PLEASE CAREFULLY REVIEW THIS TREATMENT AGREEMENT. IT PROVIDES YOU WITH INFORMATION REGARDING YOUR RIGHTS AND RESPONSIBILITIES WHEN RECEIVING SERVICES FROM A WORKIT HEALTH CLINIC.

Overview

You are receiving this Treatment Agreement because your Workit Health Clinic is recommending that you engage in certain treatment that may involve induction, drug testing, telehealth, and the prescribing of certain controlled substances and other medications. A “Workit Health Clinic” includes Workit Health (MI) PLLC; Workit Health (CA), P.C.; Workit Health (NJ), LLC; Workit Health (OH), LLC; A.M. Physician Practice (NY), PLLC; and any other Workit Health professional entity that is established in the future. For more information regarding the benefits and risks associated with our treatment, please see the WORKIT HEALTH CLINIC INFORMED CONSENT FOR TELEHEALTH, TREATMENT, AND PRESCRIPTION OF CONTROLLED SUBSTANCES.

In order to receive treatment and medication from a Workit Health Clinic and a Workit Health Clinic provider, you agree that you must meet certain obligations as outlined in this Treatment Agreement. In addition, your Workit Health Clinic wants you to understand your rights when receiving your treatment. By signing this Treatment Agreement, you acknowledge that a Workit Health Clinic provider or clinician (or designee) has explained to you all of the following or that you have read, understood, and had the opportunity to ask questions regarding all of the following.

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Based on all of the information provided in this Treatment Agreement, which you acknowledge that you have read carefully and in full (including clicking and reviewing any other documents and agreements incorporated in this Treatment Agreement), you hereby confirm your understanding of, and agreement to, all of the following:

Treatment Acceptance and Agreement

1. You are consenting to the provision of medical care, health care, diagnosis, and treatment by, and/or receiving prescriptions of medicinal drugs and controlled substances from, your Workit Health Clinic and its respective providers, and such consent will remain in effect unless and until you cancel such consent in writing;
2. There is no guarantee that you will be issued a prescription and the decision of whether a prescription is appropriate will be made in the professional judgment of the Workit Health Clinic provider; however, if your Workit Health Clinic provider issues a prescription, you have the right to select the pharmacy of your choice;
3. It is your duty to provide your Workit Health Clinic provider, and its designee and agent, truthful, accurate and complete information, including all relevant information regarding care, treatment, and medications that you may have received or may be receiving from your other health care providers;
4. Your treatment may include prolonged or continuous use of this medication, and that an appropriate treatment goal may also include the eventual withdrawal from the use of this medication;
5. Your treatment plan will be tailored specifically for you and you will participate in any other treatment that your Workit Health Clinic provider may recommend or prescribe to treat or ease your symptoms or condition, including physical/occupational therapy and/or psychological counseling;
6. You may withdraw from your treatment plan and discontinue medication use at any time;
7. You need to inform your Workit Health Clinic provider if you intend to discontinue use of the prescribed medication since there may be a medical risk associated with abrupt termination of the treatment;
8. You will be provided with withdrawal management and medical supervision if needed when discontinuing medication use;
9. You have been given the opportunity to ask questions about your condition and treatment, risks of non-treatment, and risks and benefits of the specific drug therapy, medical treatment or diagnostic procedures that may be used to treat your condition;
10. Workit Health Clinic cannot make any assurances or guarantees as to the results of treatment;
11. Before prescribing any controlled substance to you, the Workit Health Clinic provider may review information from the Prescription Drug Monitoring Program in your state of residence regarding your prior receipt of controlled substances;
12. The medication you are being prescribed may cause addiction, tolerance, and dependence and your Workit Health Clinic provider has explained the potential risks, the potential short and long term side effects, the risk of drug interactions and over-sedation, and the risk of misuse and overdose which could result in death;
13. You will take your medication only as prescribed by your Workit Health Clinic provider;
14. You will attend all scheduled appointments with your Workit Health Clinic providers;
15. You will not obtain controlled substances from any other providers unless authorized by your Workit Health Clinic provider;
16. You will only use your medications for your personal use;
17. It is illegal, and can be reported to the police, to give or sell your medication to others or to use medications that are not prescribed to you;
18. You will not use any illegal substances, including but not limited to marijuana, cocaine, or any other “street drugs”;
19. You are responsible for safeguarding your own medications; lost or stolen medications will not be replaced;
20. It is your responsibility to make an informed decision whether to accept a treatment plan that the Workit Health Clinic provider proposes after weighing the risks and benefits of the medicine being prescribed, alternative treatment options and the risks and benefits of such alternatives, and the option of not seeking any treatment;
21. It is your responsibility to read the manufacturer’s leaflet that comes with a medicine, including an over-the-counter, behind-the-counter medicine, or controlled substance, and you agree to read the leaflet before you take any medicine because this leaflet includes important information about risks and warnings;
22. You agree that you will obtain your controlled substances from only one pharmacy, and you agree to update the Workit Health Clinic of any changes in the pharmacy you use;
23. Your medications may interfere with your ability to drive and/or operate heavy machinery;
24. Some medications that you are prescribed may not be approved by the FDA to treat your condition;
25. As part of your treatment, Workit Health Clinic providers will require you to provide an emergency contact person as well as ensuring any weapons at home are both unloaded and locked;
26. As part of your treatment, the Workit Health Clinic providers will require you to abstain from any alcohol;
27. You have notified, or will notify, your Workit Health Clinic provider if you are pregnant, think you might be pregnant or are trying to become pregnant or if you are diagnosed with HIV or Hepatitis C;
28. You consent to random pill counts for prescriptions conducted by your Workit Health Clinic provider or his/her designee; and
29. You are legally able to accept the terms and conditions in this Treatment Agreement.

