patients Form

1. I      give permission to Rogo Healthcare Services to provide psychiatric/medical treatment to me and/or my loved one.

2. I understand that:

Rogo Healthcare Services will not submit a claim for insurance benefits to pay for the care I receive. I understand that:

• All services I receive must be paid by cash, debit or credit card in full at time of service.

• It is my responsibility that if I have insurance, I will contact my insurance company to discuss reimbursement of services paid for.

• I must pay for the cost of these services if even if my insurance does not pay or I do not have insurance.

3. I understand:

• I have the right to refuse any procedure or treatment.

• I have the right to discuss all medical treatments with my healthcare provider.

• I have the right to request to be seen or referred to another healthcare provider such as a physician or nurse practitioner.

Patient’s Name:   

Signed by (Guardian’s sign if patient is below 18):   

Date   

Rogo Healthcare services reserves the right to charge a fee for any scheduled visits that are:

1. Cancelled with less than 24 hours’ notice.

2. Missed without calling to cancel (no call/no show)

Cancellation Fee: New Patient $35.00 Established Patient: $25.00

Signed by (Guardian’s sign if patient is below 18):   

Date:   

Our Notice of Privacy Practices provides information about how we may use or disclose protected health information.

The notice contains a patient’s rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent.

The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date.

You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations.

By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive.

By signing this form, I understand that :

• Protected health information may be disclosed or used for treatment, payment, or healthcare operations.

• The practice reserves the right to change the privacy policy as allowed by law.

• The practice has the right to restrict the use of the information, but the practice does not have to agree to those restrictions.

• The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.

• The practice may condition receipt of treatment upon execution of this consent.

May we phone, email, or send a text to you to confirm appointments?YesNo

May we leave a message on your answering machine at home or on your cell phone?YesNo

May we discuss your medical condition with any member of your family?YesNo

If YES, please name the members allowed :

Signed by (Guardian’s sign if patient is below 18):   

Date   

Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. The Notice contains a Patient Rights section describing your rights under the law. You have the right to review our Notice before signing this consent. The terms of our Notice may change. If we change our Notice, you may obtain a revised copy by contacting our office.

You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment or health care operations. We are not required to agree to this restriction, but if we do, we shall honor that agreement.

By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment and health care operations. You have the right to revoke this consent, in writing, signed by you. However, such a revocation shall not affect disclosures we have already made in reliance on your prior consent. The Practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

The patient understands that:

• Protected health information may be disclosed or used for treatment, payment or health care operations

• The Practice has a Notice to Privacy Practices and that the patient has the opportunity to review this Notice

• The Practice reserves the right to change the Notice of Privacy Policies

• The patient has the right to restrict the uses of their information but the Practice does not have to agree to those restrictions

• The patient may revoke this consent in writing at any time and all future disclosures will then cease

• The Practice may condition treatment upon the execution of this consent

Patient Name (print) :   

Signed by (Guardian’s sign if patient is below 18):   

Relationship to Patient (if other than patient) :  

Date :  

Practice Representative Date :  

Membership Agreement For DPC patients

This is an Agreement between Rogo Healthcare Services (Ayo Okoro, Advanced

Practice Psychiatric/Family Nurse Practitioner in her capacity as owner of Rogo Healthcare Services and you

Patient   

On This Date   

Background

The APRN, who specializes as a board-certified psychiatric/family nurse practitioner, delivers care on behalf of Rogo Healthcare Services at a designated office or at a private location of the patient. In exchange for certain fees paid by Patient. Rogo Healthcare Services through its APRN, agrees to provide Patient with the Services described in this Agreement on the terms and conditions set forth in this Agreement.

Definitions

1. Patient: A patient is defined as those persons for whom the APRN shall provide Services, and who are signatories to, or listed on the documents attached as Appendix 1, and incorporated by reference, to this agreement

2. Services: As used in this Agreement, the term Services, shall mean a package of services or individual services both patient care and non-patient care, and certain amenities (collectively “Services”), which are offered by Rogo Healthcare Services and set forth in Appendix 1.

