Patient Facing Document

PRACTICE: OHIO MUSCULOSKELETAL SPORTS AND SPINE COMPANY, AN OHIO PROFESSIONAL CORPORATION

Name: Dr. Chauncy Eakins
Title: President

SCHEDULE A EXAM SERVICES & SERVICES FEES

1. Exam Services
   Exam Services make available one (1) comprehensive rehabilitative and preventative health annual diagnostic exam with unlimited follow-up diagnostic exams and supported by year-long robust communication services, all focused on achieving improved rehabilitative and preventative health Patient education with an emphasis on lifestyle guidance, disease avoidance, weight loss, hormone optimization, and risk mitigation to help support improved overall health outcomes. All Exam Services provide enhanced Patient education and behavior modification guidance. Exam Services exceed Plan-covered or Plan-reimbursed medically indicated or necessary services.
   Exam Services shall integrate the following health principles and goals:
   • Optimizing health through enhanced Patient education and behavior modification guidance focused on proactive mitigation and management
   • Creating and guiding Exam Services-based lifestyle goals
   • Improving overall health awareness and equipping Patient with enhanced health education
   • Improving awareness regarding various additional healthcare options
     Exam Services may include certain lab tests, examinations, supplements, medications, and procedures that may constitute out-of-pocket Patient costs that Patient may be able to submit to Patient’s Plan for reimbursement, but such reimbursement is not guaranteed. Such out-of-pocket Patient cost items are not included in or covered by Services Fees.
2. Services Programs
   Exam Services:
   Standard Tier: $6,000.00/year. - Rehabilitative and preventative health Exam Services
   Premier Tier: $12,000.00/year. - Standard Tier plus at-home or at-work rehabilitative and preventative health Exam Services (reasonable geographical limitations apply).

ADDITIONAL TERMS: Services Fees Exam Services only. Practice’s reduced patient panel, and detachment from dependence on Plan reimbursement that often include services/time restrictions and limits, collectively enables Practice to provide expedited and unhurried Exam Services. Exam Services are entirely outside of and beyond Plan coverage. Services Fees must never be submitted to Medicare or any other Plan for reimbursement.

Practice may separately elect to deliver Plan-covered services, when appropriate, if Practice is in-network with Patient’s Plan. Plan-covered services will be submitted to that Plan for reimbursement with co-payments/deductible charges collected per Plan requirements. Services Fees do not cover Plan-covered services or Plan-mandated Patient Plan’s copayment/deductible charges.

Services and Services Fees do not include any Medicare-covered services. Medicare-eligible patients may request and receive Medicare-covered services outside of Exam Services/Services Fees (co-payment/deductible charges will apply)

SCHEDULE B INTEGRATIVE SERVICES INFORMED CONSENT

Integrative Exam Services are: a) outside strictly allopathic healthcare guidelines; b) incorporated into Exam Services based on Practice’s medical judgement; and c) entirely outside Plan coverage. This Schedule B confirms integrative Exam Services (collectively “Integrative Services”) risks and potential side-effects that Practice has also verbally discussed with Patient and Patient’s informed consent to such Integrative Services.

GENERAL STATEMENTS ABOUT INTEGRATIVE SERVICES

There is no guarantee that Integrative Services will restore or promote health. There is no guarantee Integrative Services will reverse or prevent disease. Patient’s health outcomes depend on a wide range of variable factors. Patient understands that Integrative Services may include treatments that have not been reviewed or received any FDA approval or are considered “off label” and not FDA approved for Patient’s specific age, history, or symptom(s), meaning the treatment may not meet standard treatment guideline recommendations. Additionally, clinical research is ongoing to better establish the benefits and harms of Integrative Services. No healthcare services are guaranteed to provide positive results. Integrative Services pose risks and may cause potential complications. Practice’s healthcare professionals have explained those risks and potential complications, and this Schedule B is intended to confirm Patient’s acknowledgment of those explanations and to confirm Patient’s informed consent to such Integrative Services that Patient elects to receive.

Practice has not promised or guaranteed any specific benefits from the administration of Integrative Services. Patient has weighed the benefits of, and alternatives to, Integrative Services. Practice’s healthcare professionals cannot know or anticipate and explain every possible risk or complication that may connect Integrative Services to the complexities of causes related to human health. Patient willingly and voluntarily consents to any Integrative Services Patient elects to receive from Practice with an understanding there is no guarantee of benefits, and there is a potential for side effects and negative outcomes.

Patient further understands there are viable alternatives to electing to receive Integrative Services. Traditional allopathic diagnosis and treatment of detected illness constitutes standard healthcare. Lifestyle/behavior changes, including beneficial changes to nutrition, exercise, improved mental health/wellness support, cessation of smoking, limiting or reducing alcohol or recreational drug intake, and ensuring adequate sleep/rest, have all also been proven to help reduce the risk of illness and increase wellbeing. Adopting some or all these lifestyle changes, in tandem with traditional allopathic diagnosis and treatment of detected illness, can provide Patient with important and substantiated health benefits. Health coaches routinely provide support with lifestyle change efforts toward improved health outcomes. Licensed healthcare professionals can assist with health conditions that are directly connected to lifestyle issues and may provide referrals to a wide variety of professionals who can assist (nutritionists, dietitians, physical therapists, etc.).

Practice needs to receive complete and accurate information from Patient about Patient’s health, whether Patient elects to receive Integrative Services or not. Patient agrees to accurately report any side effects or worsening conditions related to Integrative Services therapies or medications and participate in regular monitoring and follow-up appointments as recommended by Practice to increase safety and efficacy.

Patient understands and acknowledges that Integrative Services do not replace: regular allopathic healthcare monitoring, preventative measures in general, and specifically recommended tests and preventative procedures such as complete physicals, rectal examinations and/or colonoscopy, EKG, lab tests, x-rays, ultrasounds, mammograms, pelvic/breast exams, pap smears, prostate exams, PSA levels, etc., at least on a yearly basis. Integrative Services are intended to enhance rather than replace traditional allopathic healthcare.

BHRT SERVICES BACKGROUND

Practice may prescribe some of the bio-identical hormone preparations for Patient that pharmacy compounding laws regulate. These laws follow the Pharmacy Compounding Accreditation Board (“PCAB”) guidelines.

Services related to the evaluation for and use of bio-identical hormone replacement therapies (“BHRT Services”), while common in alternative practices, may be debated in the traditional allopathic medical community. Patient has the right to be informed about Patient’s condition and the identification of conventional/allopathic, integrative, complementary, alternative, non-conventional, or non-standard procedures to be used so that Patient can make an informed decision whether or not to undergo non-allopathic BHRT Services treatments with an appreciation of the risks, hazards, and alternatives.

