee.
4. I am aware of alternative methods of medical care available to me and can choose one or more of these options at any time.
5. Telemedicine may involve the electronic communication of my personal medical information to other medical practitioners, potentially in different locations or out of state.
6. I will inform my physician of any electronic interactions I have with other healthcare providers regarding my care.
7. While I may anticipate benefits from the use of telemedicine, I understand that no results can be guaranteed or assured.
8. I confirm that I am located in the state of [State Name] and will be present in [State Name] during all telehealth encounters.

PATIENT CONSENT TO THE USE OF TELEMEDICINE

I have read and understood the information provided above regarding telemedicine. I have had the opportunity to discuss it with my physician or designated assistants, and all my questions have been answered satisfactorily. I hereby give my informed consent for the use of telemedicine in my medical care.

• I acknowledge that a copy of this form will be available for me to print.

AUTHORIZATION FOR USE OF TELEMEDICINE AND CLIENT CONTACT PREFERENCES

Telemedicine Authorization

I hereby authorize Prometheuz HRT to utilize telemedicine in my diagnosis and treatment.

Client Contact Authorization

Please note that Prometheuz HRT does not disclose or sell any client protected health information to any third-party business or online database.

I, the undersigned, authorize Prometheuz HRT to contact me regarding aspects of my care, including information requests, payment or benefits verification, and appointment reminders. I understand that Prometheuz HRT may leave messages on my home or cell phone, or send reminders via U.S. mail, email, or text message.

Preferred Method of Communication

I acknowledge that Prometheuz HRT may use email or text messages for communication about my treatment and for marketing purposes. This may include appointment reminders, health reminders, feedback requests, newsletters, and other practice-related information.

I understand that this authorization will remain in effect until I either submit a subsequent Client Contact Authorization changing my above-stated preferences or I revoke or withdraw this authorization in writing. To do so, I must send written notice to the Practice at the email or mailing address listed in the Practice's Notice of Privacy Practices.

I acknowledge and agree that the Practice and its employees, officers, and physicians are released from any legal responsibility or liability resulting from the authorized disclosure of my health or billing information.

I have read this form in its entirety and agree to be bound by all of its terms and conditions as described above. I acknowledge and agree that I have been given the opportunity to ask any questions and have either declined the opportunity to do so or had all my questions answered to my satisfaction.