3. Terms: This agreement shall commence on the date signed by the parties below and shall continue every month, automatically renewed each month.

4. Fees: In exchange for the services described herein, Patient agrees to pay Rogo Healthcare Services, either with insurance if they are insured or the amount as set forth in Appendix 1, attached. This fee is payable upon execution of this agreement and is in payment for the services provided to Patient during the term of this Agreement. If this Agreement is cancelled by either party before the agreement termination date, then Rogo Healthcare Services shall refund the Patient’s pro- rated share of the original payment, remaining after deducting individual charges for services rendered to Patient up to cancellation.

5. Non-Participation in Insurance: Patient acknowledges that neither Rogo Healthcare Services, nor the APRN participates in any health insurance or HMO plans or Medicare or Federal Healthcare plans. Neither of the above make any representations whatsoever that any fees paid under this Agreement are covered by your health insurance or other third-party payment plans applicable to the Patient. The Patient shall retain full and complete responsibility for any such determination. If the Patient is eligible for Medicare, or during the term of this Agreement becomes eligible for Medicare, then Patient is not eligible for Rogo Healthcare Services. This agreement acknowledges your understanding that the APRN does not provide services to patients eligible for Medicare and Medicaid and will not seek reimbursement from Medicare, Medicaid, or any Federal Healthcare panels and as a result, Medicare, Medicaid, or any Federal Healthcare panels cannot be billed for any services performed for Patient by the APRN. Patient agrees not to bill Medicare, Medicaid, or any Federal Healthcare panels or attempt Medicare, Medicaid, or any Federal Healthcare panel reimbursement for any such services.

     Initials.

6. Insurance or Other Medical Coverage: Patient acknowledges and understands that this Agreement is not a health insurance plan, and not a substitute for health insurance or other health plan coverage (such as membership in an HMO). It will not cover hospital services, or any services not personally provided by Rogo Healthcare Services or its Providers. Patient acknowledges that Rogo Healthcare Services has advised that patient obtain or keep in full force such health insurance policy(ies) or plans that will cover Patient for general healthcare costs. Patient acknowledges that this Agreement is not a contract that provides health insurance, and this Agreement is not intended to replace any existing or future health insurance or health plan coverage that Patient may carry.

7. Term; Termination: This Agreement will commence on the date first written above and will extend monthly thereafter. Notwithstanding the above, both Patient and Rogo Healthcare Services shall have the absolute and unconditional right to terminate the Agreement, without showing any cause for termination, upon giving 30 days prior written notice to the other party. Unless
   previously terminated as set forth above, at the expiration of the initial one-month term (and each
   succeeding monthly term), the Agreement will automatically renew for successive monthly terms
   upon the payment of the monthly fee each contract month.

8. Communications:You acknowledge that communications with the Provider using e- mail, facsimile, video
   chat, instant messaging, and cell phone are not guaranteed to be secure or confidential methods
   of communications. As such, you expressly waive the provider’s obligation to guarantee confidentiality with respect to correspondence using such means of communication. You acknowledge that all such communications may become a part of your medical records. By providing Patient’s e-mail address on the attached Appendix 1, Patient authorizes the Rogo Healthcare Services and its providers to communicate with Patient by e-mail regarding Patient’s “protected health information” (PHI) (as that term is defined in the Health Insurance Portability and Accountability Act (HIPAA) of 1996 and its implementing regulations) By inserting Patient’s e-mail address in Exhibit 1, Patient acknowledges that:

   1. E-mail is not necessarily a secure medium for sending or receiving PHI and, there is always a possibility that a third party may gain access;

   2. Although and the provider will make all reasonable efforts to keep e-mail communications confidential and secure, neither Rogo Healthcare Services, nor the provider can assure or guarantee the absolute confidentiality of e-mail communications;

   3. In the discretion of the provider, e-mail communications may be made a part of
      Patient’s permanent medical record; and,