BHRT SERVICES THERAPEUTIC THEORIES

Many individuals have inadequate hormone levels despite technically “normal” blood tests. Some individuals suffering symptoms related to menopause or andropause or inability to lose weight may also benefit from hormone therapies. BHRT Services can be used to augment hormone levels in many conditions where diminished hormone levels are evident. BHRT Services hormone therapies may arguably “optimize” hormone levels in the blood although there is no guarantee this will yield positive results (and there are potentially harmful side effects). This approach to hormone optimization is not universally accepted by the medical community, and, may be contrary to the approach an endocrinologist would adopt for hormone health.

The following bio-identical hormone therapeutic theories are non-allopathic (non-traditional medical thinking) and subject to medical debate:
-Estradiol replacement therapy can, although not always, help maintain vaginal and urethral function and might slow the progression of osteoporosis. It might also improve sleep, decrease hot flashes and night sweats, decrease visceral fat, improve cognitive function, improve libido and overall sense of well-being.
-Progesterone replacement therapy can be used to treat conditions related to relatively low progesterone, which may include PMS/PMDD, PCOS, irregular or heavy menstruation, vasomotor symptoms, poor sleep quality, and anxiety. It may, although not always, offer protection against breast and uterine cancer.
-Testosterone replacement therapy can be used to treat symptoms or lab tests suggesting suboptimal hormone levels as determined by Patient’s provider. Low testosterone may pose some risks to both men and women. Low testosterone is linked to elevated cholesterol, high blood pressure, diabetes, and prostate problems. Other low testosterone symptoms include excessive fatigue, abdominal weight gain, irritability, and decreased sexual drive and function.
-Thyroid replacement can be used to improve thyroid hypo-functioning, in which suboptimal levels of bioactive thyroid hormone cause symptoms of low thyroid. Such symptoms may include fatigue, cold intolerance, hair/eyebrow thinning, weight gain, constipation, and dry skin.
-DHEA (Dehydroepiandrosterone) replacement can be used to improve low or suboptimal levels of DHEAS, which often decrease with age and/or inflammatory conditions. DHEA may counterbalance the negative effects of high cortisol states, reduce musculoskeletal pain, and improve a sense of wellbeing.

BHRT SERVICES POTENTIAL RISKS

Practice cannot guarantee the safety of any hormone therapy during pregnancy. Notify Practice’s healthcare professional if Patient is pregnant, suspects that Patient is pregnant, or is planning to become pregnant during BHRT Services therapy.

Bio-identical hormone replacement therapy is the preferred formulation when prescribing BHRT by Practice. “Bio-identical” refersto the molecular makeup of the hormone, being identical to that which our body produces naturally.

Although many studies have shown the use of bio-identical hormone replacement therapy might be safer than synthetic hormone replacement therapy, the risk of cancer-related side effects is still possible. As referenced above, not all healthcare professionals agree with the use of bio-identical hormones to optimize hormone health.
-Estrogen Therapy: Bio-identical estradiol is available in various forms including oral capsules, troches, patches, pellets, and topical creams. Adverse reactions may include bloating, breakthrough bleeding, breast swelling and tenderness, fluid retention, weight gain, liver cysts, mood swings, Alzheimer's dementia, and death (e.g. from strokes, heart attacks, blood clots, or cancer). While not the first-line treatment choice of Practice, high potency conjugated synthetic estrogens (e.g. Premarin) have been linked to an increased risk of breast cancer and blood clots (the latter especially in smokers). Nonetheless, the whole area of estrogen replacement is undergoing further evaluation. Do not take estrogen if Patient has breast cancer.
-Progesterone Therapy: Bio-identical progesterone is available in various forms including oral capsules, troches, vaginal or rectal suppositories, and topical creams or gels. Progesterone therapy may be sedating, so it is recommended to coordinate dosing with the sleep cycle. Adverse reactions may include bloating, breakthrough bleeding, missed menstrual cycles, breast swelling and tenderness, fluid retention, weight gain, sedation, and depression.
-Testosterone Therapy: Bio-identical testosterone therapy is available in various forms including sublingual drops, troches, topical creams, pellets, and injections. Side effects include acne, chronic priapism (persistent, abnormal erection of the penis), change in libido, erythrocytosis, angina or heart attacks, hirsutism (facial hair growth), scalp hair loss, clitoral engorgement, voice changes, water retention, sleep apnea, blood clots, liver issues, swelling, lipid changes, and decrease in thyroid binding globulin. In men, it may also cause testicular atrophy and infertility. Because it may improve insulin resistance in males, diabetics who use insulin should monitor glucose levels closely, as diabetics may need less insulin. Topical testosterone may cause local skin irritation and has the potential to be transferred to a significant other, child, pregnant or breastfeeding woman, or woman who may become pregnant and be teratogenic (cause fetal/baby abnormalities/deformities).
-Thyroid Therapy: Bio-identical thyroid hormone may cause heart palpitations, arrhythmia, tremors, and sleep disturbance. -DHEA Therapy: DHEA replacement may cause acne and hirsutism. DHEA is not recommended in Patients with active Breast or Prostate Cancer.

ALTERNATIVES TO BHRT SERVICES HORMONE THERAPIES BHRT

Services hormone therapies apply hormone balancing and treatments to different conditions, some of which may not qualify as an “illness” requiring “treatment” under traditional allopathic medical thinking. In other words, traditional medical thinking does not identify “feeling better” or having more energy or vitality as medically necessary for patients to justify BHRT Services hormone therapy intervention.

An endocrinologist is a healthcare professional licensed and trained specifically to address issues involving hormone health. Their approach is more traditional in that their training and protocol is to only prescribe hormone therapy if medically indicated for a specific diagnosed disease state. For example, a male experiencing the side effects of having low testosterone may not qualify under an endocrinologist’s treatment algorithm for testosterone supplementation. Females experiencing the effects of pre-menopause or post-menopause may be suffering from those side effects, yet not meet traditional medical criteria for hormone treatment. Seeking non-integrative healthcare from professionals other than Patient’s provider (who is an integrative healthcare professional trained to implement hormone therapies) is an alternative Patient should pursue if Patient feels uncomfortable about the side effects of hormone therapies or if Patient wishesto adopt a more conservative approach to hormone health.

INFORMED CONSENT FOR BHRT SERVICES HORMONE THERAPY (MEN)

Patient understands that treatment(s) may be considered “off label” and/or not FDA approved for Patient’s specific age, history, or symptom(s), meaning the treatment may not meet standard treatment guideline recommendations. Testosterone therapy is not FDA-approved for symptom management in men. Other BHRT replacements for men may include thyroid and DHEA.

