Mandeve Wellness Center 1309 Coffeen Ave Suite 1200 Sheridan, WY, 82801 Ph: 719-453-2970 _____________________________________________________________________________ Privacy Policy OUR LEGAL RESPONSIBILITIES We are required by law to give you this notice. It provides you on how we may use and disclose protected health information about you and describes your rights and our obligations regarding the use and disclosure of that information. We shall maintain the privacy of protected health information and provide you with notice of our legal duties and privacy practices with respect to your protected health information. We have the right to change these policies at any time. If we change our privacy policies, we will notify you of these changes immediately. This current policy is in effect unless stated otherwise. If the policy is changed, it will apply to all your current and past health information. You may request a copy of our notice any time. You may contact Mandeve Wellness Center at 1309 Coffeen Ave Suite 1200 Sheridan, WY, 82801 Ph: 719-453-2970 at any time to request a copy of this privacy policy. HOW WE MAY USE OR DISCLOSE YOUR PROTECTED HEALTH INFORMATION The following examples describe ways that we may use your protected health information for your treatment, payments, healthcare operations etc. but please be advised that not every use or disclosure in a particular category will be listed. Treatment: We may use and disclose your protected health information to provide you with treatment. This includes disclosing your protected health information to other medical providers, trainees, therapists, medical staff, and office staff that are involved in your health care. For example, your medical provider might need to consult with another provider to coordinate your care. Also, the office staff may need to use and disclose your protected health information to other individuals outside of our office such as the pharmacy when a prescription is called in. Payment: Your protected health information may also be used to obtain payment from an insurance company or another third party. This may include providing an insurance company with your protected health information for pre-authorization for a medication we prescribed. Health Care Operations: We may use or disclose your protected health information to operate this medical practice. These activities include training students, reviewing cases with employees, utilizing your information to improve the quality of care, and contacting you be telephone, email, or text to remind you of your appointments. If we must share your protected health information to third party “business associates” such as a billing service, if so, we will have a written contract that contains terms that will protect the privacy of your protected health information. We may also use and disclose your protected health information for marketing activities. For example, we might send you a thank you card in the mail with a coupon for specialized services or products. We may also send you information about products or services that might be of interest to you. You can contact us at any point to stop receiving this information. We will not use or disclose your protected health information for any purpose other than those identified in this policy without your specific, written Authorization. You may give us written authorization to use your protected health information or to disclose it to anyone for any purpose. You can revoke this authorization at any time but will not affect the protected health information that was shared while the authorization was in effect. Appointment reminders: We may contact you as a reminder that you have an appointment for your initial visit, follow up visit, or lab work via text, phone or email. Others Involved in Your Health Care: We may disclose protected health information about you to your family members or friends if we obtain your verbal agreement to do so, or if we give you an opportunity to object to such a disclosure and you do not raise an objection. For example, we may assume that if your spouse or friend is present during your evaluation, that we can disclose protected professional information to this person. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment if there is an urgent or emergent need. Research: We will not use or disclose your health information for research purposes unless you give us authorization to do so. Organ Donation: If you are an organ donor, we may release protected health information to organizations that handle organ procurement or organ, eye, or tissue transplantation if it is necessary to facilitate this process. Public Health Risks: We may disclose your protected health information, if necessary, to prevent or control disease, report adverse events from medications or products, prevent injury, disability or death. This information may be disclosed to healthcare systems, government agencies, or public health authorities. We may have to disclose your protected health information to the Food and Drug Administration to report adverse events, defects, problems, enable recalls etc. if required by FDA regulation. Health Oversight Activities: We may disclose protected health information to health oversight agencies for audits, investigations, inspections, or licensing purposes. These disclosures might be necessary for state and federal agencies to monitor healthcare systems and compliance with civil law. Required by Law: We will disclose protected health information about you when required to do so by federal, state and/or local law. Workman’s compensation: We may disclose your protected health information to workman’s comp or similar programs. Lawsuits: We may disclose your protected health information in response to a court action, administrative action, or a subpoena. Law Enforcement: We may release protected health information to a law enforcement official in response to a court order, subpoena, warrant, subject to all applicable legal requirements. YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION Access to medical records: