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.
This Informed Consent for Clinical Services and Telehealth Services (the “Consent”) sets forth the terms and policies for the clinical services provided by Superpower Medical Group of CA PC, a California professional medical corporation, and other third-party medical groups (the “Medical Groups”) through the online technology platform (“Platform” or “Superpower Platform”), which is owned and operated by Superpower Health, Inc. (“Superpower”).
The purpose of the Consent is to obtain your informed consent to care and the use of telehealth in the delivery of healthcare to you by physicians, physician assistants, and/or nurse practitioners and other licensed medical providers (“Healthcare Providers”) of the Medical groups using the Superpower Platform. Superpower’s goal is to provide users with access to a broad array of health focused strategies and an integrated multidisciplinary approach to health. The Superpower Platform provides users with access to both typical biomedical standards of care as well as integrative and functional medicine approaches which may not be considered standard for conventional care. By signing up to receive Clinical Services and Telehealth Services (as defined herein) through the Superpower Platform, you authorize the Medical Groups and their Healthcare Providers to provide you with telehealth and other clinical services.
In this Consent, the terms “you” and “yours” refer to the person using the Clinical Services and Telehealth Services and, the person signing this Consent as a representative for another person (a “Family Member”) as such Family Member’s lawful guardian, conservator, or custodian. Please read this Consent carefully and ask any questions you might have before agreeing.
The Healthcare Providers of the Medical Groups provide certain virtual medical services as described in this Consent (the “Clinical Services”) via the Superpower Platform. Superpower is a non-clinical entity that provides technology services to the Medical Groups and does not engage in the practice of medicine. This Consent describes the Medical Groups’ Clinical Services.
When you become a patient of a Medical Group (a “Patient”), you will be given access to the Healthcare Providers. The Platform provides simple tools for scheduling your blood draw, ordering your laboratory results, viewing your laboratory results, connecting you with a Healthcare Provider to review your labs and provide an action plan which may include dietary and lifestyle changes, dietary supplements, additional lab testing, referrals or recommendations to follow-up with other medical providers or specialists and prescription medications prescribed by a Healthcare Provider after appropriate intake and review, and serving as a hub of your information. No prescription is guaranteed, and prescriptions are made solely in the professional judgment of the Healthcare Provider.
Please note that the Healthcare Providers do not act as your primary care providers, and the services provided by the Healthcare Providers via the Superpower Platform are in addition to, and not a replacement for, the care of your primary care physician and other specialists. Because the Medical Groups utilizing the Superpower Platform are focused on health optimization and all services are provide via telehealth, responsibility for your overall medical care should remain with your primary care physician. If you do not have a primary care physician, we strongly recommend you locate one for in-person care, routine screenings that the Superpower Healthcare Providers do not provide, as well as for after-hours or urgent health needs, on-call physician access, and emergencies.
By utilizing the Clinical Services, you understand that that the Superpower Healthcare Providers do not act as your primary care providers, and the services provided by the Superpower Healthcare Providers are in addition to, and not a replacement for, the care of your primary care provider (PCP). Furthermore, you understand that they do not treat cancer.
By agreeing to this form, you hereby authorize the following Clinical Services which may include, but are not limited to:
There may be other services and treatments that will be discussed with you and have separate informed consent documents prior to treatment as well.
Some FDA approved pharmaceutical medications may be prescribed for off-label uses.
Common Pharmaceutical Treatments include:
Please see the full list of risks and benefits for your specific treatment in the informed consent form provided to you at the time of treatment.
Prescriptions are only made after appropriate intake and review by a Healthcare Provider licensed in your state.
We strive to provide individualized care relevant to your case which could include external referrals or specialized procedures such as regenerative injections, acupuncture, Chiropractic/OMT, biotherapies, and physical medicine. Other ancillary treatments include, but or not limited to V02 max testing, DEXA scans, full-body MRI, laser, red-light therapy, electromagnetic therapy, and other services or procedures, which your provider considers helpful and/or necessary.
The Healthcare Providers will discuss with you the risks, benefits and alternatives to recommended treatments. You understand that Clinical Services may be rendered by nurses or other medical professionals such as medical assistants or phlebotomists under supervision.
You understand that the Superpower Healthcare Providers are not psychologists or psychiatrists, and any counseling is for support of improved lifestyle strategies only. You also understand the U.S. Food and Drug Administration has not approved nutritional, herbal, and homeopathic substances to treat specific diseases.
No Guarantees: You understand that results from the Clinical Services are not guaranteed, and the Medical Groups do not make any representations, promises, claims, warranties, assurances or guarantees that your medical problems or conditions will be helped or cured by undergoing any of Clinical Services.
Potential Benefits include but are not limited to: Restoration of health and the body’s maximal functional capacity; relief of pain and symptoms of disease; assistance in injury and disease recovery; and prevention of disease or its progression.