Current FDA-listed potential risks of testosterone replacement therapy (“TRT”) can include but are not limited to heart attack, stroke, blood clots, prostate cancer, deepening of voice, hypersexuality, acne, abnormal hair growth, gynecomastia, breast tenderness, worsening of sleep apnea, infertility, testicular shrinkage, increased RBC/hemoglobin/hematocrit (erythrocytosis) and/or peripheral edema (swelling, which could increase blood pressure). Although the FDA warns of increased risk of cardiovascular events, prostate cancer, stroke, and/or death: the current available evidence does not support increased risk of cardiovascular events with testosterone therapy, the evidence does not support increased risk of prostate cancer with testosterone therapy. Available evidence reveals no increased risk of VTE blood clots with testosterone therapy.

Patient understands that transference of testosterone cream to a child, pregnant woman, breastfeeding woman, or woman who may become pregnant can be teratogenic (cause fetal/baby abnormalities/deformities). Patient understands that those who use tobacco products and those with a personal and/or family history of heart disease, stroke, blood clot, prostate cancer, diabetes, hypertension, and/or sleep apnea are at a higher risk of developing complications to testosterone replacement therapy.

Once discontinued, it can take up to one year, or longer, for the return of spermatogenesis (sperm volume, fertility), however, it is possible to have no, or minimal, return of fertility. Some patients may require additional specialty treatments to enhance fertility not offered by Practice.

If applicable, Patient was advised and understands the following for testosterone therapy:

1. Patient acknowledges and agrees that Patient was advised against transference to significant other, children, and pets. Patient must always wash their hands after applying transdermal testosterone or wear and dispose of gloves with each application. Transference can occur by vapor, so Patient should be aware of this if Patient’s spouse, child(ren) or pets begin to develop symptoms of hyperandrogenism and/or other side effects associated with testosterone use.
2. If Patient is within the parameters of screening for prostate cancer as per the AUA Guidelines, Patient acknowledges and agrees to obtain both a prostate-specific antigen exam and digital rectal exam annually to continue testosterone therapy.
3. The protocols Practice recommends for the application or use of BHRT Services hormone therapyrelated medications, drops, troches, topical creams, or injections are intended to minimize the possibility of adverse health effects from the use of such treatments. However, Practice neither promises nor guarantees that Patient’s adherence to Practice’s recommended application protocols will minimize or eliminate such risks or adverse health effects.

INFORMED CONSENT FOR BHRT SERVICES HORMONE THERAPY (WOMEN)

Patient understands that treatment(s) may be considered “off label” and/or not FDA approved for Patient’s specific age, history, or symptom(s), meaning the treatment may not meet standard treatment guideline recommendations. Testosterone therapy is not FDA-approved for use in women.

Patient reviewed the most up-to-date clinical guidelines regarding the use, dose, route, frequency, and duration of BHRT, including herein as, but not limited to, progesterone, estrogen(s), testosterone, and/or DHEA.

Current known potential risks of hormone replacement therapies can include, but are not limited to heart attack, stroke, blood clot(s), cancer, deepening of voice, clitoral enlargement, increased clitoral sensitivity, hypersexuality, acne, fetal deformity in pregnant women, breastfeeding women or women who may become pregnant, abnormal hair growth, worsening of sleep apnea, fertility/pregnancy and/or early mortality.

Oral estrogen use may be associated with elevations in lipids, transient liver enzyme elevations, and, rarely, clinical hepatotoxicity (liver toxicity), pancreatitis, cholelithiasis (gallstones), and subsequent cholecystectomy. Current evidence-based research indicates that hormone therapy can be safe and effective forsymptom management, however, those individuals with certain health histories are more likely to be at risk for the above-listed potential risks/adverse outcomes. Those higher-risk health histories include, but are not limited to, those individuals who are older than sixty (60) years of age, have established cardiovascular disease, are diabetic, use tobacco products, have a history of migraines with aura, a history of sleep apnea, a history of poorly controlled hypertension, are outside of the ten (10) year menopause window, have a history of heart disease, blood clots and/or stroke, are overweight/obese, and/or have a personal history of sex organ cancer and/or have a family history of sex organ cancer.

Patient acknowledges and agrees that further risks of estrogen use include but are not limited to cardiovascular disease, blood clots, and breast cancer. Patient was advised by Practice to obtain an annual mammogram and regular pap smears if Patient engages in estrogen use.

If applicable, Patient was advised and understands the following for testosterone therapy:

1. Patient acknowledges and agrees that Patient was advised against transference to significant other, children, and pets. Patient must always wash their hands after applying transdermal testosterone or wear and dispose of gloves with each application. Transference can occur by vapor, so Patient should be aware of this if Patient’s spouse, child(ren) or pets begin to develop symptoms of hyperandrogenism and/or other side effects associated with testosterone use.
2. Testosterone therapy may increase Patient’s risk of deep vein thrombosis and/or myocardial infarction.
3. If Patient becomes pregnant, Patient agrees to discontinue testosterone therapy.
4. The protocols Practice recommends for the application or use of BHRT Services hormone therapyrelated medications, drops, troches, topical creams, or injections are intended to minimize the possibility of adverse health effects from the use of such treatments. However, Practice neither promises nor guarantees that Patient’s adherence to Practice’s recommended application protocols will minimize or eliminate such risks or adverse health effects.
   
   Current guidelines recommend limiting hormone replacement therapy to no more than five (5) years, however, it has been acknowledged that continuing BHRT Services past that duration is a decision that should be made by the Patient with their healthcare provider, based on the Patient’s preference, health history, symptoms and the most up to date guidelines.

HGH SERVICES BACKGROUND

Services related to the evaluation and use of synthetic human growth hormones (“HGH Services”), while common in alternative practices, may be debated in the traditional allopathic medical community. Patient has the right to be informed about Patient’s condition and the identification of conventional/allopathic, integrative, complementary, alternative, non-conventional, or non-standard procedures to be used so that Patient can make an informed decision whether or not to undergo nonallopathic HGH Services treatments with an appreciation of the risks, hazards, and alternatives.

Patient understands HGH Services treatment(s) may be considered “off label” and/or not FDA approved for Patient’s specific age, history, or symptom(s), meaning the treatment may not meet standard treatment guideline recommendations.

HGH SERVICES THEORIES

Synthetic human growth hormone can potentially work similarly to naturally produced growth hormones in the body by stimulating growth and regeneration. This theory is non-allopathic and subject to medical debate.