   4. Patient understands and agrees that E-mail is not an appropriate means of
      communication regarding emergency or other time-sensitive issues or for inquiries regarding sensitive information. In the event of an emergency, or a situation in which the member could reasonably expect to develop into an emergency, Member shall call 911 or the nearest Emergency Department, and follow the directions of emergency personnel. If Patient does not receive a response to an e-mail message within one business day (Monday through Friday), Patient agrees to use another means of communication to contact the provider. Neither Rogo Healthcare Services nor the provider will be liable to Patient for any loss, cost, injury, or expense caused by, or resulting from, a delay in responding to Patient as a result of technical failures, including, but not limited to,

      1. technical failures attributable to any internet service provider,

      2. power outages, failure of any electronic messaging software, or failure to properly
         address e-mail messages,

      3. failure of the Practice’s computers or computer network, or faulty telephone or cable
         data transmission,

      4. any interception of e-mail communications by a third party; or

      5. your failure to comply with the guidelines regarding use of e-mail communications
         set forth in this paragraph.

9. Change of Law: If there is a change of any law, regulation or rule, federal, state or local, which affects the Agreement including these Terms & Conditions, which are incorporated by reference in the Agreement, or the activities of either party under the Agreement, or any change in the judicial or administrative interpretation of any such law, regulation or rule, and either party reasonably believes in good faith that the change will have a substantial adverse effect on that party’s ights, obligations or operations associated with the Agreement, then that party may, upon written notice, require the other party to enter into good faith negotiations to renegotiate the terms of the Agreement including these Terms & Conditions. If the parties are unable to reach an agreement concerning the modification of the Agreement within forty-five days after of date of the effective date of change, then either party may immediately terminate the Agreement by written notice to the other party.

10. Severability: If for any reason any provision of this Agreement shall be deemed, by a court of competent jurisdiction, to be legally invalid or unenforceable in any jurisdiction to which it applies, the validity of the remainder of the Agreement shall not be affected, and that provision shall be deemed modified to the minimum extent necessary to make that provision consistent with applicable law and in its modified form, and that provision shall then be enforceable.

11. Reimbursement for services rendered: If this Agreement is held to be invalid for any reason, and if Rogo Healthcare Services therefore required to refund all, or any portion of the monthly fees paid by Patient, Patient agrees to pay Rogo Healthcare Services an amount equal to the reasonable value of the Services actually rendered to Patient during the period of time for which the refunded fees were paid.

12. Amendment: No amendment of this Agreement shall be binding on a party unless it is made in writing and signed by all the parties. Notwithstanding the foregoing, the provider may unilaterally amend this Agreement to the extent required by federal, state, or local law or regulation (“Applicable Law”) by sending You 30 days advance written notice of any such change. Any such changes are incorporated by reference into this Agreement without the need for signature by the parties and are effective as of the date established by Rogo Healthcare Services except that Patient shall initial any such change at Rogo Healthcare Services request.Moreover, if Applicable Law equires this Agreement to contain provisions that are not expressly set forth in this Agreement, then, to the extent necessary, such provisions shall be incorporated by reference into this Agreement and shall be deemed a part of this Agreement as though they had been expressly set forth in this Agreement.

13. Assignment: This Agreement, and any rights Patient may have under it, may not be assigned or transferred by Patient.

14. Relationship of Parties: Patient and the APRN intend and agree that the APRN, in performing their duties under this Agreement, is an independent contractor, as defined by the guidelines promulgated by the United States Internal Revenue Service and/or the United States Department of Labor, and the provider shall have exclusive control of her work and the manner in which it is performed.

15. Legal Significance: Patient acknowledges that this Agreement is a legal document and creates certain rights and responsibilities. Patient also acknowledges having had a reasonable time to seek legal advice regarding the Agreement and has either chosen not to do so or has done so and is satisfied with the terms and conditions of the Agreement.

16. Miscellaneous: This Agreement shall be construed without regard to any presumptions or rules requiring construction against the party causing the instrument to be drafted. Captions in this Agreement are used for convenience only and shall not limit, broaden, or qualify the text.

17. Entire Agreement: This Agreement contains the entire agreement between the parties and supersedes all prior oral and written understandings and agreements regarding the subject matter of this Agreement.