Your Rights

1. You have the right to withdraw your consent to the use of telehealth or your treatment at any time, which you may exercise by providing written notice to your Workit Health Clinic provided; however, the withdrawal of such consent will prevent you from receiving your medical care and treatment through or not through telehealth; provided, further, that any withdrawal of your consent will be effective upon receipt of the written notice described above, except that such withdrawal will not have any effect on any action taken by your Workit Health Clinic provider, or its designees, in reliance on this Treatment Agreement before receiving your written notice of withdrawal;
2. Nothing in this Treatment Agreement modifies any rights you may have to review or receive a copy of your medical records from your Workit Health Clinic provider, including any information included in such medical records that has been transmitted to your Workit Health Clinic provider through telehealth;
3. Your medical information is subject to all applicable laws regarding the confidentiality of such medical information and the rights set forth therein;
4. You have the right to access, inspect, and amend your medical information as and to the extent permitted under applicable federal and state laws;
5. You have the right to discuss the risks and benefits of all procedures and courses of treatment proposed by your Workit Health Clinic provider(s), together with any available alternatives;
6. You have the right to be treated with consideration and respect for personal dignity, autonomy and privacy;
7. You have the right to reasonable protection from physical, sexual or emotional abuse, neglect, and inhumane treatment;
8. You have the right to receive services in the least restrictive, feasible environment;
9. You have the right to participate in any appropriate and available service that is consistent with an individual service plan (ISP), regardless of the refusal of any other service, unless that service is a necessity for clear treatment reasons and requires the person’s participation;
10. You have the right to give informed consent to or to refuse any service, treatment or therapy, including medication absent an emergency;
11. You have the right to participate in the development, review and revision of your individualized treatment plan and receive a copy of it;
12. You have the right to freedom from unnecessary or excessive medication, and to be free from restraint or seclusion unless there is immediate risk of physical harm to self or others;
13. You have the right to be informed and the right to refuse any unusual or hazardous treatment procedures;
14. To the extent in-person services are rendered, you have the right to be advised and the right to refuse observation by others and by techniques such as one-way vision mirrors, tape recorders, video recorders, television, movies, photographs or other audio and visual technology although this right does not prohibit an agency from using closed-circuit monitoring to observe seclusion rooms or common areas, which does not include bathrooms or sleeping areas;
15. You have the right to confidentiality of communications and personal identifying information within the limitations and requirements for disclosure of client information under state and federal laws and regulations;
16. You have the right to have access to your own medical records unless access to certain information is restricted for clear treatment reasons and, if access is restricted, the treatment plan shall include the reason for the restriction, a goal to remove the restriction, and the treatment being offered to remove the restriction;
17. With respect to your own records, you have the right to appeal any decision to limit your access to your own medical records, to request the correction of inaccurate, irrelevant, outdated, or incomplete information, and to submit rebuttal data or memoranda for inclusion in your own records;
18. You have the right to be informed a reasonable amount of time in advance of the reason for terminating participation in a service, and to be provided a referral, unless the service is unavailable or not necessary;
19. You have the right to be informed of the reason for denial of a service;
20. You have the right not to be discriminated against for receiving services on the basis of race, ethnicity, age, color, religion, gender, national origin, sexual orientation, physical or mental handicap, developmental disability, genetic information, human immunodeficiency virus status, or in any manner prohibited by local, state or federal laws;
21. You have the right to know the cost of services;
22. You have the right to be verbally informed of all client rights, and to receive a written copy upon request;
23. You have the right to exercise these rights without reprisal, except that no right extends so far as to supersede health and safety considerations;
24. You have the right to file a grievance and to receive oral and written instructions concerning the procedure for filing a grievance, and to assistance in filing a grievance if requested;
25. You have the right to be informed of your own condition;
26. You have the right to consult with an independent treatment specialist or legal counsel at your own expense; and
27. You have the right to retain your civil rights and liberties when receiving care or treatment.

Emergencies

You should never use the Workit Health Clinic in a medical or psychiatric emergency. If you have an emergency, you should call 911 or go to an emergency room.

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By signing this Treatment Agreement, you represent that (1) you have read this Treatment Agreement carefully and in full; (2) you have the legal capacity and authority and mental competency to provide this Treatment Agreement for yourself; and (3) you acknowledge, understand, and agree that this Treatment Agreement is subject to our Terms of Service, Privacy Policy, Notice of Privacy Practice, and Consent, each of which is incorporated by reference herein and that address, without limitation, indemnification, intellectual property, dispute resolution, limitation of liabilities, waiver of consequential, special, and other damages, among other terms and conditions.

If you are a parent, guardian, conservator, or custodian signing on behalf of another individual who is unable to consent for him or herself, such as a minor, you represent that you are legally able and entitled to consent on behalf of such individual and agree to all of the above regarding such individual’s receipt of medical care and health care and in the possible treatment and medications provided to such individual by a Workit Health Clinic provider.