HGH SERVICES POTENTIAL RISKS

Practice does not recommend HGH Services during pregnancy. Notify Practice’s healthcare professional if Patient is pregnant, suspects that Patient is pregnant, or is planning to become pregnant during HGH Services administration.

As outlined below, potential risks do exist with HGH Services, and not all healthcare professionals agree with the use of HGH Services as a method of treatment. Clinical research is ongoing to determine the benefits and risks of such services.

HGH Services are administered through injections. Injection site reactions include redness, pain, itching, burning, or swelling.

HGH Services may cause fluid retention causing swelling in arms and legs, joint and muscle pain, carpal tunnel syndrome, high blood sugar levels, high cholesterol, headaches, enlargement of organs, hypothyroidism, numbness, and tingling of the skin, increased risk of cancer, Acromegaly (disorder related to abnormal growth of bones and tissues), and allergic reactions.

ALTERNATIVES TO HGH SERVICES

HGH Services treatments may be applied to different conditions, some of which may not qualify as an “illness” requiring “treatment” under traditional allopathic medical thinking. In other words, traditional medical thinking does not identify “feeling better” or having more energy or vitality as medically necessary for Patient to justify HGH Services intervention.
Multiple alternative methods, therapies, and treatments to HGH Services exist and Patient acknowledges they have been advised of such alternatives.
Traditional allopathic medicine alternatives to HGH Services include but are not limited to:
Medications: Allopathic medicine provides a range of pharmaceuticals that can address specific symptoms or underlying causes of your condition. These medications are designed to target the specific issues you are experiencing and may include oral medications, injectables, or topical treatments.
Physical Therapy: Physical therapy involves the use of exercises, stretches, manual techniques, and other modalities to improve mobility, strength, and function. It is often used for musculoskeletal conditions, rehabilitation after surgery or injury, and management of chronic pain.
Surgery: In some cases, surgical intervention may be necessary to address your specific health issue. Surgical procedures can range from minor to major, depending on the condition being treated. Your healthcare provider will discuss the potential risks, benefits, and alternatives if surgery is deemed appropriate.
Lifestyle Modifications: Making lifestyle changes can have a significant impact on your health. These changes may include adopting a healthy diet, engaging in regular physical activity, managing stress, improving sleep patterns, and avoiding harmful habits like smoking or excessive alcohol consumption.
Physical Interventions: Allopathic medicine also includes physical interventions such as external physical modalities like ultrasound therapy for musculoskeletal injuries.
Symptomatic Treatment: Allopathic medicine focuses on managing symptoms and improving your quality of life. This can involve the use of analgesics for pain relief, anti-inflammatory drugs for reducing inflammation, or medications for managing specific symptoms like nausea, insomnia, or anxiety.

It is important to note that the appropriate treatment approach will depend on your specific condition and individual factors. Practice will discuss these alternatives with you, explaining the potential risks, benefits, and expected outcomes of each option. They will guide you towards the most suitable alternative treatments based on their professional expertise and your unique circumstances.
Patient agrees to proceed with the HGH Therapy Services health treatment and to comply with recommended dosages and other protocols by Practice. Patient agrees to comply with requests for ongoing testing to ensure proper monitoring of Patient’s treatments that may include laboratory evaluation and other diagnostic testing.

PEPTIDE THERAPY SERVICES BACKGROUND

Practice may prescribe some of the peptide therapy preparations for Patient that pharmacy compounding laws regulate. These laws follow the Pharmacy Compounding Accreditation Board (“PCAB”) guidelines.

Services related to the evaluation and use of peptides (“Peptide Therapy Services”), while common in alternative practices, may be debated in the traditional allopathic medical community. Patient has the right to be informed about Patient’s condition and the identification of conventional/allopathic, integrative, complementary, alternative, non-conventional, or non-standard procedures to be used so that Patient can make an informed decision whether or not to undergo non-allopathic Peptide Therapy Services (as defined below) treatments with an appreciation of the risks, hazards, and alternatives.

PEPTIDE THERAPY SERVICES THEORIES

Peptide Therapy Services focus on the use of specific peptides as therapeutic agents to target various physiological processes and imbalances in the body. While research is ongoing to better understand peptides, there are theories on how Peptide Therapy Services potentially work in the body and treat certain conditions. All of the following is non-allopathic (outside traditional medical thinking) and subject to ongoing medical debate.
-5 Amino 1 MQ may or may not potentially block the activity of an enzyme called nicotinamide Nmethyltransferase (NNMT).
-PT-141, also known as bremelanotide, may or may not potentially stimulate melanocortin receptor activity.
-Semaglutide may or may not potentially stimulate insulin secretion and lower glucagon secretion.
-Sermorelin may or may not potentially stimulate growth hormone production.

PEPTIDE THERAPY SERVICES POTENTIAL RISKS

Practice cannot guarantee the safety of any peptide therapy during pregnancy. Notify Practice’s healthcare professional if Patient is pregnant, suspects that Patient is pregnant, or is planning to become pregnant during Peptide Therapy Services administration.

As outlined below, potential risks do exist with Peptide Therapy Services, and not all healthcare professionals agree with the use of peptide therapy as a method of treatment. Many peptide therapies have limited clinical evidence supporting their use, and many have had limited or no clinical trials on humans.

Peptide Therapy Services may be administered through injections. Injection site reactions include redness, pain, itching, burning, or swelling. Additionally:
-5 Amino 1 MQ may cause sleeplessness and difficulty in carrying out cardiovascular exercise.
-PT-141 may cause nausea, vomiting, blurred vision, dizziness, headache, nervousness, pounding in ears, and irregular heartbeat.
-Semaglutide may cause nausea, vomiting, diarrhea, abdominal pain, constipation, heartburn, and burping. More serious side effects include:

• ongoing pain that begins in the upper left or middle of the stomach but may spread to the back, with or without vomiting;
• rash; itching; swelling of the eyes, face, mouth, tongue, or throat; difficulty breathing or swallowing;
• decreased urination; swelling of legs, ankles, or feet; and
• vision changes.

Additionally, semaglutide may increase the risk that Patient will develop tumors of the thyroid gland, including medullary thyroid carcinoma (MTC; a type of thyroid cancer). Also, semaglutide may negatively interact with diabetic and blood pressure medications.
-Sermorelin may cause headaches, dizziness, flushing, hyperactivity, nausea, and, more rarely, serious side effects including allergic reactions, changes in vision, or chest pain.