You have the right to access and receive copies of your protected health information that we use to make decisions about your care. You must submit a written request to obtain your protected health information to the individual listed at the end of this privacy policy. We reserve the right to charge you a fee for the time it takes to obtain and copy the protected health information and provide it to you. Amendment: If you believe the protected health information, we have about you is incorrect or incomplete, you may ask us to amend the information. You will need to submit a written request on why you feel the health information should be amended. We may deny your request to amend it if you did not send a written request or give a reason why it should be amended. If we deny your request, we will provide you with a written explanation. We may deny your request if we believe the protected health information is accurate and complete. Accounting of Disclosures: You have the right to receive a list of instances in which we disclosed your personal health information unless the disclosure was used for treatment, payment, healthcare operations, was pursuant to a valid authorization and as otherwise provided in applicable federal and state laws and regulations. You must submit a written request to obtain this “accounting of disclosures” to the individual listed at the bottom of this policy. After your request has been approved, we will provide you the dates of the disclosure, the name of the individual or entity we disclosed the information to, a description of the information that was disclosed, the reason why it was disclosed, and any additional pertinent information. This information may not be longer than 5 years ago prior to the date the accounting is requested. We reserve the right to charge a reasonable fee for this process. Restriction Requests: You have the right to request a restriction or limitation on the protected health information we use or disclose about you for treatment, payment, or healthcare operations. We shall accommodate your request except where the disclosure is required by law. We require this be a written request submitted to the individual at the end of this policy. Confidential Communication: You have the right to request that we communicate with you about healthcare matters in a certain way and at a certain location. We must accommodate your request if it is reasonable and allows us to continue to collect payments and bill you. Paper copy of this notice: You may request a hard copy of this practice policy if you reviewed and signed it via electronic means. To obtain this copy, contact the individual at the end of this privacy policy. Complaints: If you believe your privacy rights have been violated, you may file a complaint with our office. You may also file a complaint with the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request. Name of Contact Person: ARNOLD MANDELA NANA DJOMO Signing your name indicates you have read and understood your Patient Rights. Mandeve Wellness Center 1309 Coffeen Ave Suite 1200 Sheridan, WY, 82801 Ph: 719-453-2970 _____________________________________________________________________________ Mandeve Wellness Center Clinical Policies PATIENT CONSENT FOR WEIGHT LOSS THERAPY AND TREATMENT WITH Mandeve Wellness Center. If you have any questions, please feel free to ask us. Please initial each point acknowledging you understand that: -Your consultation fee for each visit is $25 (Taken from your card or Zelle you used to book your appointment). -If you are 10 minutes late or miss your appointment, you may be subject to a $25 fee (Taken from your card you used to book your appointment). -Services must be paid for at the time of service. -Health insurance typically does not cover services provided at Mandeve Wellness Center. If you want to seek insurance reimbursement, we would be happy to provide you with itemized invoices that you can submit to your insurance company. -Phentermine and Vyvanse are considered controlled substances. I agree that I will take my medications as prescribed. I agree to follow my medical providers' instructions. I also agree that I will not sell or share my prescriptions to other individuals. -I understand that treatments used at Mandeve Wellness Center might not be considered a medical necessity. Treatments rendered are for the purpose of improving your quality of life through hormone restoration, nutritional and supplemental counseling, and weight loss treatment. -I agree that if I am having any side effects or become sick, that I will follow up with my primary care provider or go to an urgent care or emergency department. -I acknowledge that Mandeve Wellness Center and any of their providers is not my primary care provider. I agree that I will continue with routine care through my primary care provider and notify them of treatments prescribed at Mandeve Wellness Center. -I understand that there are no refunds for services or products rendered. We cannot accept back used medications once they have been dispensed per state regulation. -I understand that having an appointment with Mandeve Wellness Center does not necessarily entitle me to being issued a prescription for hormone replacement, weight loss medication or additional medications. Every individual is different, and it is at the medical providers' discretion to issue a prescription. -I understand that I must maintain my follow-up appointments to remain on treatment. It is important that lab work is monitored regularly for safety purposes. It is important that Mandeve Wellness Center providers manage my treatment, and it is at their discretion to provide. -I acknowledge that I have been advised of the risks and benefits of treatment. I also acknowledge that I have been advised of possible complications and side effects. I understand the risks, benefits, complications, and side effects of treatment. -I am voluntarily requesting treatment with Mandeve Wellness Center and their providers in regard to weight loss therapy as determined by a mutual decision between myself and the medical