Notices Specific to States

Surrogacy4all follows and is governed by these notices. On your becoming a patient of the practice, you acknowledge receipt of these notices and accept that they will  govern your medical treatment by Surrogacy4all  PC. You acknowledge that you accept the practices and policies mentioned below.

USE OF PROTECTED HEALTH INFORMATION AND DISCLOSURES

ALASKA  

I am aware that my primary care doctor may request a copy of my telehealth encounter data. (Alaska Stat. 08.64.364).

ARIZONA

I am aware that any medical records generated by a telemedicine consultation will become a component of my medical file. (A.R.S. § 12-2291.)

CALIFORNIA

The Medical Board of California issues licenses and administers regulations to physicians. Visit www.mbc.ca.gov, send an email to licensecheck@mbc.ca.gov , or dial 800-633-2322 to check the status of a license or to submit a complaint.

Visit https://www.mbc.ca.gov/licensing/Notice-to-Consumers.aspx  to view the Medical Board of California’s Notice to Consumers website.

COLORADO

According to what I have been told, I should make a formal complaint about a provider at https://dpo.colorado.gov/FileComplaint.

CONNECTICUT

I am aware that my telehealth encounter records may be shared with my primary care physician and that I have the right to withdraw my permission at any time. 19a-906 of the Connecticut General Statutes.

D.C.

I have been told that there are alternative ways for me to contact a doctor in case of an emergency. D.C. Mun. Regs. Tit. 17, Section 4618.10.

FLORIDA

Florida’s Consumer Bill of Rights for Weight Loss

The rights of customers looking for expert weight-loss services are outlined in Florida Statute 501.0575. Please review the following rights:

1. Warning: Serious health issues could result from rapid weight reduction. Rapid weight loss after the second week of involvement in a weight loss program is defined as weight loss of more than 1 12 to 2 pounds per week or weight loss of more than 1% of body weight per week.
2. Before beginning any weight-loss program, speak with your personal doctor.
3. Long-term weight loss can only be aided by permanent lifestyle changes, like choosing wholesome foods and upping physical exercise.
4. On request, this provider’s credentials are accessible.

You are entitled to:

1. Inquire about the program’s dietary provisions, psychological support, and instructional aspects as well as any health risks.
2. Get a detailed statement detailing the cost of the weight reduction program, including any additional items, services, supplements, checkups, or lab tests.
3. Be aware of the program’s real or projected duration.
4. In accordance with Section 468.505(1)(I) of the Florida Statutes, be aware of the name, address, and credentials of the physician, dietician, or nutritionist who has examined and authorized the weight-loss program.

Please attentively read the following information before signing the patient’s informed consent to use appetite suppressants. Please sign the following page to acknowledge your comprehension and agreement.

1. Alternatives and procedures:
2. I have read and comprehend each of the following statements, and I am aware that there is a lack of scientific evidence pertaining to the possible risk of long-term use of combination weight-management programs that include GLP-1 medications. B. I am aware that it is my responsibility to closely adhere to my doctor’s instructions and to report any medical issues as soon as possible, regardless of whether I believe they may be connected to my weight management program. I further declare that I am not pregnant right now and that I will notify my doctor right away if I become pregnant. C. I am aware that there are additional strategies and programs that can help me lose weight and keep it off. If I adhered to a healthy diet and exercise regimen, I could achieve success without taking a GLP-1 agonist.
3. Risks of Proposed Treatment:

I am aware that there are several side effects when taking any drug, and that taking GLP-1 medications has been linked to gastrointestinal symptoms, particularly nausea, vomiting, and diarrhea. Reactions at the injection site, headaches, and nasopharyngitis are additional frequent adverse effects. If I am taking another medication known to lower blood sugar at the same time, such as sulfonylureas or insulin, hypoglycemia (low blood sugar levels) may be a danger. I am aware that taking GLP-1 medicines is not advised if I have had pancreatitis, multiple endocrine neoplasia, medullary thyroid cancer, or either of these conditions in the past.

III. Risks of Being Overweight or Obese:

I am aware that being overweight or obese entails several risks, including a propensity for high blood pressure, diabetes, heart disease, hip, knee, and foot arthritis, as well as some malignancies. I am aware that these risks could be minimal if I am not extremely overweight, but that they rise with any weight gain.

1. No Promises:

I am aware that my efforts and adherence to the program will be a big part of its success. I am aware that despite my efforts, there are no assurances or guarantees that this program will be effective. I also realize that if I want to succeed, I will have to maintain a healthy weight throughout my existence.

Signature of the patient: _________________ Signature of the doctor: _________________

When: ________________________ When: ________________________

Title XXXIII governs regulation of trade, commerce, investments, and solicitations.

Consumer Protection Act, Chapter 501

Weight-Loss Consumer Bill of Rights, Section 501.0575.