ALTERNATIVES TO PEPTIDE THERAPY SERVICES

Peptide Therapy Services treatments may be applied to different conditions, some of which may not qualify as an “illness” requiring “treatment” under traditional allopathic medical thinking. In other words, traditional medical thinking does not identify “feeling better” or having more energy or vitality as medically necessary for patients to justify Peptide Therapy Services intervention.
Multiple alternative methods, therapies, and treatments to Peptide Therapy Services exist and Patient acknowledges they have been advised of such alternatives. Traditional allopathic medicine alternatives to Peptide Therapy Services include but are not limited to:
Medications: Allopathic medicine provides a range of pharmaceuticals that can address specific symptoms or underlying causes of your condition. These medications are designed to target the specific issues you are experiencing and may include oral medications, injectables, or topical treatments.
Physical Therapy: Physical therapy involves the use of exercises, stretches, manual techniques, and other modalities to improve mobility, strength, and function. It is often used for musculoskeletal conditions, rehabilitation after surgery or injury, and management of chronic pain.
Surgery: In some cases, surgical intervention may be necessary to address your specific health issue. Surgical procedures can range from minor to major, depending on the condition being treated. Your healthcare provider will discuss the potential risks, benefits, and alternatives if surgery is deemed appropriate.
Lifestyle Modifications: Making lifestyle changes can have a significant impact on your health. These changes may include adopting a healthy diet, engaging in regular physical activity, managing stress, improving sleep patterns, and avoiding harmful habits like smoking or excessive alcohol consumption.
Physical Interventions: Allopathic medicine also includes physical interventions such as radiation therapy for cancer treatment, electroconvulsive therapy (ECT) for certain psychiatric conditions, or external physical modalities like ultrasound therapy for musculoskeletal injuries.
Symptomatic Treatment: Allopathic medicine focuses on managing symptoms and improving your quality of life. This can involve the use of analgesics for pain relief, anti-inflammatory drugs for reducing inflammation, or medications for managing specific symptoms like nausea, insomnia, or anxiety.

It is important to note that the appropriate treatment approach will depend on your specific condition and individual factors. Practice will discuss these alternatives with you, explaining the potential risks, benefits, and expected outcomes of each option. They will guide you towards the most suitable alternative treatments based on their professional expertise and your unique circumstances.

Patient agrees to proceed with the Peptide Therapy Services health treatment and to comply with recommended dosages and other protocols by Practice. Patient agrees to comply with requests for ongoing testing to ensure proper monitoring of Patient’s treatments that may include laboratory evaluation and other diagnostic testing.

Specific to semaglutide, Patient agrees to:

• Inform Practice if you are allergic to semaglutide (Ozempic, Rybelsus), albiglutide (Tanzeum; no longer available in the US); dulaglutide (Trulicity), exenatide (Bydureon, Byetta), liraglutide (Saxenda, Victoza, in Xultophy), lixisenatide (Adlyxin, in Soliqua), any other medications, or any of the ingredients in semaglutide tablets.
• Inform Practice what prescription and nonprescription medications, vitamins, nutritional supplements, and herbal products you are taking or plan to take. It is especially important to tell your healthcare professional about all the medications you take by mouth because semaglutide may change the way your body absorbs these medications.
• Inform Practice if you have or have ever had pancreatitis (inflammation of the pancreas), diabetic retinopathy (damage to the eyes caused by diabetes), gall bladder disease, or kidney disease. Also tell your healthcare professional if you have recently had diarrhea, nausea, or vomiting or if you cannot drink liquids by mouth, which may cause dehydration (loss of a large amount of body fluids).
• Inform Practice if you plan to become pregnant.
• Inform Practice if you are pregnant or are breastfeeding. If you become pregnant while taking semaglutide, immediately inform Practice.
• Inform Practice if you are having surgery, including dental surgery.
• Inform Practice if there is a large change in your diet, exercise, or weight; or if you get sick, develop an infection or fever, experience unusual stress, or are injured. These changes and conditions can affect your blood sugar and the amount of semaglutide you may need.

Additionally, Practice recommends semaglutide should be taken with a:

• fibrous diet rich in fruits and vegetables;
• small high protein meals as digestion is slowed while on semaglutide;
• at least 64 oz of water/day to help potentially avoid constipation; and
• avoid foods high in fat as they take longer to digest.

Semaglutide should not be taken when Patient has a:

• personal or family history of medullary thyroid carcinoma (Thyroid Cancer);
• You have a personal history of Multiple Endocrine Neoplasia syndrome type 2 (MEN2);
• pregnant or plan to become pregnant while taking this medicine;
• diabetic and/or taking any medications related to lowering your blood sugar levels without speaking with Practice and following Practice's guidance. Specifically, if you are prescribed insulin because the combination may increase your risk of hypoglycemia (low blood sugar) and dosage adjustments by your provider may be necessary; and
• allergic to Semaglutide or any other GLP-1 agonist such as Adlyxin, Byetta, Bydureon, Ozempic, Rybelsus, Trulicity, Victoza, Wegovy (THIS IS NOT AN ALL-INCLUSIVE LIST).

PLATELET-RICH PLASMA THERAPY BACKGROUND

Practice may inject platelet-rich plasma, a fraction of your blood which contains a high concentration of platelets, into where your ligament or tendon attaches to the bone, at the joint capsule or inside the joint, as a part of Services (“PRP Services”). Services related to the evaluation and use of plateletrich plasma, while common in alternative practices, may be debated in the traditional allopathic medical community. Patient has the right to be informed about Patient’s condition and the identification of conventional/allopathic, integrative, complementary, alternative, non-conventional, or non-standard procedures to be used so that Patient can make an informed decision whether or not to undergo non-allopathic PRP Services treatments with an appreciation of the risks, hazards, and alternatives.

PLATELET-RICH PLASMA THERAPY THEORIES

While research is ongoing to better understand PRP, there are theories on how PRP Services potentially work in the body and treat certain conditions. All of the following is non-allopathic (outside traditional medical thinking) and subject to ongoing medical debate. Research indicates platelet-rich plasma contains large quantities of growth factors which attract stem cells and stimulate the healing of damaged tissues. Clinical work over the last several years has established the usefulness of platelet-rich plasma for tissue repair and healing in joints and ligaments, resulting in reduced pain, improved function, and rejuvenating/cosmetic effects on the skin (e.g., improved skin texture, thickness, fine lines and wrinkles; increased volume; and diminished/improved appearance of scars).

