This agreement between ("Patient'') and TestoCore HRT Solutions LLC, dba TestoCore Hormonal Wellness
(TC establishes guidelines and conditions for the use of IV Vitamin and Hydration Therapy. TC and patient agree
that these guidelines and conditions are an essential factor In maintaining a successful patient/practitioner
relationship. Adverse side effects and/or physical/psychological dependence may develop after repeated use of
these medications and, therefore. these agents are prescribed with caution. The patient agrees and accepts to the
following conditions:
1. I understand that the Vitamins I am receiving are based on my submitted medical history, and the results of lab work (if
needed) and a physical examination. The medications are to be used exclusively for treatment of medical conditions In
accordance with applicable state and Federal law.
2. I certify that the answers I provided to the health questions on the Health History laboratories are accurate and correct to
the best of my knowledge and that I have not been coached by any third party nor have I knowingly been deceptive for
secondary gain, for medical treatment or prescription of a medication.
3. I do not have any history of Diabetes, Congestive heart failure or any other type of heart disease.
4. I have discussed and understand the risks and benefits associated with IV hydration therapy. I will immediately report any
adverse side effect related to my treatment to TestoCore HRT Solutions LLC, dba TestoCore Hormonal Wellness and
discontinue use until advised to resume usage by my health care provider. I voluntarily assume any and all possible risks which
may be associated with IV Hydration Therapy.
5. I understand that representatives of TestoCore HRT Solutions LLC, dba TestoCore Hormonal Wellness and/or Licensed
Physicians Assistant are available 'for questions and/or. concerning during normal business hours throughout the course of
my treatment.
6. I understand that IV Hydration Therapy is not covered by health insurance. I agree that all services and medications provided
by TestoCore HRT Solutions LLC, dba TestoCore Hormonal Wellness Vero Beach or its associated providers are to be paid for
in advance. I will not seek reimbursement through my health insurance company, Medicare, Medicaid, or other third party
payer.
7. I agree that the TestoCore HRT Solutions LLC, dba TestoCore Hormonal Wellness/physician relationship is not intended to
replace the existing patient/physician relationship with my current primary care provider (PCP) and the treatment provided
by TestoCore HRT Solutions LLC, dba TestoCore Hormonal Wellness Vero Beach will be in conjunction with the care provided
by my current PCP.
8. I agree that I will use my medication at the prescribed rate and dosage and will keep the medication In its respective labeled
container.
9. I have read and agree to the terms of this the Therapy Management Agreement.
10. I consent to text and email message appointment reminders. (Data rates may apply).
This agreement between ("Patient") and TestoCore HRT Solutions LLC, dba TestoCore Hormonal Wellness establishes
guidelines and conditions for the use of hormone replacement therapy ("HRT") involving DEA "controlled" or
"scheduled" medications. PP and patient agree that these guidelines and conditions are an essential factor in
maintaining a successful patient/practitioner relationship. Adverse side effects and/or physical/psychological
dependence may develop after repeated use of these medications and, therefore, these agents are prescribed with
caution. The patient agrees and accepts to the following conditions:
1. I understand that the medications I am receiving or will receive are prescribed for me based on diagnoses derived from my
submitted medical history, and the results of lab work and a physical examination. The medications are to be used exclusively
for treatment of hormonal deficiencies and related medical conditions in accordance with applicable state and Federal law.
2. I understand and agree that no medical treatment or medication provided to me by.
3. TestoCore HRT Solutions LLC, dba TestoCore Hormonal Wellness will be used for the purposes of bodybuilding, performance
enhancement or physical appearance.
4. I certify that the answers I provided to the health questions on the Health History laboratories are accurate and correct to
the best of my knowledge and that I have not been coached by any third party nor have I knowingly been deceptive for
secondary gain, for medical treatment or prescription of a medication.
5. I will not attempt to obtain HRT medications from any other health care practitioner without disclosing my current
medical usage of HRT or other medications. I understand that it may be against the law to do so.
6. I have discussed and understand the risks and benefits associated with HRT. I will immediately report any adverse side
effect related to the use of my HRT to TestoCore HRT Solutions LLC, dba TestoCore Hormonal Wellness and discontinue
use until advised to resume usage by Progressive Health Institute. I voluntarily assume any and all possible risks
which may be associated with HRT.
7. I understand that representatives of TestoCore HRT Solutions LLC, dba TestoCore Hormonal Wellness and/or licensed
Physicians Assistant are available for questions and/or concerning during normal business hours throughout the course of
my treatment.
