Celesta Informed Consent for Diagnosis & Treatment

This Informed Consent was last updated on November 11th, 2023.

Introduction:
At Celesta Health, we are dedicated to delivering high-quality healthcare services, which encompass Telemedicine, At-Home Diagnostic Testing, and Health Coaching. To effectively provide these services, we require your informed consent to participate in and receive medical care via our platform.

Telemedicine Services
Definition and Understanding of Telemedicine:
Telemedicine, or Telehealth, involves the use of electronic communication, information technology, and other means to enable healthcare providers and patients to access, diagnose, consult, treat, transfer medical data, and educate when not in the same physical location. This can include video conferencing, internet services, store-and-forward imaging, and other electronic data communications.

Technologies Used:
By agreeing to this consent, you acknowledge the use of various technologies for your care including electronic health records, live two-way video, store-and-forward imaging, remote patient monitoring, and mobile health communications.

Consent to Receive Telemedicine Treatments:
You hereby consent to receiving healthcare services via telemedicine technologies as an alternative to in-person visits, understanding the nature of telemedicine and your right to withdraw consent at any time.

At-Home Diagnostic Testing Consent with Reportable Disease Notification
Informed Consent for At-Home Diagnostic Testing:
By consenting to participate in at-home diagnostic testing provided by Celesta Health, you are engaging in an important aspect of your healthcare that allows for the convenient collection of medical samples in the comfort of your own home. These tests may include blood draws, saliva swabs, urine tests, and other sample collections as directed by your healthcare provider.

Compliance with Instructions:
You agree to follow the specific instructions provided with each diagnostic kit to ensure the accuracy and validity of the test results. Improper collection or handling of samples may lead to erroneous results.

Understanding of At-Home Testing Procedures:
You understand that at-home diagnostic testing involves procedures that require attention to detail and adherence to strict guidelines to maintain the integrity of the samples and the accuracy of the results.

Reportable Disease Results:
You acknowledge that if your at-home diagnostic test results indicate the presence of a reportable or notifiable disease, Celesta Health is legally obligated to report this information to local, state, or federal public health authorities in accordance with public health reporting laws. The purpose of this reporting is to allow public health authorities to prevent or control the spread of disease.

Diseases Subject to Reporting:
Reportable diseases typically include, but are not limited to, certain infectious diseases such as tuberculosis, hepatitis, and sexually transmitted diseases, among others as defined by local laws.

Privacy and Confidentiality:
Celesta Health is committed to maintaining the privacy and confidentiality of your health information within the constraints of the law. Other than the legally required reporting of certain diseases, your test results and personal health information will be handled in accordance with applicable federal and state privacy laws.

Responsibility and Rights:
You understand that it is your responsibility to provide accurate information for the at-home diagnostic test and that you have the right to discuss your results with a healthcare provider, who can help interpret the results and guide you on the appropriate next steps.

Consent:
By agreeing to this consent, you are authorizing Celesta Health to perform at-home diagnostic testing. You understand the nature of the testing, your responsibilities in the testing process, the potential need for result reporting to public health authorities, and the measures taken to protect your privacy.

Consent for Mail-Order Pharmacy
Informed Consent for Mail-Order

Pharmacy Services:
By accepting this consent form, you authorize Celesta Health to coordinate with licensed pharmacies to manage the fulfillment of your medication prescriptions via our mail-order pharmacy services. This service is designed to provide you with a convenient, efficient, and confidential means of receiving your medications.

Understanding Mail-Order Pharmacy Services:
Mail-order pharmacy services involve the processing of your prescriptions by a licensed pharmacy and the delivery of those medications directly to your designated address. This service is particularly beneficial for receiving ongoing medication supplies, such as for chronic conditions, without the need to visit a pharmacy in person.

Process of Prescription Fulfillment:
Upon receipt of a valid prescription from your healthcare provider, Celesta Health will work with a licensed pharmacy partner to process the prescription. The pharmacy will dispense the medication according to the prescribed instructions and ship it to the address you have provided to us.