provider, even if my lab levels are considered to be in the normal range for my age based off of other medical society recommendations and guidelines or if I am just considered overweight and not obese. -I do not hold any medical practitioner of Mandeve Wellness Center responsible for performing age-related preventive care. I agree that I will follow up with my primary care provider to obtain these screenings and I hold Mandeve Wellness Center and their practitioners harmless if an adverse event occurs during my treatment. I will ensure that my primary care provider provides the results of such screenings with Mandeve Wellness Center as this could change the treatment prescribed to me. Signing my name signifies that I have read, understood, and agreed with all of the above statements. Mandeve Wellness Center 1309 Coffeen Ave Suite 1200 Sheridan, WY, 82801 Ph: 719-453-2970 _____________________________________________________________________________ CONSENT FOR TELEHEALTH CONSULTATION I understand that I am voluntarily engaging in a telemedicine consultation with Mandeve Wellness Center. I understand that the video conferencing technology and/or phone consultations will not be the same as a direct patient/health care provider visit due to the fact that I will not be in the same room as my health care provider. I understand that a telehealth consultation has potential benefits, including easier access to care, decreasing costs, and allowing visits to be performed from the comfort of my home. I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my health care provider, or I can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation. I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. I understand that if there is another individual present during the telehealth consultation, I will be informed of their presence and I will also disclose if there is another individual with me. It is agreed that these individuals will maintain confidentiality of the information obtained. I further understand that I will be informed of their presence at the consultation and thus will have the right to request the following: (1) omit specific details of my medical history/physical examination that are personally sensitive to me; (2) ask non‐medical personnel to leave the telemedicine examination room: and or (3) terminate the consultation at any time. I understand that the alternative to a telemedicine consultation is to forgo evaluation and treatment with Mandeve Wellness Center and to seek out an in-person evaluation elsewhere. Thus, I am freely choosing to participate in a telemedicine consultation. I understand that telemedicine has limitations in regard to the physical examination. I understand that the physical exam portion of the care provided by Mandeve Wellness Center will be limited to inspection via video conferencing and some parts of the exam such as physical tests, examination of certain body parts, and vital signs may be conducted by individuals at my location at the direction of the consulting health care provider or not done at all. Telemedicine services offered through Mandeve Wellness Center is not an Emergency Service and in the event of an emergency or urgent medical issue, I will use a phone to call 911, go to the emergency department, or go to an urgent care. To maintain my privacy, I will not share telemedicine login information or video conferencing links with anyone unauthorized to attend the appointment. I certify: That I have read or had this form explained/read to me and I understand its contents, including the risks and benefits of telemedicine. That I have had the opportunity to ask questions and have had them answered to my satisfaction. BY SIGNING MY NAME BELOW, I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT. Mandeve Wellness Center 1309 Coffeen Ave Suite 1200 Sheridan, WY, 82801 Ph: 719-453-2970 _____________________________________________________________________________ Informed Consent: Medical Weight Loss Therapy I acknowledge that I am voluntarily entering into a medically managed weight loss program with Mandeve Wellness Center. I fully realize that entering any program involving weight reduction, which includes moderate calorie restriction, exercise, and medication, involves potential risks and side effects. The risks include, but may not be limited to, the following: 1. Cardiovascular (heart or blood pressure): Problems may include, but are not limited to heart palpitations, irregular beats, or rapid heartbeat. These effects are usually mild but can result in serious problems including heart attack or stroke. The consumption of these medications may increase blood pressure, which if left untreated can lead to heart attack or stroke. If you discontinue the weight loss medication, the elevated blood pressure usually resolves. For this reason, if you are on blood pressure medication, you are required to monitor your blood pressure daily and follow up with your primary care physician to determine if discontinuation of medication is the best option. 2. Sudden Death: Patients who are obese with disease processes such as hypertension, heart disease, or diabetes have a statistically higher chance of sudden death when compared to individuals without cardiovascular or other medical diagnosis. Rare instances of sudden death have occurred while obese patients were undergoing medically supervised weight reduction, though no cause and effect relationship with the diet has been established. The possibility cannot be excluded that some undefined or unknown factor in the treatment program could increase this risk in an already medically vulnerable patient. 3. Reduced Potassium Levels: The calorie level you will be consuming is 800 or more calories per day and it is important that you consume the calories which have been prescribed in your diet to minimize side effects. Failure to consume all of the food and fluids, nutritional supplements or the consumption of diuretic medication (water pill) may cause low blood potassium levels or deficiencies in other nutrients. Low potassium levels can cause serious heart irregularities. When someone has been on a reduced calorie diet, a rapid increase in calorie intake, especially overeating or binge-eating, can be associated with bloating, fluid retention, disturbances in electrolytes, or gallbladder attacks and abdominal pain. For these reasons, following the diet carefully and following the gradual increase in calories after weight loss is essential. 