8. I agree that the HRT medications furnished by TestoCore HRT Solutions LLC, dba TestoCore Hormonal Wellness are for my
personal use only and for no other purpose. I will not share, sell. or trade my medications. I will safeguard my
medications from loss or theft and will be responsible for their safekeeping.
9. I will be able to purchase the medications from the pharmacy designated by TestoCore HRT Solutions LLC, dba
TestoCore Hormonal Wellness and the pharmacy will send medication directly to me. I understand I have the right to
purchase my medications from any.
10. Pharmacy of my choice. If I chose to obtain medications from a pharmacy of my own choice, I must notify TestoCore
HRT Solutions LLC, dba TestoCore Hormonal Wellness in writing of my intention to do so and include the name of the
pharmacy in my request.
11. I agree and understand that federal regulations prohibit the return of prescribed medications.
12. I understand that HRT treatment and medications are not covered by health insurance. I agree that all services
and medications provided by TestoCore HRT Solutions LLC, dba TestoCore Hormonal Wellness or its associated providers are
to be paid for in advance. I will not seek reimbursement through my health insurance company, Medicare, Medicaid, or
other third party payer.
13. I agree that the TestoCore HRT Solutions LLC, dba TestoCore Hormonal Wellness patient/physician relationship is
not intended to replace the existing patient/physician relationship with my current primary care provider (PCP) and the
treatment provided by TestoCore HRT Solutions LLC, dba TestoCore Hormonal Wellness will be in conjunction with the care
provided by my current PCP.
14. I agree that I will use my medication at the prescribed rate and dosage and will keep the medication in its respective
labeled container.
15. I understand that TestoCore HRT Solutions LLC, dba TestoCore Hormonal Wellness only treats patients over the age of
30 with documented symptoms of hormone deficiencies (Hypogonadism and Adult Growth Hormone Deficiency). No
prescription will be provided unless a clinical need exists based on required lab work, physician consultation, and current
health history through either patient's personal physician or a Progressive Health Institute - affiliated physician. Agreeing
to lab work does not automatically qualify patient to clinically necessity and prescription of HRT.
I consent to text and email message appointment reminders. (Data rates may apply)
HIPAA
The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your
privacy. Implementation of HIPAA requirements officially began April 14, 2003. Many of the policies have
been our practice for years. This form is a “friendly” version. A more complete text is posted in the office.
What is this all about: Specifically, there are rules and restrictions on who may see or be notified of your
Protected Health Information (PHI). These restrictions do not include the normal interchange of
information necessary to provide you with office services. HIPAA provides certain rights and protections
to you as the patient. We balance these needs with our goal of providing you with quality professional
service and care. Additional information is available from the U.S. Department of Health and Human Services. www.hhs.gov
We have adopted the following policies:
1. Patient information will be kept confidential except as is necessary to provide services or to
ensure that all administrative matters related to your care are handled appropriately. This
specifically includes the sharing of information with other healthcare providers, laboratories,
health insurance payers as is necessary and appropriate for your care. Patient files may be stored
in open file racks and will not contain any coding which identifies a patient’s condition or
information which is not already a matter of public record. The normal course of providing care
means that such records may be left, at least temporarily, in administrative areas such as the
front office, examination room, etc. Those records will not be available to people other than
office staff. You agree to the normal procedures utilized within the office for the handling of
charts, patient records, PHI and other documents or information.
2. It is the policy of this office to remind patients of their appointments. We may do this by
telephone, e-mail, U.S. mail, or by any means convenient for the practice and/or as requested by
you. We may send you other communications informing you of changes to office policy and new
technology that you might find valuable or informative.
3. The practice utilizes several vendors in the conduct of business. These vendors may have access
to PHI but must agree to abide by the confidentiality rules of HIPAA.
4. You understand and agree to the inspection of the office and review of documents which may
include PHI by government agencies or insurance payers in normal performance of their duties.
5. You agree to bring any concerns or complaints regarding privacy to the attention of the office
manager or medical providers.
6. Your confidential information will not be used for the purposes of marketing or advertising of
products, goods, or services.
7. We agree to provide patients with access to their records in accordance with state and federal
laws.
8. We may change, add, delete, or modify any of these provisions to better serve the needs of both
the practice and patient.
9. You have the right to request restrictions in the use of your protected health information and to
request change in certain policies used within the office concerning your PHI. However, we are
not obligated to alter internal policies to conform to your request.
