Consent to Telehealth Services

Last updated: March 1, 2021

MyMenopauseRx is an online doctor's office devoted to menopause care.

Medical Team

The dedicated medical team at MyMenopauseRx is made up of doctors and nurse practitioners - collectively known as the “Providers”, nurses and medical assistants. The providers are all members of the North American Menopause Society and are certified menopause practitioners or actively working toward certification.

Video Visits

MyMenopauseRx medical visits are conducted via a live video consultation. Phone or email visits are not utilized to deliver healthcare. Secure clinical messaging is available on your patient dashboard.

I understand and agree that telemedicine involves the use of audio, video or other electronic communications to interact with me and/or review my medical information for the purpose of diagnosis, treatment, follow-up and /or education related to menopause. I understand ancillary health care professionals (i.e. nursing or medical assistants) may participate in the MyMenopauseRx telehealth service under the supervision of the provider.

I understand one of the benefits of the MyMenopauseRx online doctor’s office is having access to menopause specialists and additional medical information/education without having to travel outside of my local healthcare community. However, I understand there are limitations of the MyMenopauseRX model of care via telehealth and the risks and benefits of any proposed treatment plan.

I understand that by using an online doctor’s office to treat my menopause symptoms, the provider won't have the opportunity to conduct a detailed in-person physical examination. I understand this is an important difference between MyMenopauseRX and traditional gynecologic healthcare.

I understand there is a risk that an alternative and potentially life-threatening cause of my symptoms (such as cancer, infection, stroke, thyroid problems, etc) could be missed with an online model of care. A delay in diagnosing and treating the true cause of my menopause symptoms could occur and I may take prescription medicines unnecessarily thus exposing myself to the risks of taking those medicines. I understand the provider will rely on my self-reported medical history, menopause questionnaire, and discussion over live video to help rule out alternative causes of my menopause symptoms. If I do not provide accurate information, I understand the provider may misdiagnose my symptoms and offer treatment that was unnecessary potentially delaying a diagnosis or exposing me to treatment that I did not need. I understand that by using MyMenopauseRx, I accept the responsibility to provide full and truthful answers to all questions asked. I understand that even if I provide information that is true and complete, I'm still at risk of adverse events from any treatment that the provider prescribes. I understand that the provider is unable to independently verify the information that I provide.

Privacy

I understand my video visit will not be recorded. If people are close to me during my video visit, they may hear something I did not want them to know. I understand MyMenopauseRx recommends I be in a private place, so other people cannot hear me. MyMenopauseRx uses telehealth technology that is designed to protect my privacy. If I use the Internet for telehealth, I understand it is recommended I use a network that is private and secure. While MyMenopauseRx employs the latest industry standards to run their telehealth platform, I understand technical problems may interrupt or stop my visit before my visit is complete.

I understand that although MyMenopauseRx implements a wide range of administrative, physical, and technical safeguards to protect my health information, in rare circumstances security protocols could fail or be hacked causing a breach of my patient privacy. For these reasons, MyMenopauseRx cannot guarantee the privacy and confidentiality of my health information.

Requirements for Care

I understand that I should not use MyMenopauseRx for my menopause symptoms if I am younger than age 40 or have a history of breast cancer, uterine cancer or vulvar cancer. I understand that I should not use MyMenopauseRx for online care if I have been diagnosed with a genetic mutation that would increase my risk of a gynecologic related cancer.

Prescriptions

MyMenopauseRx is not a pharmacy. Medications will be sent to the pharmacy I listed in my patient dashboard. I understand I may change my preferred pharmacy at any time. I understand it is my responsibility to change my pharmacy in my patient dashboard. If I desire a pharmacy change after the initiation of my video visit, it is my responsibility to arrange a pharmacy-to-pharmacy transfer by calling the pharmacy I would like to fill my prescription. MyMenopauseRx does not send prescriptions to pharmacies based outside the US.

I understand the providers do their best to prescribe FDA approved medications to treat my menopause symptoms. Generic medications are recommended first when they are available. Some of the medications recommended to me may be considered ‘off label,’ meaning they are not officially FDA approved for the symptom they were recommended to treat but their use is supported in the medical literature in line with the standard of care in clinical practice. MyMenopauseRx does not prescribe controlled substances.

Emergency Care

I understand that I should never use MyMenopauseRx in a medical or psychiatric emergency. I understand that in an emergency, I should dial 911 or go to the closest emergency department.

Accepting Responsibility of Care

I understand that the MyMenopauseRx provider will take responsibility for my care only after he or she has determined I am a good candidate for online menopause care. The duty of care only begins when the provider accepts the duty of care. The duty of care does not begin at me making an appointment, answering health questions, making payment, starting a video visit or requesting treatment.

Only after I have created an account, answered all the required health questions, completed the menopause questionnaire, made payment and have had a video visit, can the provider determine that I am a good candidate for the telehealth services provided by MeMenopauseRx.

I understand that the provider has the right to refuse to take responsibility for my care if they make a professional judgment that I am not a good candidate for their online service. I understand that making a request for treatment or a lab service (making payment or by starting a video visit), completing a lab service or sending a message through the website does not in and of itself create a duty of care or create a doctor-patient relationship.

MyMenopauseRx duty of care does not extend to my wider health, even if I told the provider information about my health as part of the intake questionnaire or during a video visit.