4. Gall Bladder Disease: Any program resulting in rapid weight loss may cause the formation of gallstones, which could lead to cholecystitis (inflammation of your gallbladder), which is a medical urgency or emergency and could require surgery. This is usually due to the rapid weight loss, not the medications prescribed. Symptoms include right upper abdominal pain, which could migrate to the lower quadrants. Other symptoms include, but not limited to nausea, and vomiting. 5. Pancreatitis: Pancreatitis, or an infection in the bile ducts, may be caused by gallstones or the development of sludge or obstruction in the bile ducts. The symptoms of pancreatitis include pain in the left upper abdominal area, nausea, and fever. Pancreatitis may be precipitated by binge-eating or consuming a large meal after a period of dieting. Also associated with pancreatitis is long-term abuse of alcohol and the use of certain medications and increased age. Pancreatitis may require surgery and may be associated with more serious complications and death. 6. For men over 40, post-menopausal women, and patients with risk factors for cardiovascular disease, it is recommended to have a cardiovascular evaluation performed by a cardiologist prior to starting any weight loss program. Cardiovascular exams may include ECG, stress tests, or other testing procedures at the discretion of a cardiologist. 7. Common, but troublesome side effects may include but not be limited to dry mouth, palpitations, anxiety, energy, headaches, sleeplessness, rash, fever, nausea, vomiting, allergic reactions, decreased insulin sensitivity, flushing, headache, fatigue, lightheadedness, abdominal cramping, constipation, diarrhea, indigestion, mood changes, joint pain, and fluid retention. These side effects are generally rare, and most patients tolerate treatment without problems. 8. Drug Interaction is a reaction between two (or more) drugs or between a drug and a food, beverage, or supplement. It is important to tell your practitioner all drugs (prescribed, un-prescribed, legal/illegal) that you are consuming. This is important because drug interactions can cause unwanted side effects. 9. While on a weight-loss program, certain previously diagnosed medical conditions may worsen, such as but not limited to hypertension, heart disease, glaucoma, anxiety, and depression. 10. Pregnancy (Female assigned at birth). If you become pregnant or are trying to become pregnant, it is important to tell your provider immediately. You must take precautions to avoid becoming pregnant during the course of your weight-loss journey. 11. The use of medications for weight management is indicated for individuals who have a BMI of 25 with other medical conditions such as but not limited to, hypertension, diabetes type 2, high cholesterol or cardiac disease. 12. You acknowledge that the consumption of any alcoholic beverages or illicit drug use is prohibited while in the weight loss programs. Drugs like cocaine or amphetamines, when used in conjunction with certain weight-loss drugs and other medications prescribed, can cause serious injury or death. 13. I understand that I must strictly adhere to an agreed upon diet plan and caloric intake. 14. I understand that the amount of weight loss varies from patient to patient and is dependent on each patient's personal motivation and commitment to their diet and exercise plan. 15. I understand the importance of routinely following up with Mandeve Wellness Center to monitor my progress during treatment. I understand this is vital to the safety of the treatment program and certify that I will be returning monthly or as ordered by my Practitioner. 16. I hereby authorize Mandeve Wellness Center, admission into a weight management program and treat me accordingly. I consent to obtaining blood work before treatment if deemed necessary. I certify that I am signing this under my free will and am competent to make my own medical decisions. 17. I have reviewed the risks and benefits associated with medically managed weight-loss therapy with Mandeve Wellness Center. I release any claim in court or any type of complaint that could result from treatment with Mandeve Wellness Center and any other staff associated with Mandeve Wellness Center and will not hold liable any provider or staff of Mandeve Wellness Center. 18. I understand that treatment modalities utilized by Mandeve Wellness Center might not be supported by scientific/medical literature and could be seen as experimental or based off anecdotal claims. Many medical providers, including endocrinologists, surgeons, family practice doctors, etc., might see these types of treatments as not medically necessary. I also understand that many of the medications being utilized within Mandeve Wellness Center medically managed weight loss program are considered to be used “off label” and might not be FDA approved for weight loss purposes. By signing below, I acknowledge that I have had an opportunity to voice any concerns about the above information with Mandeve Wellness Center either in person or by telephone conversation. I consent to the treatment being offered to me by Mandeve Wellness Center, and I am satisfied with the explanation. I acknowledge that I have read the above consent and understand the information presented. Risks and Benefits Acknowledgement Potential Risks: Pancreatitis Thyroid Cancer Hypoglycemia Tachycardia (elevated heart rate) Palpitations Mood fluctuations (anxiety, depression, suicidal thoughts) Hypertension (high blood pressure) Fatigue Gallstones Kidney Disease Risk to unborn baby if pregnant Potential Benefits: Lower risk of heart disease Decreased risk of stroke Normalized blood pressure Lowered