18. Jurisdiction: This Agreement shall be governed and construed under the laws of the State of Maryland and All disputes arising out of this Agreement shall be settled in the court of proper venue and jurisdiction for Rogo Health Services registered address in 11226 Cherry Hill Road, #302, Beltsville, 20705.

19. Service: All written notices are deemed served if sent to the mailing address of the party written above or appearing in Exhibit A by first class U.S. mail. The parties have signed duplicate counterparts of this Agreement on the date first written above. By signing below, both parties agree to the terms of this Agreement.

Patient’s full name:      Date   

Signed by (Guardian’s sign if patient is below 18):       Date   

APRN’s full name and title Date: Ayo Okoro, PMHNP-BC/FNP-C 05/03/2024

APRN’s signature:   

Appendix A

Services and Payment Terms

1. Patient Services:As used in this Agreement, the term Patient Services shall mean those patient services that the APRN, herself is permitted to perform under the laws of the State of Maryland and that are consistent with her training and experience as a family nurse practitioner, as the case may be. Patient shall also be entitled to an annual or semi-annual “wellness examination and evaluation,” (no more than two visits per year at least 6 months apart) which shall be performed by the provider, and include the following but not limited to:

   Complete Health Assessment, Mental Health /Risk Assessment, Comprehensive Lab Screening*, Psychosocial Screening

   *Some restrictions may apply.

   Each patient is entitled to unlimited visits for acute conditions and new problem visits as deemed necessary by the provider, per each paid membership month, with a limit of 24 visits per year, unless an additional visit is deemed necessary by the provider.

   Each additional visit will be $50 per visit. Rogo Healthcare Services and the APRN have all rights to defer any medical condition for further evaluation to another provider or medical facility such as a specialist, urgent care or emergency department.

   The APRN may from time to time, due to vacations, sick days, and other similar situations, not be available to provide the services referred to above in this paragraph 1.

   During such times, Patient’s calls to the APRN, or to the APRN’s office, will be directed to a provider who is “covering” for the APRN during her absence or an office staff member.

   Rogo Healthcare Services will make every effort to arrange for coverage but does not guarantee such coverage.

2. Non-Medical, Personalized Services: Rogo Healthcare Services shall also provide Patient
   with the following non- medical services (“Non-Medical Services”):

1. After hours and Weekend Access. Patient shall have access to the Provider via messaging, email, phone and video conferencing. Patient shall be given a phone number where the patient may reach the Provider. During the Provider’s absence for vacations, continuing medical education, illness, emergencies, or days off, Rogo Healthcare Services will provide the services of an appropriate licensed healthcare provider for assistance in obtaining patient services. Patient shall be given instructions as to how to contact such healthcare provider. Such provider shall be available to Patient to the same extent as would the APRN, however provider may be contacted through an answering service rather than through a direct phone line.

2. E-Mail Access. Patient shall be given the Provider’s e-mail address to which non-urgent communications can be addressed. Such communications shall be dealt with by the Provider or staff member of the Practice in a timely manner. Patient understands and agrees that email and the internet should never be used to access patient care in the event of an emergency, or any situation that Patient could reasonably expect may develop into an emergency. Patient agrees that in such situations, when a Patient cannot speak to a Provider immediately in person or by telephone, that Patient shall call 911 or the nearest emergency medical assistance provider and follow the directions of emergency medical personnel.

3. No Wait or Minimal Wait Appointments. Every effort shall be made to assure that the Patient is seen by the Provider immediately at scheduled visit time or after only a minimal wait. If the APRN foresees a minimal wait time, Patient shall be contacted and advised of the projected wait time.

4. Same Day/Next Day Appointments. Same day and next day appointments are available based on the time Patient contacts the office for an appointment and the APRN’s schedule. There is no guarantee that an appointment will be available for the patient.

5. Home or Office Visits. Patient has access for the APRN to see Patient in Patient’s home, office or a location in which there is privacy, such as a hotel room, and in situations where the Provider considers such a visit reasonably necessary and appropriate, she will make every reasonable effort to comply with Patient’s request. Visits outside of the main office are mainly reserved for urgent situations and disabled patients.