Potential Risks include but are not limited to: Herbs and dietary supplements are available over the counter and generally considered safe when used as instructed. However, they may lack therapeutic effect or could cause allergic reactions or unpleasant side effects which could possibly range from mild to severe. The interactions between herbs, and between herbs and medications are also not always thoroughly understood. While unlikely, it is possible to have an adverse reaction or experience a reduction or increase in the effect of other medications when taking herbs. These can have serious consequences for some medications, such as for the control of high blood pressure or blood sugar. Homeopathic medicines can potentially cause aggravation or worsening of current or pre-existing symptoms. There is also the risk of injury, infection, pain, discomfort, discoloration, minor bruising, and blistering from venipuncture other procedures or topical applications. There may also be other potential risks which may be discussed and clarified in separate consents specifically applicable to such treatments.
Unforeseeable complications could occur, and while the Healthcare Providers will make every reasonable effort to screen for contraindications to care, they cannot anticipate and explain all possible risks and complications and may only have a limited amount of your health information.
Following Instructions: You understand that it is extremely important that you follow any instructions provided by a Healthcare Provider with respect to all treatments including, herbs, nutritional supplements, hormones, and other prescriptions. This means not changing products or dosages or adding new products. You understand that following all instructions, whether orally and/or in writing, helps to improve safety and outcomes. You understand that taking more than the prescribed/recommended amounts of supplements or medications or self-treating with additional supplements or medications can be dangerous.
Complete Medical History: Some treatments may be inappropriate and unsafe if you have certain health conditions, allergies or take certain medications or supplements, whether prescribed or over-the-counter. You understand that it is vital that you truthfully and accurately disclose all health information requested by the Medical Groups and Healthcare Providers including, but not limited to, all medications, sensitivities and allergies, presence of a pacemaker, bleeding disorder, use of anti-coagulants, damaged heart valves or occluded vessels, immune deficiencies, or any other medical conditions, as well as keep the Healthcare Providers updated as to any changes, including any new treatments or procedures you are undergoing. You understand that failure to do so may negatively affect the outcome and safety of any treatments you receive, and you agree there shall be no liability on the part of the Medical Groups or Healthcare Providers should you fail to do so. Furthermore, you understand that the Healthcare Providers do not monitor the Superpower Platform or Data Vault and do not necessarily review any labs or other information that you upload yourself to the Platform. You should not assume that anyone is reviewing anything you upload.
Notice Regarding Pregnancy and Breastfeeding: You understand that some treatments could present a risk during pregnancy and breastfeeding, and you agree that you will notify your Superpower Healthcare Provider immediately if you are or become pregnant, suspect that you may be pregnant, if you are planning to become pregnant in the next three months or if you are breastfeeding.
Limitations of Clinical Services:
All of the Clinical Services provided by the Medical Groups via the Platform are virtual, and the Clinical Services are limited in scope and time. Healthcare Provider(s) will order your prescription medications and laboratory testing asynchronously and without a prior medical visit based on information you provide via the Platform. The Healthcare Provider(s) will not be seeing you in-person and will only be reviewing your intakes and laboratory results and then prescribing any necessary medications, recommending diet, lifestyle and supplement plans, making referrals or suggestions for additional lab tests and other medical providers or specialists you should see, and/or educating you about your laboratory results. This limited virtual care is a flexible and convenient way to get healthcare, but it may not be right for treating certain symptoms or illnesses that need in-person clinical care.
PLEASE NOTE: THE MEDICAL GROUPS DO NOT ADDRESS MEDICAL EMERGENCIES. IF YOU BELIEVE YOU ARE EXPERIENCING A MEDICAL EMERGENCY, ARE CONSIDERING HARMING YOURSELF OR OTHERS, OR ARE OTHERWISE IN IMMINENT DANGER, YOU SHOULD DIAL 9-1-1 AND/OR GO TO THE NEAREST EMERGENCY ROOM.
You should seek emergency help or follow-up care when recommended by any Healthcare Provider or when otherwise needed. You should never discontinue medications or stop a course of treatment without first contacting your primary care provider or other medical professionals for advice. You should not delay treatment or advice from your primary care provider or other medical professionals based on information provided by the Healthcare Provider(s) via the Superpower Platform. You understand that your use of our Clinical Services will not give rise to an ongoing treatment relationship, treatment plan or course of action. Healthcare Provider(s) will only interpret and provide action plans regarding your laboratory results ordered through the Platform. Please discuss using the Platform with your treating provider.
You understand that all Clinical Services will be provided via telehealth. Telehealth involves the delivery of healthcare services 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 systems used will incorporate network and software security protocols to protect the confidentiality of customer identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.
Due to Healthcare Provider licensing reasons, you have to physically be in the state that your Healthcare Provider is licensed in during your telehealth visit. By agreeing to this Consent, you are confirming that you will only opt in to care when you are in your state of residence or in one of our locations. Furthermore, you are confirming that your state of residence is one in which the Medical Groups are licensed to treat.
By signing this Informed Consent to Telemedicine, you acknowledge and confirm that you understand and agree to the following with respect to telemedicine services:
You understand that the Clinical Services provided by the Medical Groups are extremely limited as described below. You will have asynchronous access to Healthcare Provider(s) for purposes of ordering your laboratory tests and prescription medications through the Platform. Healthcare Provider(s) will order your laboratory testing and prescription medications asynchronously and without a prior medical visit based on information you provide via the Platform.
