Telehealth Medical Disclaimer & Informed Consent

Lunaris Health PLLCFor Patients Receiving Telehealth Services in Arizona, Florida, and West Virginia

 

 

1. Nature of Telehealth Services

Lunaris Health PLLC (“we,” “us,” “our”) provides healthcare services exclusively via telehealth. Telehealth involves the remote delivery of healthcare using electronic communication technologies such as video, phone calls, and secure messaging. While telehealth allows timely access to care, it has inherent limitations compared to in-person visits, including inability to perform physical examinations or certain diagnostics.

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2. No Emergency Care

We do not provide emergency medical services. If you are experiencing a medical emergency or symptoms requiring immediate attention (e.g., chest pain, difficulty breathing, severe injury), call 911 or visit the nearest emergency room.

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3. Scope of Practice and Licensing

Services are provided only to adult patients (18 years or older) physically located in Arizona, Florida, or West Virginia at the time of the telehealth visit. All services are delivered by Meltem Randle, AGACNP-BC, licensed and authorized to practice in these states with full prescriptive authority, including controlled substances prescribing per applicable laws. Services are limited to those within the scope of practice for an Adult-Gerontology Acute Care Nurse Practitioner.

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4. No In-Person Visits or Insurance

All consultations and care are delivered remotely via telehealth platforms. We do not offer in-person visits, and we do not accept insurance. Our services are provided strictly on a self-pay basis. Patients are responsible for all fees.

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5. Prescribing and Medication Disclaimer
Medications, including controlled substances, may be prescribed following a telehealth visit if clinically appropriate and compliant with state and federal laws. Prescriptions require establishing a provider-patient relationship via telehealth. Prescriptions are issued only when medically necessary and may be declined based on clinical judgment.

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6. Privacy and Security
We use HIPAA-compliant platforms, including Charm Health and doxy.me, for telehealth consultations, messaging, scheduling, and medical records access. While we take reasonable measures to protect your privacy, no electronic transmission or storage of health information can be guaranteed 100% secure. We require all patients to register for and use the secure Charm Health patient portal for communication and records.

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7. Patient Responsibilities
You agree to provide accurate and complete medical information during telehealth visits and to follow all instructions and recommendations. You understand that telehealth may not be appropriate for all conditions and that follow-up or in-person evaluation may be necessary.

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8. No Guarantee of Outcomes
Healthcare outcomes vary by individual. Lunaris Health PLLC does not guarantee any specific results from telehealth services.

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9. Governing Law
This disclaimer and all telehealth services are governed by the laws of the state in which you are physically located at the time of service (Arizona, Florida, or West Virginia).

Controlled Substance Prescribing Limitations for Florida and West Virginia Telehealth Patients

Lunaris Health PLLC providers are licensed in Arizona and hold telehealth registrations in Florida and West Virginia. While we offer comprehensive telehealth mental health services including diagnosis and management of conditions such as depression, anxiety, postpartum depression, ADHD, and mood disorders, the ability to prescribe controlled substances (Schedule II-V) via telehealth is limited by state law in Florida and West Virginia.

• In Florida:
  Without a Florida Controlled Substance Registration and Florida DEA registration, we cannot prescribe Schedule II-V controlled substances to Florida patients, even after establishing a telehealth provider-patient relationship. Non-controlled medications may still be prescribed under your Arizona license and telehealth registration.

• In West Virginia:
  Similarly, without West Virginia Controlled Substance Registration and a West Virginia DEA registration, prescribing Schedule II-V controlled substances via telehealth is not permitted. Non-controlled medications may be prescribed consistent with your Arizona license and West Virginia telehealth registration.

• In All Cases:
  When controlled substance prescribing is not possible due to these restrictions, we will discuss alternative treatment plans or referrals to appropriate providers licensed in your state.

• Patients are responsible for understanding these prescribing limitations and are encouraged to ask questions if unsure about medication options.

 

 

Telehealth Informed Consent

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By electronically signing below, you acknowledge and agree to the following terms regarding your telehealth care with Lunaris Health PLLC:

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1. Consent to Telehealth Services
I voluntarily consent to receive healthcare services via telehealth from Lunaris Health PLLC. I understand that telehealth involves the use of electronic communications to enable healthcare providers to diagnose, treat, and manage my care remotely.

 

2. Risks and Benefits
I understand that telehealth has benefits, including increased access and convenience. I acknowledge the risks, including potential delays, technical issues, limited physical examination, and privacy risks inherent in electronic communications.

 

3. Provider-Patient Relationship
I understand that a provider-patient relationship will be established via telehealth consultation. I acknowledge that prescriptions, including controlled substances, will be issued only after such a relationship is established and based on clinical appropriateness.

 

4. Privacy and Security
I understand that Lunaris Health PLLC uses HIPAA-compliant platforms (Charm Health and doxy.me) for telehealth. I agree to register for and use the secure Charm Health patient portal for messaging and access to my medical records. I understand there are inherent security risks despite safeguards.

 

5. Emergency Situations
I agree that Lunaris Health PLLC does not provide emergency services. In case of emergency, I will seek care immediately at an emergency facility or call 911.

 

6. Location and Eligibility
I certify that I am physically located in Arizona, Florida, or West Virginia at the time of the telehealth visit and that I am 18 years or older.

 

7. Financial Responsibility
I understand that telehealth services are self-pay and that I am responsible for all fees at the time of service. I understand insurance is not accepted.

 

8. Patient Rights
I understand I may refuse telehealth services at any time and that I have the right to request an in-person visit if clinically necessary.

 

9. Acknowledgment and Consent
I have read, understood, and agree to the Medical Disclaimer and Telehealth Informed Consent terms. I consent to receive telehealth services from Lunaris Health PLLC under these conditions.

Patient Acknowledgment

Patient Name (Print): ___________________________
Date of Birth (MM/DD/YYYY): _____________________
Electronic Signature: ____________________________
Date (MM/DD/YYYY): ____________________________