6. Specialists. APRN shall coordinate with patient care specialists to whom Patient is referred to assist Patient in obtaining specialty care. Patient understands that fees paid under this Agreement do not include and do not cover Specialist’s fees or fees due to any healthcare professional other than the APRN.

By signing below, both parties agree to the terms of Appendix A.

Patient’s full name:      Date   

Signed by (Guardian’s sign if patient is below 18):   

Date:   

APRN’s full name and title Date: Ayo Okoro, PMHNP-BC/FNP-C 05/03/2024

APRN’s signature:   

Appendix B Patient Account Enrollment –

All fees as set out in the fee schedule shall apply to the following Patient(s), who by signing below agree to the terms and conditions of Rogo Healthcare Services Agreement form.

Full Name:   

Date of Birth Age:  

Address City, State, Zip code:  

Home Phone:  

Mobile Phone:  

E-mail address:   

Payment Method

All patients must have a credit or debit card on file to cover the cost of membership, and other
services that are not covered under the Agreement.

Circle oneVisaMasterCardAmerican ExpressOther (Cash)

Card Number:   

Expiration Date:  

Security code:  

Zip code:  

Date of payment each month:  

By signing this form, you certify that you have read, understand and agree to the terms set forth
in Agreement and that you agree to automatic monthly draft payments for the total month amount in Appendix C with this card on file. You agree to contact Rogo Healthcare Services if you obtain a new credit or debit card. Failure of automatic monthly draft payment will result in immediate termination of the Direct Primary Care Agreement and no health care services will be rendered.

Name:   

Signed by (Guardian’s sign if patient is below 18):       Date   

Your Nurse Practitioner may prescribe certain controlled substances for You from time to time as she deems medically appropriate. However, Your Nurse Practitioner does not treat chronic pain and does not provide chronic pain management. As such, any controlled substances that may be prescribed to You will be prescribed on a limited, short-term basis. Should You require long-term, chronic pain management, Your Nurse Practitioner will refer You to a provider to treat Your chronic pain and/or will assist You in transferring Your care and treatment to the provider of Your choice.

By signing below, You understand and acknowledge that neither Your Nurse Practitioner nor the Practice provides long-term pain management/treatment services and that You will not be prescribed any controlled substances on a long-term basis. You further agree to inform Your Nurse Practitioner of all controlled substances that are prescribed to You by any other provider and acknowledge that this is an on-going obligation on Your part as a Patient of the Practice.

Print Patient/Legal Representative Name   

Relationship to Patient   

Signed by (Guardian’s sign if patient is below 18):   

Date:  

By acknowledging the Terms and Agreements during time of enrollment, you accept the billing and
delinquent account policies of Rogo Healthcare Services. This agreement authorizes the credit/debit card entered at time of enrollment to be billed automatically on a recurring monthly basis.

DELINQUENT ACCOUNT POLICY

• If account is overdue by 30 days or more, the overdue Patient’s status will be changed from active to inactive. The membership status will be maintained at this point. However, no services will be provided to the Inactive Patient until payment is made in full. This will include access to medication refills, office visits, referrals, etc.

• If full payment is not received prior to the 60-day mark (2 months of consecutive non-payment), it will be assumed the Patient has chosen to self-terminate and the account will be archived and the associated membership spot with Rogo Healthcare Services will be cancelled.

• If a Patient wishes to re-join Rogo Healthcare Services after having been archived and their membership removed, the Patient will need to re-enroll. The re-enrollment process will include payment of any past due balance and a re-enrollment fee equal to 3 months of membership. Applications for re- enrollment will be accepted at the discretion of Rose Godwin Support Services, Inc staff.

Membership enrollment terms (please initial selection):

MonthlyQuarterlyBi-annualAnnual

*BY CHECKING THIS BOX PATIENT AGREES TO Rogo Healthcare Services’s BILLING POLICIES.