(1) The following clauses make up the weight-loss consumer bill of rights: 

RAPID WEIGHT LOSS IS WEIGHT LOSS OF MORE THAN 11/2 POUNDS TO 2 POUNDS PER WEEK OR WEIGHT LOSS OF MORE THAN 1% OF BODY WEIGHT PER WEEK AFTER THE SECOND WEEK OF PARTICIPATION IN A WEIGHT-LOSS PROGRAM. (A) WARNING: RAPID WEIGHT LOSS MAY CAUSE SERIOUS HEALTH PROBLEMS.

(B) BEFORE STARTING ANY WEIGHT-LOSS PROGRAM, SPEAK WITH YOUR PERSONAL PHYSICIAN.

(C) ONLY LONG-TERM WEIGHT LOSS IS PROMOTED BY PERMANENT LIFESTYLE CHANGES, LIKE SELECTING HEALTHY FOODS AND INCREASING PHYSICAL ACTIVITY.

(D) THIS PROVIDER’S QUALIFICATIONS ARE AVAILABLE UPON REQUEST.

(E) You are entitled to:

4. ASK QUESTIONS ABOUT THE POTENTIAL HEALTH RISKS OF THIS PROGRAM, AS WELL AS ABOUT THE NUTRITIONAL CONTENTS, PSYCHOLOGICAL SUPPORT, AND EDUCATORY ELEMENTS.
5. GET AN ITEMIZED STATEMENT OF THE WEIGHT-LOSS PROGRAM’S ACTUAL OR ESTIMATED COST, INCLUDING ADDITIONAL GOODS AND SERVICES, SUPPLEMENTS, EXAMS, AND LABORATORY TESTS.
6. KNOW THE PROGRAM’S ACTUAL OR ESTIMATED DURATION.
7. KNOW THE NAME, ADDRESS, AND SKILLS OF THE NUTRITIONIST OR DIETITIAN WHO HAS REVIEWED AND APPROVED THE WEIGHT-LOSS PROGRAM IN ACCORDANCE WITH S. Florida Statutes, section 468.505(1)(j).

(2) The weight-loss consumer bill of rights copies that must be displayed in accordance with s. 501.0573(6) must be displayed on one side of a sign in at least 24-point bold font. according to s., the palm-sized copies will be disseminated. 501.0573(5) must be visible and in boldface. The Weight-Loss Consumer Bill of Rights must be created and printed in the proper quantities by each weight-loss provider.

History.—s. 4, Ch. 93-274; s. 45, Ch. 2000-154

GEORGIA

If I need urgent medical attention related to the treatment, I have received clear, pertinent, and accurate directions on how to proceed. (Ga. Comp. Rules and Regulations 360-3-.07(7)).

IDAHO

I have been told to go to the medical board’s website if I want to file an official complaint about a provider.

ILLINOIS

I have been told to go to the Illinois Division of Professional Regulation if I want to file an official complaint about a provider.

INDIANA

You can use the online complaint form or contact 1-800-382-5516 or 317-232-6330 to obtain a complaint form, which you can then submit to the Attorney General’s Office.

IOWA

I have been told to go to the medical board’s website if I want to file an official complaint about a provider.

KANSAS

I am aware that if I have a primary care physician or another treating physician, I have the right to request that the person providing telemedicine services send a report of the treatment and services provided to me during the telemedicine encounter to my primary care or other treating physician within three business days (see Kan. Stat. Ann.  40-2,212(2)(d)(2)).(A). I am aware that this website, http://www.ksbha.org/complaints.shtml, contains information on the complaint procedure.

KENTUCKY

I have been told to go to the medical board’s website if I want to file an official complaint about a provider.

LOUISIANA

I am aware that in addition to the telehealth service, other medical professionals may be present during the consultation. (46 La. Administrative Code, Pt. XLV, 7511).

MAINE

I have been told to go to the medical board’s website if I want to file an official complaint about a provider.

MARYLAND

I am aware that one key distinction between telehealth and in-person service delivery for audiologists, speech language pathologists, and hearing aid dispensers is the inability to have direct, physical interaction with the patient. It is not necessary for the provider of telehealth services to fully understand or be aware of the knowledge, experiences, and credentials of the consultant giving data and information to them. The provider’s ability to deliver high-quality services may be impacted by the content of transmitted data. It might not be feasible to alter the environment or test conditions while providing telehealth services. Telehealth services cannot be given exclusively via email. 10.41.06.04 of the Maryland Code). I have been told to go to the medical board’s website if I want to file an official complaint about a provider.

NEBRASKA

If I am a Medicaid recipient, I have the choice to decline the telehealth consultation at any time without jeopardizing my ability to receive future care or treatment or running the risk of having any program benefits to which I would otherwise be eligible being lost or withdrawn. The telehealth consultation shall be subject to all currently in effect secrecy safeguards. As permitted by legislation for access to my medical records, I shall have access to all medical information resulting from the telehealth consultation. Without my written permission, no images or data from the telehealth consultation that could be used to identify the patient will be shared with researchers or other organizations. I am aware that I have the option to ask for an in-person consultation right away following the telehealth consultation, and that I will be told if one is not offered. (Neb. Rev. Stat. Ann. 71-8505; 471 Neb. Admin. Code 1-006.05). (“Informed Consent & Use of Telehealth Technology | Right way”) I have been told to go to this website if I want to file an official complaint about a provider.