PLATELET-RICH PLASMA THERAPY POTENTIAL RISKS

As outlined below, potential risks do exist with PRP Services, and not all healthcare professionals agree with the use of platelet-rich plasma as a method of treatment. PRP Services may be administered through injections. Injection site reactions include redness, pain, itching, burning, or swelling. Additional risks may include but are not limited to the following:

• increased pain and allergic reactions due to local anesthetics, iodine, contrast (X-Ray dye), materials containing latex, IV anesthetics, other medications;
• infection of skin, tissue, bones, joints, discs, nerves, ligaments, blood stream (sepsis), brain, and spinal cord (meningitis);
• bleeding;
• nerve damage, tissue injury/damage, and temporary or permanent numbness/weakness, paralysis, spinal cord injury;
• headache; and Page 16 of 17
• death

PLATELET-RICH PLASMA THERAPY ALTERNATIVES

Multiple alternative methods, therapies, and treatments to PRP Services exist, and Patient acknowledges Patient has been advised of such alternatives. Traditional allopathic medicine alternatives to PRP Services include, but are not limited to: allopathic medications, physical therapy, lifestyle modifications, physical interventions, and symptomatic treament. It is important to note that the appropriate treatment approach will depend on your specific condition and individual factors. Practice will discuss these alternatives with you, explaining the potential risks, benefits, and expected outcomes of each option. They will guide you towards the most suitable alternative treatments based on their professional expertise and your unique circumstances.

BOTOX TREATMENT BACKGROUND AND THEORIES

Practice may inject the botulinum toxin, commonly known as Botox, as part of a cosmetic procedure that Patient may voluntarily elect to receive (“Botox Treatment”). The botulinum toxin is a neurotoxin produced by the bacterium Clostridium A, and it can relax the muscles on areas of the face and neck which cause wrinkles associated with facial expressions or facial pain. Botox Treatment can cause facial expression lines or wrinkles to be less noticeable or essentially disappear. Areas most frequently treated are: a) glabellar area of frown lines, located between the eyes; b) crow’s feet (lateral areas of the eyes); c) forehead wrinkles; d) radial lip lines (smokers lines), e) head and neck muscles. Botox is diluted to a very controlled solution and when injected into the muscles with a very thin needle, it is almost painless. Patients may feel a slight burning sensation while the solution is being injected. The procedure takes about 15-20 minutes and the results can last up to 3 months. With repeated treatments, the results may tend to last longer.

BOTOX TREATMENT RISKS AND ALTERNATIVES

No procedure is completely risk-free. Potential risks of Botox Treatment include but are not limited to: discomfort, redness, swelling, and bruising; double vision; weakened tear duct(s); bacterial or fungal infection; allergic reaction; minor temporary drooping of eyelid(s); occasional numbness; transient headache; and flu-like symptoms. Patient agrees to notify Practice if Patient is pregnant, suspects that Patient is pregnant, or is planning to become pregnant. Patient warrants that, to the best of Patient’s knowledge, Patient is not lactating (nursing), does not have any significant neurological disease (including but not limited to myasthenis gravis, multiple sclerosis, lambert-eaton syndrome, amyotrophic lateral sclerosis (ALS), and Parkinson’s disease), and does not have any allergies to botulinum toxin or to human albumin. Botox Treatment is a voluntary cosmetic procedure. Patient may refuse consent to receive Botox Treatment, and Patient may discontinue treatment at any time. Alternatives to Botox Treatment include other cosmetic treatments, such as beauty products (e.g., topical creams and chemical peels), dermal fillers, and surgical procedures (e.g., facelifts).

PATIENT COVENANTS RELATED TO INTEGRATIVE SERVICES

Patient agrees to proceed with Integrative Services recommended treatment and to comply with recommended dosages. Patient agrees to comply with requests for ongoing testing to ensure proper monitoring of Patient’s treatments that may include laboratory evaluation of all aforementioned hormone levels or other diagnostic testing

INTEGRATIVE SERVICES DELEGATION

Practice may delegate certain specific Integrative Services to be performed by someone other than Practice’s owner (referred to as a Delegatee). Delegatee may be another licensed healthcare professional (nurse, nutritionist) or a non-licensed health coach or lifestyle medicine educator trained to provide the services below. Practice’s healthcare professional owner shall supervise any such Delegatee and will remain accountable for Delegatee services.

The services to be provided by Delegatee are detailed below and are part of the licensed healthcare professional-approved evidence-based protocols:

1. Perform initial and serial follow-up examinations of vital signs and/or anthropometric measurements.
2. Performing symptom-based health assessments.
3. Taking, assessing, and reviewing a lifestyle health history.
4. Patient education and counseling related to therapeutic food plans, lifestyle changes, etc.
5. Providing Patient education regarding healthcare professional’s care plan instructions, the significance of laboratory data, etc.
6. Providing education, counseling, and monitoring of food plans and compliant menus.
7. Providing education, motivational interviewing support, counseling, and monitoring of exercise/activity/fitness plan.
8. Providing education, support, and counseling regarding implementing therapeutic nutrition protocols.
9. Providing education, support, and counseling on stress management techniques to incorporate.
10. Providing Patient education on sleep, recuperation, and restoration.
11. Enter detailed medical record notes of all education/counseling/services provided to Patient during the visit and summarize any progress, obstacles, behavior change, and actions Patient plans to take.

OHIO MUSCULOSKELETAL SPORTS AND SPINE COMPANY ELECTRONIC COMMUNICATIONS AGREEMENT

Ohio Musculoskeletal Sports And Spine Company, an Ohio professional corporation (“we”, “us” or “Practice”), and the undersigned patient (“you” or “Patient”) enter into this Electronic Communications Agreement (“EC Agreement”) regarding the use of e-communications/transmissions, such as e-mail, mobile or cellular telephone (if applicable), Zoom, FaceTime, internet portal-enabled communications, SMS or text or DM messaging, or, any other version of electronic communication (collectively “E-Communication”) concerning Patient protected health information (“PHI”). (Practice and Patient are each a “Party” or collectively the “Parties”).

PATIENT AUTHORIZATION DESPITE RISKS OF PRIVACY BREACH

While Practice and Patient commonly rely on electronic communication platforms and services to achieve immediate communication, you acknowledge there are E-Communication risks that are outside Practice’s control. You authorize all forms of E-Communications exchanged between Parties unless you instruct us otherwise in writing. You acknowledge that the use of E-Communication is inherently risky and prone to unintentional release of data. E-Communications may incorporate or communicate references to your PHI with sensitive health and personal identification information included. You acknowledge that E-Communications lack any guarantee of privacy and are subject to system privacy failure, cookies and other tracking efforts, phishing attacks, hacking attacks, data breaches, unintended misdirections, misidentifications of senders/recipients, technology failures, and user errors.

