At ELM, we are committed to providing high-quality, patient-centered care through a combination of endocrinology and lifestyle medicine services. This Consent to Treat outlines your agreement to receive care from our providers.

Nature of Services

By consenting to treatment at ELM, you agree to receive care that may include:

• Medical evaluation, diagnosis, and management of endocrine and metabolic conditions

• Lifestyle medicine counseling, including nutrition, physical activity, sleep, stress management, and behavior change

• Preventive care and health education

• Telehealth (virtual) visits

Care recommendations are individualized and may evolve over time based on your health status, preferences, and goals.

Collection and Use of Health Information (PHI)

To provide safe and effective care, ELM will collect, store, and use your Protected Health Information (PHI).

This may include:

• Medical history, medications, allergies, and health conditions

• Lab results, imaging, and diagnostic reports

• Visit notes, care plans, and communications

• Billing and payment information

Your PHI may be collected through:

• Intake forms and questionnaires

• Telehealth visits and in-person encounters

• Secure messaging, email, and other communications

• Third-party sources involved in your care (e.g., labs, pharmacies)

Your information will be:

• Stored in secure, HIPAA-compliant electronic systems

• Accessed only by authorized personnel as needed for your care and operations

• Shared only with your consent or as required by law (e.g., public health reporting)

You may receive a separate Notice of Privacy Practices outlining your rights regarding your health information.

Electronic Communication Consent

By receiving care at ELM, you consent to communicate electronically when appropriate.

This may include:

• Email

• Text messaging (SMS)

• Patient portals or secure messaging platforms

• Telehealth platforms

You understand that:

• These methods may be used for scheduling, follow-up, care coordination, education, and limited clinical communication

• While ELM uses reasonable safeguards, electronic communication carries some risk of interception or unauthorized access

• Response times may vary, and electronic communication should not be used for urgent or emergency concerns

You agree to:

• Provide accurate and up-to-date contact information

• Notify ELM of any changes to your preferred communication methods

• Use appropriate channels for urgent needs (call 911 or seek emergency care)

You may opt out of certain forms of electronic communication by notifying ELM in writing.

Subscription-Based & Cash-Pay Model

ELM operates on a cash-pay and/or membership (subscription-based) model.

• ELM does not bill or submit claims to insurance for clinical services

• Medicaid is not accepted

• Payment is required at the time of service or through an active membership plan

• If enrolled in a membership, you understand the structure, services included, and recurring payment terms

You will be provided with a superbill, which you may submit independently for:

• Possible out-of-network reimbursement

• Flexible Spending Accounts (FSA)

• Health Savings Accounts (HSA)

• Personal medical expense tracking

Reimbursement is not guaranteed and depends on your individual insurance plan.

Use of Insurance Outside of ELM

While ELM does not bill insurance for services:

• Insurance may be used for prescriptions, laboratory testing, diagnostic studies, imaging, and durable medical equipment (DME) ordered as part of your care

• Coverage, co-pays, deductibles, and prior authorizations are determined by your insurance plan and are your responsibility

Patient Participation

You acknowledge that:

• You are an active participant in your care

• You have the right to ask questions and receive clear explanations

• You are responsible for providing accurate and complete health information

• You are encouraged to follow agreed-upon treatment plans and communicate any concerns

Lifestyle and behavior change are core components of care at ELM, and outcomes depend in part on your engagement.

Risks and Benefits

You understand that:

• All medical care carries potential risks and benefits

• No guarantees or assurances have been made regarding specific outcomes

• Recommendations, including lifestyle interventions, are based on current medical knowledge and clinical judgment

You have the right to accept or decline any recommended treatment.

Telehealth Consent

You consent to receive care through telehealth technologies when appropriate.

You acknowledge that:

• Telehealth involves the use of secure electronic communication platforms

• There may be limitations compared to in-person care, including the inability to perform a full physical exam

• Technical issues (e.g., connectivity disruptions) may occur

• While reasonable safeguards are in place, there is a small risk of unauthorized access to health information

You understand that telehealth is not appropriate for all medical concerns and that in-person care or referral may be recommended when necessary.

Privacy and Confidentiality

Your health information will be handled in accordance with applicable privacy laws, including HIPAA.

• Your information will only be shared with your consent or as required by law

• You may receive additional documentation outlining your privacy rights

Emergency Situations

ELM does not provide emergency medical services.

If you are experiencing a medical emergency, you agree to:

• Call 911

• Go to the nearest emergency room

Financial Responsibility

You understand and agree to the following:

• Full Financial Responsibility: You are responsible for all fees associated with services provided by ELM, regardless of insurance reimbursement

• Payment Timing: Payment is due at the time of service unless covered under an active membership plan

• Membership Fees:

  • Membership fees are billed on a recurring basis (e.g., monthly) as agreed upon at enrollment

  • You are responsible for maintaining an active payment method

  • Failed or declined payments may result in suspension of services until resolved

• No Insurance Billing: ELM does not submit claims to insurance. You are responsible for submitting any superbills if you choose to seek reimbursement

• Medicaid Non-Participation: You acknowledge that ELM does not accept Medicaid and that you agree to receive care on a cash-pay basis

• Additional Costs: You are responsible for costs associated with labs, imaging, medications, or other services not provided directly by ELM

• Missed Appointments & Late Cancellations:

  • A fee may be charged for missed appointments or cancellations made without sufficient notice

• Administrative Fees:

  • Fees may apply for form completion, extensive record requests, or other non-visit services

• Refund Policy:

  • Fees for services already rendered are non-refundable

  • Membership fees are non-refundable once billed, except as required by law or explicitly stated in a separate membership agreement

Right to Withdraw

You have the right to discontinue care at any time. We ask that you notify ELM so we can support a safe transition of care if needed.

Acknowledgment and Consent

By signing below (or electronically acknowledging), you confirm that:

• You have read and understand this Consent to Treat

• You have had the opportunity to ask questions

• You voluntarily consent to receive care from ELM providers

• You consent to the collection and use of your health information as described

• You consent to electronic communication as outlined above