I understand that if I complete an online visit and the provider refuses to accept the duty of care, I will be recommended to seek treatment with a traditional menopause provider listed on the North American Menopause Society Website. Payment for service will not be reimbursed as the provider used their medical judgment to review my medical history, menopause questionnaire and then completed medical decision making regarding my personal health complaints to determine the best possible care for me. If I am recommended to utilize an in-person menopause specialist, I may still use the MyMenopauseRx self-order lab testing service.

Treatment

I understand that the providers at MyMenopauseRx will educate me with information to help me make an informed decision about whether to accept a proposed treatment plan. This information includes but is not limited to the benefits, risks and alternative treatment options available to me, including the option of not taking any treatment. I understand that it is ultimately my responsibility to make an informed decision whether to accept a treatment plan the provider recommends.

I understand that any medications the provider may prescribe or recommend, including over-the-counter medicines can cause side effects and/or adverse events. This includes a severe allergic reaction, permanent disability, and even death. I understand the importance of reading all information that comes with a medicine, including an over- the-counter medicine/supplement, before I take a medicine.

I understand that adverse events can be caused by a number of things, including an allergic reaction, side effects, or interactions between a medicine that a provider prescribes and any medical conditions I may have, other prescription medicines, supplements, herbs, over-the- counter medicines, or recreational drugs I'm taking. I understand my lifestyle choices such as smoking tobacco products, drinking alcohol, using marijuana or illegal drugs can contribute to an adverse event.

I understand I am expected to refer to my video visit summaries for a review of the risks/benefits and alternatives to treatment discussed at my video consultation.

I understand that the providers at MyMenopauseRx encourage me to share my visit summaries available on my patient dashboard with my primary care provider and or local Ob/Gyn.

Lab Testing

I understand the lab testing ordered by MyMenopauseRx is performed at Quest Diagnostics and not by MyMenopauseRx itself. I understand that if advised to fast for lab testing as indicated on the website, and I do not follow instructions, lab results may not be accurate and I may be asked to repeat the testing at my own expense. I understand that MYMenopauseRx does not accept medical insurance for payment for lab testing. I understand that I may be able to use my FSA/HSA accounts.

I understand there may be a delay of a number of days before MyMenopauseRx providers review my completed lab test or any messages I send.

Provider Recommended Lab Testing

I understand that MyMenopauseRx providers may order lab tests, help me understand the tests results and advise me on next steps. The duty of care related to lab testing ordered by MyMenopauseRx is restricted exclusively to the act of ordering and interpreting specific lab tests ordered and completed utilizing the MyMenopauseRx lab testing service and only after payment was made to MyMenopauseRx and the lab test was completed.

I understand that it's my responsibility to seek follow-up care and ongoing care from an in person healthcare provider if recommended by MyMenopauseRx after interpretation of my lab results. The duty of care of MyMenopauseRx does not include outside lab testing I may have provided to the provider for information related to my complaints.

Self-ordered Lab Testing

If I elect to use the self-ordered lab testing service available on the MyMenopauseRx website, the duty of care of MyMenopauseRx providers and associated clinical staff is restricted to ordering and interpreting the specific lab testing I self selected. I understand the MyMenopauseRx provider will interpret the results of my self-ordered lab testing for my informational purpose only and does not begin a doctor-patient relationship. I understand interpretation of labs will occur via a message in my patient dashboard. I agree that I am solely responsible for checking my dashboard for results and arranging any follow up with a local in person provider.

Breast Health

I understand that if I choose to use hormone therapy, MyMenopauseRx requests I upload a recent mammogram report into my patient dashboard. I understand that the My MenopauseRx provider will not order testing for my breast health and I am expected to have my primary care physician or local OB/GYN order and interpret my breast health testing. I understand the duty of care for evaluation and treatment of my breast health does not extend to MyMenopauseRx or it’s providers.

Messaging

I understand that I may message the MyMenopauseRx clinical team through my patient dashboard for all non-urgent questions. I understand there may be a delay of a number of days before they review any messages I send. I understand that I must check my dashboard for messages because this is the way that the provider will communicate important information to me. I understand that if I don't check my dashboard regularly, then my care may be delayed. I understand that to read important information in my messages and on the website, I may need to both click on links and various titles to expand the information that's visible.

Professional Medical Advice

I understand that the only content that constitutes professional medical advice is the personalized messages a provider sends me and/or advice that a provider discusses in my video consultation (once the provider has taken responsibility for my care), No other content on the Website constitutes professional medical advice and is for information purposes only. Never disregard professional medical advice or delay in seeking it because of something you have read on the MyMenopauseRx Website.

Payment for Services

I understand that I am not utilizing my medical insurance for this service. I understand that a menopause specialist covered on my health plan may be available for an in person visit but have chosen to seek convenient, affordable menopause care at MyMenopauseRx. I understand that it is my responsibility to submit any information that may be required by my medical insurance/FSA/HSA, if I try to obtain reimbursement. I understand that all information is available to me on my patient dashboard.

Accounts

I understand that it is important that I don't create more than one account. Creating more than one account makes it impossible for the provider to see my full history of care that I've received from MyMenopauseRx. I understand that creating more than one account could influence the provider’s clinical decision-making regarding my care.

Signing this Consent

I understand and agree that by using MyMenopauseRx, I seek to enter into a relationship where the provider relies exclusively upon information that I provide to decide whether or not treatment for me is safe and appropriate. I understand that I will not receive any other medical services that go beyond the diagnosis and treatment of menopause care.