Safety and Quality Assurance:
All partner pharmacies are required to comply with federal and state regulations regarding the dispensing of medications and patient privacy. They ensure that medications are stored and handled in accordance with pharmaceutical standards to maintain their efficacy and safety.

Privacy and Confidentiality:
The confidentiality of your medication information and personal data will be maintained in compliance with HIPAA regulations and state privacy laws. Your information will only be used to process your medication orders and will not be disclosed to any third parties without your express consent, except as required by law.

Medication Information and Counseling:
You have the right to receive comprehensive information about your medications, including instructions for use, potential side effects, and interactions with other drugs. You can request counseling from a licensed pharmacist at any time regarding your medications.

Responsibility for Reporting:
You agree to promptly report any issues with your medication delivery, such as delays, damages, or discrepancies, to Celesta Health or the dispensing pharmacy.

Consent:
By consenting to the use of mail-order pharmacy services provided by Celesta Health, you acknowledge that you understand the benefits and procedures of the service. You agree to the terms and conditions outlined in this consent and affirm that the information you provide for prescription fulfillment will be accurate and up-to-date.

Health Coaching
Informed Consent for Health Coaching:
This consent acknowledges your decision to engage in Health Coaching services offered by Celesta Health. Health Coaching is designed to support and guide you in making informed decisions about your health, fostering healthy lifestyle changes, and improving your overall well-being.

Nature of Health Coaching Services:
Health Coaching is a collaborative approach to care that involves helping you to set health-related goals, develop strategies to meet those goals, provide accountability, and offer support and education on health and wellness. Our Health Coaches are trained to facilitate behavior change but do not diagnose conditions, prescribe treatments, or provide psychological therapeutic interventions.

Scope of Practice:
You recognize that Health Coaching is not a substitute for professional medical advice, diagnosis, or treatment. It is intended to complement your healthcare regimen by focusing on health promotion and disease prevention. Our Health Coaches will work in conjunction with your healthcare provider to ensure a cohesive approach to your health.

Confidentiality:
Discussions with your Health Coach are confidential and will be protected as such. Information will only be shared with your healthcare provider with your consent, except as required by law.

Responsibilities:
You agree to communicate openly with your Health Coach, provide accurate information about your health, and work collaboratively to develop and implement your health plans. You understand that achieving health goals requires your active participation and adherence to the agreed-upon plan.

Voluntary Participation:
Your participation in Health Coaching is entirely voluntary, and you are free to withdraw at any time without affecting your future care.

Consent:
By consenting to Health Coaching services, you acknowledge that you have read and understand the nature and purpose of Health Coaching. You agree to actively engage in the process and incorporate the guidance into your health routine under the terms of this consent.

Use and Release of Medical Information
Informed Consent for Use and Release of Medical Information:
By accepting this consent, you authorize Celesta Health and its affiliates to use and disclose health information pertaining to your treatment, payment, and healthcare operations as permitted under the Health Insurance Portability and Accountability Act (HIPAA).

Purpose of Disclosure:
Your medical information may be used for the purposes of providing treatment, processing payment for services rendered, and conducting standard healthcare operations such as quality assessments, accreditation, and certification activities.

Limits of Disclosure:
Celesta Health will limit the release of information to the minimum necessary to accomplish the intended purpose, except where full disclosure is authorized by you or required by law.

Financial Agreement
Acknowledgment of Financial Responsibility:

You understand that Celesta Health provides services that are paid out-of-pocket and are not billed to insurance. Payment is required at the time of service, and you agree to be solely responsible for all charges incurred during your care.

Receipt for Reimbursement:
Celesta Health will provide a receipt for services, which you may submit to your insurance company for potential reimbursement. However, Celesta Health does not guarantee that you will be reimbursed by your insurance company.

Assignment of Benefits
Non-Applicability of Assignment of Benefits:
Given that Celesta Health does not participate in insurance billing, the usual Assignment of Benefits where an insurer pays the healthcare provider directly is not applicable. You are responsible for the full payment, and any reimbursement process is strictly between you and your insurance carrier.