Once the laboratory testing that is ordered is performed and the results are received from the Lab, a Healthcare Provider will review your laboratory results and notify you of (i) abnormal values via the Platform and email and (ii) critical values via the Platform, phone and email. A Healthcare Provider will be available to discuss your laboratory results via synchronous audio-visual communication after you receive your results. You understand that you must maintain care with a primary care physician or other licensed healthcare provider for all examinations, diagnosis, treatment, and ongoing clinical care. The Superpower Healthcare Providers do not act as your primary care provider and only provide limited medical services. It is your responsibility to discuss the results of any laboratory tests with your treating physician(s) or specialists whose care you may be under for diagnosis and treatment.
Laboratory Products and Services. With respect to the lab testing, the laboratory tests will require that you complete an at-home diagnostic test or have blood drawn. These diagnostic tests are provided by third-party laboratories, and neither Superpower nor the Medical Groups can guarantee the accuracy or reliability of these tests. These laboratory tests can provide false negative, false positive, or inconclusive results that could impact a Healthcare Provider’s ability to correctly explain your results.
You understand that the Medical Groups do not currently accept insurance of any kind. You understand that you will be fully responsible for payment for Clinical Services received via the Platform. You understand that Superpower performs billing services and acts as a paymaster on behalf of the Medical Groups and the Healthcare Providers. The fees for the Clinical Services the Medical Groups provide (“Clinical Fees”) are as shown on the invoice provided to you at checkout. Superpower will collect the Subscription fee (as described in the Superpower Terms of Service), which includes the Clinical Fees, at checkout and remit directly to the Medical Groups the full amount for the Clinical Fees. The remainder of the Subscription fee will be as described in your invoice at checkout. You understand that you must pay us any costs due unless state or federal regulations do not allow this.
By providing Superpower with your credit card information and associated billing information, you are authorizing Superpower as the Medical Groups’ paymaster to charge your credit card for the Clinical Services and to save your credit card information for future transactions on your account.
The Medical Groups follow federal healthcare privacy and security laws to protect your health information and use standard physical, electronic, and business security methods to help prevent access to your health information by people who should not see it. However, the Medical Groups cannot promise that data sent over the Internet or through a data storage facility will be perfectly secure. Additionally, you are responsible for information security on your personal device, including but not limited to, computer, tablet, or phone, as well as using it in a location with secure internet connection, when you use our services. So, although the Medical Groups try to protect your personal information, they cannot guarantee the security of any information you send to the Medical Groups. You can read more information about the Medical Groups’ use of health information and other personal information in the Medical Group Notice of Privacy Practices (“Medical Group Notice of Privacy Practices”). You understand all medical reports resulting from the Clinical Services are part of your medical record.
As part of providing Clinical Services, the Medical Groups may share your health records and health information with the following individuals under the following circumstances without further notice to you:
By signing below, you agree you have received a copy of the Medical Group Notice of Privacy Practices.
You have the right to request a copy of your medical records. You can request to obtain or send a copy of your medical records to your primary care or other designated health care provider by contacting compliance@superpower.com. A copy will be provided to you at a reasonable cost of preparation, shipping and delivery.
By initializing below and providing your phone number and email, you consent to receive from the Medical Groups and/or Superpower marketing texts, and other text messages and emails related to our products and services such as appointment reminders, messages from your Healthcare Providers, lab results, and other notifications. You understand SMS text messages are not always secure because they travel over networks that we do not control. This consent for text messages with your Healthcare Provider is required for you to receive certain telehealth services and direct communication with your Healthcare Provider, but it is not required for marketing texts. You may ask us to stop sending you marketing texts at any time by contacting superpower@superpower.com or replying STOP to one of our messages. You understand that messaging frequency may vary, and data rates may apply.
All Patients have the right to communicate grievances regarding their care. Should you wish to make a formal complaint you may do so in writing and submit the concern to Practice at compliance@superpower.com.
The Healthcare Provider(s) hold professional licenses issued by the professional licensing boards or agencies in the states where they practice. You can report a complaint relating to the care provided by a Healthcare Provider by contacting the professional licensing board in the state where the care was received. You can find the contact information for each of the state professional licensing boards governing medicine on the Federation of State Medical Boards website.
By clicking “I Agree”, checking a related box to signify that you have read and understand the above Consent, that you understand the risks and benefits and that you are giving your acceptance and consent to receive the Clinical Services via the Superpower Platform.
If you have questions about any of the contents of this Consent, the Medical Group procedures or policies, or the Clinical Services, please discuss them with us at compliance@superpower.com.
I have read and understood this document, and I agree to abide by its terms. Further, I certify that if I am signing as a personal representative of a family member, I have legal authority to provide consent for such person.
I have read and understand the information provided above regarding telehealth and the Clinical Services provided, have discussed it with my treating physician if necessary, and all my questions have been answered to my satisfaction. I hereby give my informed consent to receive the limited Clinical Services from the Medical Groups as described in this Agreement.
YOU CERTIFY THAT YOU ARE NOT CONSENTING ON BEHALF OF A MINOR CHILD. WE DO NOT PROVIDE SERVICES TO CHILDREN UNDER THE AGE OF 18.