You agree to undertake efforts to protect your privacy, which include refraining from including sensitive information in E-Communications that you do not want to be at risk of any data security breach. Practice will undertake reasonable efforts to protect your privacy to the extent required by applicable laws. You authorize us to respond electronically to all E-Communications that appear to be provided by you, whether or not such communications arrive from the electronic contact information that you provide us.

PATIENT MUST PROVIDE ACCURATE AND UPDATED CONTACT INFORMATION

You agree to provide us with your accurate electronic contact information (email address, Zoom or FaceTime contact information, phone number, and any other applicable E-Communication contact information). You will immediately inform us of any changes or corrections to your electronic contact information to avoid misdirected E-Communications. You will also inform us of your permanent mailing residential address, and any changes to that address.

PATIENT MUST NOT RELY ON ELECTRONIC COMMUNICATION IN EMERGENCIES: USE 911 AND GET TO THE EMERGENCY ROOM

Practice does not guarantee that we will read your E-Communications immediately or within any specific amount of time. You agree not to utilize E-Communications to contact us regarding an emergency or time-sensitive situation, as there is too much risk that the communication response may be delayed, ineffective, untimely, or inadequate. You MUST call 9-1-1 in an emergency and/or immediately seek emergency medical attention.

PATIENT AGREES TO UTILIZE ELECTRONIC COMMUNICATION TO REPORT ANY NEGATIVE CONDITIONS RESULTING FROM ANY PRACTICE SERVICES

If Patient experiences any side effects or worsening conditions (that do not constitute an emergency or timesensitive situation as mentioned above) related to any Practice services, Patient shall immediately utilize ECommunications to timely inform Practice of such side effects or worsening conditions.

HIPAA/HITECH/DATA PRIVACY LAWS

Practice values and appreciates your privacy and will take commercially reasonable steps to protect Patient’s privacy in compliance with the Health Insurance Portability and Accountability Act of 1996 and related laws such as HITECH (collectively referred to as “HIPAA”). Practice shall also comply with other data privacy laws related to Patient’s data.

We will obtain your express written or electronic consent (to the extent required by applicable law) if we are required or requested to forward your identifiable PHI to any third party other than as authorized in our Notice of Privacy Practices or as authorized or mandated by applicable law. You hereby consent to the use of ECommunication of Patient’sinformation as we consider it helpful to coordinate care and schedule visits (including virtual visits) with you and all those responsible for providing or overseeing your care. You agree to identify individuals or entities authorized to receive your PHI from us in connection with authorized consulting, education, and all other aspects of your care, and we may share your PHI with such parties without additional written or electronic consent from you.

You have the right to ask us for a copy of your PHI, including an explanation or summary. The following services will not be the subject of any additional charges to you (and are outside Services Fees): maintaining PHI storage systems; recouping capital or expenses for PHI data access, PHI storage, and infrastructure; or retrieval of PHI electronic information.

Practice may charge you fees for actual costs that we incur to provide such electronic PHI, but only to the extent authorized by applicable laws. Such fees may include: skilled technical staff time spent to create and copy PHI; compiling, extracting, scanning, and burning PHI to media and distributing the media (with media costs charged to you); and time spent by our administrative staff preparing additional explanations or summaries of PHI. If you request PHI on a paper copy, or portable media (such as compact disc/CD, or universal serial bus/USB flash drive), we may charge you for our actual supply costs for such equipment, and you agree to pay us any such costs.

PATIENT ACCEPTS RESPONSIBILITY FOR ELECTRONIC COMMUNICATION RISKS

You will hold Practice (and our owners, officers, directors, agents, and employees) harmless from and against any demands, claims, and damages to persons or property, losses, and liabilities, including reasonable attorney fees arising out of or caused by E-Communication (whether encrypted or not) and losses or disclosures caused by any of the risks outlined above, by some person or entity other than Practice, or not directly caused by us. Patient acknowledges and understands that, at our discretion, E-Communication may or may not become part of your permanent medical record. These terms do not relieve Practice from Practice’s obligations to comply with all applicable E-Communication laws. You acknowledge that your failure to comply with the terms of this EC Agreement may result in our terminating the use of E-Communication methods with you and may cause the termination of your Agreement for our services.

ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

We are required to provide you with a copy of our Notice of Privacy Practices, which states how we may disclose your health information. You hereby acknowledge receipt of the Notice of Privacy Practices.

OPEN PAYMENTS DATABASE

The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. It can be found at https://openpaymentsdata.cms.gov. For informational purposes only, a link to the federal Centers for Medicare and Medicaid Services (CMS) Open Payments web page is provided here. The federal Physician Payments Sunshine Act requires that detailed information about payment and other payments of value worth over ten dollars ($10) from manufacturers of drugs, medical devices, and biologics to physicians and teaching hospitals be made available to the public.

ADDITIONAL TERMS

This EC Agreement will remain in effect until either Party provides written notice to the other Party revoking this EC Agreement or otherwise revoking consent to E-Communications between the Parties. Such revocation will occur thirty (30) calendar days after written notice of such revocation.

Revocation of this EC Agreement will preclude us from providing treatment information in an electronic format other than as authorized or mandated by applicable law or by you. Either Party may use a copy of this signed original EC Agreement for all present and future purposes.

Parties agree to take such action as is reasonably necessary to amend this EC Agreement from time to time as it is necessary for the Parties to comply with the requirements of the Privacy Rule, the Security Rule, and other provisions of HIPAA, or other applicable law. Parties further agree that this EC Agreement cannot be changed, modified, or discharged except by an agreement in writing and signed by both Parties.

If any term of this EC Agreement is deemed invalid or in violation of any applicable law or public policy, the remaining terms of this EC Agreement shall remain in full force and effect, and this EC Agreement shall be deemed amended to conform to any applicable law.

Each participating Patient (and authorized representative when applicable) must sign this EC Agreement. Your signature represents that you understand and agree to the terms and conditions described within this EC Agreement.

PRACTICE: OHIO MUSCULOSKELETAL SPORTS AND SPINE COMPANY, AN OHIO PROFESSIONAL CORPORATION

Name: Dr. Chauncy Eakins
Title: President

OHIO MUSCULOSKELETAL SPORTS AND SPINE COMPANY ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

Notice to undersigned patient (“Patient”):
Ohio Musculoskeletal Sports And Spine Company, an Ohio professional corporation (“Practice”), is required to provide Patient with a copy of Practice’s Notice of Privacy Practices (“Notice”) that states how Practice may use and/or disclose Patient’s health information.
Please sign this form to acknowledge receipt of the Notice.
You may refuse to sign this acknowledgment if you wish.

I acknowledge that I have received a copy of Practice’s Notice of Privacy Practices.