CREDIT/ DEBIT CARD INFORMATION

Card Type: VisaMasterCardDiscoverAmerican Express

Credit Card Number:   

Name on Card:   

Signed by (Guardian’s sign if patient is below 18):   

CVV:  

Zip code:  

Expiration Date:  

Date:  

Patient’s Name:   

Date of Birth:   

Social Security Number:  

I request and authorize (former healthcare provider & office name):   

To release healthcare information pertaining to the patient named above to:   

Name: Rogo Healthcare Services 11226 Cherry Hill Road, Beltsville MD 20705.
Phone:301-907-1700 | Fax: 877-714-8747

I authorize the release of my STD results, HIV/Aids testing, whether negative or positive, to the person(s) listed above. I understand that the person(s) listed above will be notified that I must give specific written permission before disclosure of these test results to anyone.

YesNo

I authorize the release of any records regarding drug, alcohol, or mental health treatment to the person(s) listed above

YesNo

Definition: Sexually Transmitted Disease (STD) as defined by law, includes herpes, herpes simplex, human papilloma virus, wart, genital wart, condyloma, Chlamydia, non-specific urethritis, syphilis, VDRL, chancroid, lymphogranuloma venereuem, HIV (Human Immunodeficiency Virus), AIDS (Acquired Immunodeficiency Syndrome), and gonorrhea.

Signed by (Guardian’s sign if patient is below 18):       Date:  

For Office Use Only*
This request and authorization apply to: All Healthcare information
*Immunizations Labs *Two Most Recent Office Notes Test Exam Results
*Imaging Results Other: *EKG

1. I      understand that Rogo Healthcare Services, Inc.needs my authorization to conduct a drug test monitoring for prescriptive purposes. I have been informed of and understand the testing procedure.

I agree to provide any specimen needed to conduct the drug test. I understand that if I refuse to undergo drug screening, Rogo Healthcare Services may discontinue the prescriptions of my medications. I understand that if I consent to the test and the results are positive, the reports will be reported to Rogo Healthcare Services and I maybe need to retest for violation of Rogo Healthcare Servicees. This policy exempts the use of legally prescribed medications taken under the direction of a physician.

I have taken the following drugs or substances within the last 96 hours:

1.   

2.   

3.   

I hereby give my consent to undergo the drug test (s). I authorize any physician, laboratory, hospital, or medical profession retained by Rogo Healthcare Services to conduct this drug test and to provide the results to Rogo Healthcare Services Inc. I release Rogo Healthcare Services any person affiliated with Rogo Healthcare Services and any institution or person conducting the drug test from liability. I give this consent pursuant of to all state and federal privacy statutes and waive all rights to nondisclosures of this test and results only to the extent of the disclosures authorized in this form.

Consent:   

Refuse:   

Patient Name:   

Signed by (Guardian’s sign if patient is below 18):   

Today’s Date:  

FINANCIAL RESPONSIBIILITY FORM

I understand and agree that I am financially responsible for all charges and for any and all services rendered by Rogo Healthcare Services Payment in full for services is due at the time services are performed.

If the undersigned fails to make any payments due to Rogo Healthcare Services. Rogo Healthcare Services may at any time thereafter, without notice or demand, declare the entire unpaid balance of the account to be immediately due and payable. The undersigned promise to pay all costs of the collection, including but not limited to court cost and attorney fees equal to fifteen percent (15%), of any amount due and owing to Rogo Healthcare Services.

The undersigned expressly agrees and stipulates that in any litigation or court process that is necessary, in the sole discretion of Rogo Healthcare Services, its representative, or its attorney, to enforce payment hereunder, that the venue for any such litigation or court process shall be the federal or state courts located in the city of Beltsville, Maryland and the undersigned expressly waives any right to object to such venue for any such litigation or trial.

Patient’s Name:   

Patient DOB   

Signed by (Guardian’s sign if patient is below 18):   

Date:   

TELEHEALTH CONSENT

I authorize Rogo Healthcare Services contracted providers to provide me with their observations and recommendations regarding my medical condition and potential courses of action, using telehealth. “Telehealth” means the use of synchronous or asynchronous telecommunications technology by a telehealth provider to provide health care services, including, but not limited to, assessment, diagnosis, consultation, treatment, and monitoring of a patient; transfer of medical data; patient and professional health-related education; public health services; and health administration. The term does not include audio-only telephone calls, e-mail messages, or facsimile transmissions. The use of telemedicine involves the electronic communication of my medical information. I understand that Rogo Healthcare Services offers telehealth technology services based in the state of Maryland and its contracted providers will not perform an in-person physical examination during the telehealth consult. The providers will rely solely on the information telecommunicated. I authorize the Rogo Healthcare Services, Inc provider to consult with any other physician specialists whom they may choose to involve in my case if necessary.