Release of Information
Consent for Release of Information for Reimbursement:
If you intend to seek insurance reimbursement on your own, you hereby consent to Celesta Health releasing medical information and service receipts to your insurance carrier when necessary to facilitate the reimbursement process.

Consent for Automated Reminders

Detailed Consent for Automated Reminders:
Scope of Consent:
By providing your contact information to Celesta Health, you expressly consent to receive automated reminders and notifications related to your healthcare. This may include reminders for upcoming appointments, alerts to refill prescriptions, notifications regarding at-home diagnostic testing, and other health-related messages that are part of your care and treatment plan.

Types of Automated Reminders:
You agree that Celesta Health may contact you through various means, including but not limited to:

SMS Text Messages:
You consent to receive text messages to the mobile phone number you provide. Standard message and data rates may apply.

Automated Calls:
You consent to receive pre-recorded voice messages at the contact number you provide.

Email Notifications:
You consent to receive emails at the email address you provide, which may include health care information and reminders.

Management of Preferences:
You will have the option to manage your preferences for receiving automated reminders, including the ability to opt out of certain types of notifications or all automated reminders altogether, except where such communications are required by law.

Revocation of Consent:
You understand that you may revoke this consent at any time by notifying Celesta Health in writing, and the revocation will not affect any previous automated reminders sent before Celesta Health processes your request.

Confidentiality
Commitment to Confidentiality:
Celesta Health is committed to maintaining the confidentiality of all patient communications and records. Your health information will be treated as confidential and will only be disclosed in accordance with federal and state laws, including the Health Insurance Portability and Accountability Act (HIPAA).

Protection of Information:
We implement a variety of administrative, physical, and technical safeguards designed to protect your personal and health information from unauthorized access, disclosure, alteration, and destruction.

Disclosure of Information:
Information will only be shared with your explicit consent or as required by law, such as in the case of public health reporting or legal proceedings.

Access to Records
Right to Access:
You have the right, as afforded by HIPAA, to inspect and obtain a copy of your health information that may be used to make decisions about your care. This includes medical and billing records.

Request for Access:
To access your records, you must submit a written request to Celesta Health specifying what information you want to inspect or obtain. Celesta Health may charge a fee for the costs of copying, mailing, or other supplies associated with your request.

Denial of Access:
In certain circumstances, Celesta Health may deny your request to access your records, but you will be provided with a reason for the denial and information on how you can appeal the decision.

Changes to Health Record
Right to Amend:
You have the right to request an amendment of the health information you believe is incorrect or incomplete. You must provide a reason to support your request.

Procedure for Requesting Amendments:
Requests for amendments must be made in writing, and Celesta Health will respond within a specified timeframe, typically 60 days.

Acceptance or Denial of Amendment:
Celesta Health may deny the request if the information was not created by us, is not part of the records maintained by us, is not part of the information which you are permitted to inspect and copy, or if the information is already accurate and complete in the record.

Acknowledgment and Agreement
Affirmation of Consent:
By accepting this consent, you acknowledge that you have thoroughly read, fully understand, and agree to all the terms provided herein regarding automated reminders, confidentiality, access to records, and changes to your health record.

Duration of Consent:
This consent will remain in effect until you provide written notification to Celesta Health to withdraw your consent. Withdrawal of consent will not affect any processing of your information that has already occurred.
By signing this consent form, you are affirming your agreement to these terms and conditions as part of your engagement with Celesta Health’s services. Your signature demonstrates your understanding of your rights and responsibilities as a patient and your commitment to the outlined procedures.

Revocation
Right to Revoke Consent:
You have the right to revoke any and all parts of this consent in writing at any time. The revocation will not apply to information that has already been released in response to this consent. Nor will it affect any actions taken before Celesta Health receives your written notice of revocation.

Effectiveness of Revocation:
The revocation becomes effective immediately upon Celesta Health’s receipt of your written notice, and it will be reflected in your medical records.
By signing this document, you are agreeing to the terms and conditions as described in the sections above regarding the use and release of medical information, financial agreement, and revocation. Your signature acknowledges your understanding and acceptance of these terms as part of your consent to receive services from Celesta Health.