FOR OFFICE USE ONLY

OHIO MUSCULOSKELETAL SPORTS AND SPINE COMPANY NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Dear Patient: Ohio Musculoskeletal Sports And Spine Company, an Ohio professional corporation (“we”, “us”, “our”, “Practice”), understands that patient (“you”, “your”) privacy is important. This Notice of Privacy Practices (“Notice”) applies to Practice and each of our Business Associates, as applicable.

Protected health information/PHI
Protected health information (“PHI”) relates to information about you and your health, which could be used to identify you. Each time that you visit us, we create a medical record of your PHI and the services that you receive.

Our obligations regarding your PHI
We recognize that information about you and your health is confidential, and we are committed to protecting this information. This Notice applies to all your health records that we create.
We are required by law to preserve the privacy and security of your PHI. While there is no guarantee of privacy, we are committed to protecting your privacy.
We have established reasonable and appropriate measures to protect your PHI against unauthorized uses and disclosures.
Federal law mandates that we share this Notice with you and that we make a good-faith effort to obtain a signed document acknowledging your receipt of this Notice. We are also required to follow the terms of this Notice. If we are involved in a breach of your PHI, we will immediately notify you.

This Notice’s effective date and potential changes
The effective date (“Effective Date”) shall be the date of receipt of this Notice, and it applies to health records that we create for you. We reserve the right to change this Notice after the Effective Date. We can change the terms of this Notice, and the changes will apply to all the information we have about you. The new Notice will be available upon request.

How we may disclose your PHI
The laws of the state where Practice is located, and federal laws, allow disclosures of your PHI in some cases. Some of these disclosures do not require your verbal or written permission. The following information describes how we may share your PHI. We may typically use or share your PHI in these ways:

When we treat you
We can use your PHI and share it with other professionals who are treating you. Example: A doctor treating you for an injury asks another doctor about your overall health condition.

As we operate/manage our practice organization
We can use and share your PHI to operate and manage our practice, improve your care, and contact you when necessary.
Example: We use your PHI to manage your treatment and deliver healthcare services.

When we bill for healthcare services
We can use and share your PHI to bill and obtain payment from health plans or other entities or you.
Example: We give information about you to your health insurance plan so it will pay for your services.

When we help with public health and safety issues
We can share your PHI for certain situations such as:
Preventing disease;
Helping with product recalls;
Reporting adverse reactions to medications;
Reporting suspected abuse, neglect, or domestic violence; and
Preventing or reducing a serious threat to anyone’s health or safety.

When we perform research
We can use or share your PHI for health research.

To comply with the law
We will share your PHI if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we are complying with federal privacy law.

When we respond to organ and tissue donation requests
We can share your PHI with organ procurement organizations.

When we coordinate end-of-life care and related decisions
We can work with a medical examiner or funeral director regarding your PHI shared.
We can share your PHI with a coroner, medical examiner, or funeral director at end-of-life.

To address other government requests
We can use or share your PHI:
For workers’ compensation claims;
For law enforcement purposes or with a law enforcement official;
With health oversight agencies for activities authorized by law; and
For special government functions such as military, national security, and presidential protective services.

To respond to lawsuits and legal actions
We can share your PHI in response to a court or administrative order, or to a subpoena.

How else can we use or share your PHI?
We are allowed or required to share your PHI in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. We have not listed every use and disclosure in this Notice. For more information see www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

We can use and disclose your PHI in certain situations with your verbal or written agreement
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.
In these cases, you have both the right and choice to tell us to:
Share information with your family, close friends, or others involved in your care;
Share information in a disaster relief situation; and
Include your information in a hospital directory.

If you cannot tell us your preference, for example, if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to your health or safety.

We can use and disclose your PHI in certain situations requiring your written permission
If there are situations that have not been described above, we will obtain your written permission. In these cases, we never share your PHI unless you give us written permission:
Marketing purposes;
Sale of your information; and
Most sharing of psychotherapy notes.

With fundraising, we may contact you for fundraising efforts, but you can tell us not to contact you again.
If you provide us with written permission, you may change your mind at any time. Please let us know in writing if you change your mind.

Your rights regarding your PHI
You have the following rights regarding your PHI that is created in our Practice. This section explains some of your rights and our responsibilities to assist you.

You may request an electronic or paper copy of your PHI medical record
You can ask to see or receive an electronic or paper copy of your medical record and other PHI that we have about you. Ask us how to do this.
We will provide a copy or a summary of your PHI, usually within thirty (30) days of your request. We may charge a reasonable cost-based fee.

Ask us to correct your PHI medical record
You can ask us to correct PHI about you that you think is incorrect or incomplete. Ask us how to do this. We may say “no” to your request, but we will tell you why in writing within sixty (60) days.

Request confidential communications
You can ask us to contact you in a specific way (for example, home or office phone), or to send mail to a different address.
We will say “yes” to all reasonable requests.

Ask us to limit what PHI we use or share
You can ask us not to use or share certain PHI in connection with some of our services, but…
We are not required to agree to your request, and we may say “no” if we believe that would affect your care. Because you are privately paying for some medical or health services, you may ask us to refrain from sharing PHI related to those private pay services with your health insurance plan. We will respect that request unless we are legally obligated otherwise under applicable laws.

You may request a list of who we have shared information |
You can ask for a list (accounting) of the times we have shared your PHI for six (6) years prior to the date you ask, who we shared it with, and why.
We will provide one accounting of PHI disclosures for you per year for no charge, but we can charge a reasonable, cost-based fee if you ask for another PHI disclosure accounting within the same year.
The accounting will only contain PHI disclosures required to be reported by law. Example: PHI disclosures regarding your treatment are not required by law to be reported and will not be in your accounting.

Get a copy of this Notice
You can ask for a paper copy of this Notice at any time, even if you have agreed to receive this notice electronically.
We will provide you with a Notice paper copy promptly.

Choose someone to act for you
If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
We will make sure the person has this authority and can act for you before we take any action.

Ask questions or file a complaint if you believe your rights are violated
If you have questions about this Notice or you believe that your rights are being violated, please contact us immediately

Practice contact information:
Ohio Musculoskeletal Sports And Spine Company
Attention: Dr. Chauncy Lawrence Eakins
2136 McKinley Ave
Cincinnati, OH 45224
c.eakins@hotmail.com

You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints.

Please provide as much information as possible so that the Department of Health and Human Services can thoroughly investigate your concern or complaint. We will not retaliate against you for filing a complaint with us, or the Department of Health and Human Services.

Thank you,

OHIO MUSCULOSKELETAL SPORTS AND SPINE COMPANY