I understand that I have the following rights with respect to the telehealth services performed by Rogo Healthcare Services:

Right to withdraw: I have the right to withhold or withdraw my consent to telehealth at any time, without effecting my future right to healthcare or treatment and without risking the loss of my health coverage.

Access to information: I have the right to inspect all medical information transmitted during my Rogo Healthcare Services telehealth consultation and may receive copies of this information for a reasonable fee.

Confidentiality: The laws that protect the confidentiality of medical information apply to telehealth, and no information or images from the telehealth interaction which identify me will be disclosed to other parties without my consent, except as permitted by law.

Communications: Patient acknowledges that communications with the Provider using email, facsimile, video chat, instant messaging, and cell phone are not guaranteed to be secure or confidential methods of communications. Rogo Healthcare Services currently utilizes Doxy.me for telehealth, both of which are compliant with Health Insurance Portability and Accountability Act (HIPAA) of 1996. As such, you expressly waive the provider’s obligation to guarantee confidentiality with respect to correspondence using such means of communication. Patient acknowledges that all such communications may become a part of your medical records.

Emergency: In the event of an emergency, or a situation in which the member could reasonably expect to develop into an emergency, Patient shall call 911 or the nearest Emergency Department, and follow the directions of emergency personnel. Rogo Healthcare Services. Neither Rogo Healthcare Services, nor the provider will be liable to Patient for any loss, cost, injury, or expense caused by, or resulting from, a delay in responding to Patient as a result of technical failures, including, but not limited to, (i) technical failures attributable to any I authorize Rogo Healthcare Services contracted providers to provide me with their communication of my medical information. I understand that Rogo Healthcare Services will rely solely on the information telecommunicated. I authorize the Rogo Healthcare Rogo Healthcare Services: Rogo Healthcare Services telehealth consultation and may receive copies of this confidential methods of communications. Rogo Healthcare Services currently utilizes Neither Rogo Healthcare Services, nor the provider will be liable to Patient for any Department, and follow the directions of emergency personnel. Rogo Healthcare Services. internet service provider, (ii) power outages, failure of any electronic messaging software, or failure to properly address e-mail messages, (iii) failure of the Practice’s computers or computer network, or faulty telephone or cable data transmission; or (iv) your failure to comply with the guidelines regarding use of e-mail communications set forth in this paragraph.

I understand that there are risks from telehealth, including but not limited to: loss of records from failure of electronic equipment; power failure with loss of communication; and invasion of electronic records from outsiders (hackers). In addition, signs and symptoms that might be detected during an in-person physical examination may not be detected through telehealth communications. I understand that I have the option of seeing another physician on a face to face basis who could provide me with observations and recommendations.

I warrant that the Rogo Healthcare Services provider observations and recommendations are limited in scope and nature to the specific issues discussed during the telehealth consult.

I have read and understand the information provided above. I agree with the information provided and consent to receiving the telehealth services described above.

Patient Name:   

Signed by (Guardian’s sign if patient is below 18):   

Date:   

PRESCRIPTION REFILLS

PRESCRIPTION REFILLS (does not apply to Medicare or Medicaid clients) In order to maintain consistent follow-up and care, prescriptions will be provided at the time of the visit. Refills requested outside of visits will be completed within 72 hours. Only patients or their loved ones may request refills. Pharmacy refill requests will be charged at the rate of $25.00. Please note: if prescribed any controlled substances CRISP database will be searched

Rogo Healthcare Services charges for filling forms or paperwork as follows:

Letter writing – $50.00
-FMLA, Guardianship, Disability – $50.00
-Any Form filling – $50