HAMPSHIRE, NEW

I am aware that the telehealth provider may give my primary care doctor or other treating provider access to my medical information. (N.H. Rev. Stat., Section 329:1-d).

JERSEY, NEW

I am aware that I have the right to ask for a copy of my medical records, and that they may be sent to other healthcare providers at my request or immediately to my primary care doctor or the health care provider on file. 45:1-62 of the New Jersey Revised Statutes.

OKLAHOMA

According to what I have been told, I should go to the medical board’s website at http://www.okmedicalboard.org/complaint if I want to file an official complaint about a provider. You can find the Board of Osteopathic Examiners at https://www.ok.gov/osboe/faqs.html .

NEW ENGLAND

If I communicate with my provider via email or text, I comprehend the kinds of transmissions that will be allowed and the situations in which other methods of communication or office visits should be used. I have also talked about privacy concerns and security precautions like data encryption, password-protected screen savers and data files, and the use of other trustworthy verification methods. I understand that if I do not abide by this contract, the telehealth service may end our email correspondence. (Rhode Island Medical Board Guidelines).

SAINT CAROLNIA

I am aware that my medical records might be given to other treating health care professionals in accordance with any relevant law or regulation. (S.C. Code Ann., Section 40-47-37).

SAINT DAKOTA

I have been made aware of any limitations on the treatment options and delivery modes. The diagnosis, its supporting evidence, and the advantages and disadvantages of the different treatment choices have all been discussed with the telehealth provider. (S.D. Codified Laws, section 34-52-3).

TENNESSEE

I am aware that if I am a Medicaid recipient, I may ask for an in-person evaluation before getting a telehealth evaluation.

TEXAS

I am aware that my primary care physician may receive a copy of my medical information. 111.005 of the Texas Occupations Code. I have been made aware of the upcoming notice:

NOTICE REGARDING COMPLAINTS: You can report complaints about doctors, as well as other licensees and registrants of the Texas Medical Board, such as physician assistants, acupuncturists, and surgical assistants, for investigation at the following address: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018; 1-800-201-9353; for more information, please check our website at www.tmb.state.tx.us; assistance with filing a complaint is available.

ADVICE REGARDING QUESTIONS- Concerns regarding physicians, along with those regarding other licensed and registered members of the Texas Medical Council, such as physician assistants, acupuncturists, and surgical assistants, may be brought to the following address to be investigated: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018; If you need assistance to file a complaint, call 1-800-201-9353; for more information, go to our website at www.tmb.state.tx.us.

UTAH

I am aware of the following: (i) any additional fees for telehealth services, if any, and the method of payment for those additional fees, if those fees are charged separately from any fees for in-person services provided in conjunction with the telehealth services; (ii) the recipients and purposes for which my health information may be disclosed; and (iii) any consents governing the release of my patient-identifiable information to third parties. I am aware that the telehealth services adhere to all applicable laws and regulations and satisfy industry security and privacy standards (see Section 26-60-102(8)(b)).(ii). I understand there could be privacy risks despite the security precautions in place, and I promise to hold the provider harmless if information is lost due to technical issues. I now have the website address and contact details for the telehealth business. To the extent that it was possible, I was allowed to choose my service provider. I had the option to choose my preferred drugstore. I have the following rights: a (i) access, complete, and amend my patient-provided personal health information; b (ii) get in touch with my doctor for further treatment; c (iii) request a transfer of my medical record containing the telemedicine services to another provider; and d (iv) obtain upon request an electronic or paper copy of my medical record containing the telemedicine services, including the informed consent given. (Utah Admin. Code r. 156-1-603).

VERMONT

I am aware that I am entitled to and will receive a consultation from a provider at a distant site upon request, either instantly or within a reasonable period following the conclusion of the initial consultation.

I have been told that if I want to file an official complaint about a provider, I should go to the website of the medical board or send a report to the Board of Osteopathic Examiners.

VIRGINIA

I agree to hold Surrogacy4all   harmless for data lost due to technical malfunctions; I acknowledge that I have received information on security measures taken with the use of telemedicine services, such as encrypting date of service, password-protected screen savers, encrypting data files, or utilizing other trustworthy authentication techniques, as well as potential risks to privacy notwithstanding such measures; and I give my express consent to forward patient-identifiable information. (Virginia Board of Medicine Guidance Document 85-12).

ZERO RETALIATION

We will not take any action against you in retaliation for bringing a grievance against us, the Secretary, or another state office.

To contact us:

Please email Surrogacy4all  at info@surrogacy4all.com  if you have any questions, comments, or issues about these notices.

Surrogacy4all , 1148 Fifth Avenue, Suite 1B New York, NY 10128  (“Surrogacy4all  Contact Us”)

 Phone: (212) 661-7673