cholesterol Bone strength Cancer prevention Healthier weight Less anxiety Increased emotional, psychological well-being and clarity. Improved sleep quality I acknowledge that the medically managed weight loss program recommended to me by Mandeve Wellness Center, is just one of multiple strategies to reduce weight. Alternative treatment options include: Diet and exercise alone without medication. The use of other kinds of medications to achieve appetite suppression. Non-medical weight loss programs like Weight Watchers. Bariatric Surgery. My Obligations and Representations I understand that I will be responsible for administering the medications prescribed to me if I do not have them administered to me in-person. I also promise to comply with the dosages and frequency of medications prescribed to me. I certify that I am under the regular care of a primary care provider for any other conditions I might have or am found to have. I will consult with my primary care provider or specialist regarding any other condition I might have. I understand that if I do not have a primary care provider, I will be encouraged immediately to seek one. I acknowledge that I am seeking care with Mandeve Wellness Center for medically managed weight-loss services. I acknowledge I do not want to establish primary care at Mandeve Wellness Center, and I am here for specialized care, including weight-loss therapy, diet counseling, and exercise counseling. Regaining Weight Acknowledgment There is a risk of regaining the weight that was lost during this weight-loss course. Obesity is a chronic condition, and the majority of overweight individuals who lose weight have a tendency to regain all or some weight over time. Factors which favor maintaining weight loss include exercise, adherence to a nutritious low calorie diet with lean protein and adequate fruit/vegetable intake. I understand that successful weight-loss treatment may take months or years. By signing my name, I give consent to begin weight loss treatment, have read and understand the information presented. Mandeve Wellness Center 1309 Coffeen Ave Suite 1200 Sheridan, WY, 82801 Ph: 719-453-2970 _____________________________________________________________________________ B12 injections informed consent Vitamin B-12 helps maintain optimal health and has been shown to be beneficial in helping to reduce fatigue, improve memory, and maintain a healthy body weight. It is what your body uses to help create energy, which is one of the reasons people feel more energized when they take B12. All medications and supplements have potential side effects, including B12. Most people tolerate B12 without issue, side effects are rare. Potential common B12 side effects include but are not limited to: mild diarrhea, upset stomach, nausea, pain at the injection site, swelling, headache and joint pain. You acknowledge: 1. That if I begin to have side effects, I will contact Mandeve Wellness Center immediately and notify them of what is happening. 2. I understand that although rare, vitamin B12 injections can result in serious side effects. If these occur, you should follow up with a medical provider or go to the emergency department immediately. Uncommon and dangerous side effects include: rapid heartbeat, chest pain, flushed face, muscle cramps, weakness, difficulty breathing and swallowing, dizziness, confusion, rapid weight gain, feeling of tightness in the chest, hives and rashes, shortness of breath when there is no physical exertion and unusual wheezing and coughing. 3. Before starting vitamin B12 injections I agree to make my Mandeve Wellness Center aware if I have any of these conditions: Leber’s Disease, liver disease, kidney disease, iron deficiency, folic acid deficiency, receiving any treatment or taking any medication that has an effect on bone marrow, or drug/supplement allergies. 4. I understand that there could be interactions with B12 and certain medications/supplements. 5. The use of B12 on a weekly to biweekly basis without a documented B12 deficiency is considered off label use and has not been FDA approved for increasing energy levels and weight loss. 5. Caution is advised while taking B12 if you have a sulfa allergy. By signing my name below, I acknowledge that I have read the informed consent and agree to the treatment with its associated risks. I hereby give consent for B12 injections. I agree to inform my medical provider immediately if I have any side effects. I hereby release), Mandeve Wellness Center and the person injecting the B12 of any damages or liability if anything was to occur. Mandeve Wellness Center 1309 Coffeen Ave Suite 1200 Sheridan, WY, 82801 Ph: 719-453-2970 _____________________________________________________________________________ Indemnification Clause I agree to indemnify, defend, protect, and hold harmless the medical providers employed by Mandeve Wellness Center; and their respective officers, directors, employees, stockholders, assigns, successors and affiliates (Indemnified Parties) from, against and in respect of all liabilities, losses, claims, damages, judgments, settlement payments, deficiencies, penalties, fines, interest and costs, expenses suffered, sustained, incurred or paid by the indemnified parties, in connection with, results from or arising out of, directly or indirectly, the medical providers employed Mandeve Wellness Center rendering medical care, services, advice, and/or treatment, my failure to disclose all relevant information regarding my medical and physical condition, acts or omissions, the medical providers employed by Mandeve Wellness Center harm or injury resulting from medical care or pharmaceuticals provided directly or indirectly by the medical providers employed by Mandeve Wellness Center. I am aware of the potential side effects associated with Weight Loss medication therapy provided by Mandeve Wellness Center, accept all the risks involved with oral and injectable therapies, and will not seek indemnification or damages from the indemnified parties. Signing my name below signifies that I read and agreed with the above clause.