Disclaimer

Precision Health MD

We have text messages and portal messages as a form of communication.
You can cancel the SMS service at any time. Simply text "STOP" to the shortcode. Upon sending "STOP," we will confirm your unsubscribe status via SMS. Following this confirmation, you will no longer receive SMS messages from us. To rejoin, sign up as you did initially, and we will resume sending SMS messages to you.
If you experience issues with the messaging program, reply with the keyword HELP for more assistance, or reach out directly to support@precisionhealthmdoc.com.
Carriers are not liable for delayed or undelivered messages.
As always, message and data rates may apply for messages sent to you from us and to us from you. Message frequency varies. For questions about your text plan or data plan, contact your wireless provider.
For privacy-related inquiries, please refer to our privacy policy.

I acknowledge and agree that I understand the following, with respect to services rendered by Precision Health MD and their employees, consultants, and technical assistants, including Jennifer Roelands (“Practitioner”).

Clinic Terms

GENERAL

Dr. Jennifer Roelands' clinic is for those exploring the possibility of utilizing complementary therapies in conjunction with conventional medical care. Members are required to keep a primary care provider and provide Dr. Jennifer Roelands with all medical information relevant to their health status. In certain cases, lab tests may be offered for us to evaluate the functional status of a member better and provide integrative therapeutic options. It is the responsibility of the Member to disclose any new treatments to their primary care physician.
The practice of functional medicine is founded on evidence-based science; however, no guarantees are made regarding outcomes, and it should not be considered a substitute for traditional medical care.
An integrative medicine approach is collaborative and requires active participation and cooperation by the members to achieve the best outcomes.
No Guarantee of Results: The Member understands that Dr. Jennifer Roelands cannot guarantee results. Rather, the facility provides a model based on a systematic approach that enables members to better understand their health and achieve the desired results. Dr. Jennifer Roelands and all staff help members reach their health goals by implementing positive, sustainable lifestyle changes.

MAINTAINING SEPARATE PRIMARY CARE PHYSICIAN

Dr. Jennifer Roelands may consult with your conventional medical providers. Still, her care does not replace care currently provided to the member by other physicians. The member understands that Dr. Roelands may recommend a referral to a specialist for your condition(s) if the member has not already consulted with an appropriate specialist. Dr. Roelands does not admit Members to the hospital or treat hospitalized members.
Dr. Jennifer Roelands does not function as a primary care provider. Rather, the Practice acts as an extension of the member’s medical team working on root cause resolution. As a condition of receiving services from Practice, the member must maintain a relationship with an outside physician to act as a primary care provider and to provide emergency and urgent care. If a member encounters a medical emergency and cannot obtain care from his or her primary care physician(s), the member is advised to contact 911 or report to a hospital emergency department as appropriate.

INSURANCE:

We accept many insurance plans and will bill your insurance provider for covered medical services. However:

You are responsible for understanding your specific insurance plan, including co-pays, deductibles, and covered services.
Any services not covered by insurance will be billed directly to you.
We are committed to transparency and will make every reasonable effort to inform you in advance of non-covered services.
Precision Health MD does not make any representation or warranty whatsoever that the Member’s health insurance plan covers any fees paid under this Agreement. The Member shall be fully and completely responsible for payment to Practice.
This payment is due no later than 90 days after the insurance is processed. The card on file will be charged after sending an invoice and payment not rendered within 30 days of the invoice.

NON-PARTICIPATION IN LEGAL MATTERS

If the Member is already involved in legal proceedings that pertain to consequences of symptoms regarding diagnoses, health, work capabilities, or disability, this is not a reason to seek care from Dr. Jennifer Roelands in anticipation of legal counsel. By signing below, the Member affirms they are not currently involved in legal proceedings in regard to health (mental, physical, or otherwise).

All FEES

Dr. Roelands uses encrypted, HIPAA-compliant software for billing and appointment scheduling.

Please see website for up to date pricing

ASSUMPTIONS FOR PATIENTS:

•As a Member, you are under the care of an outside primary care practitioner and should discuss any dietary changes or potential dietary supplements use with your primary doctor.
• As a Member, you should not discontinue any prescription medications without consulting your prescribing doctor.
• As a Member, you recognize this Agreement does not guarantee results and deals solely with the services to be rendered and the fees to be paid for the support provided.
• As a Member, your payment obligation is not contingent upon the care outcome.
You take full responsibility for your life, well-being, and all decisions made during and after this program. You expressly assume the risks of the Membership, including the risks of trying new foods or supplements and the risks inherent in making lifestyle changes. You release Precision Health MD from any liability, damages, causes of action, allegations, suits, sums of money, claims, and demands whatsoever, in law or equity, which the member ever had, now has, or will have in the future against Precision Heath MD, arising from the Member’s past or future participation in, or otherwise concerning the Membership, unless arising from the gross negligence of Well Woman MD / Precision Health MD.

ASSUMPTIONS FOR DR. JENNIFER ROELAND’S MEDICAL SERVICES:

One-on-one medical support with Dr. Jennifer Roelands or associates in regard to the Member’s chronic health conditions, as set forth based on service.
administrative paperwork such as referrals, filling out forms, and communicating with other medical providers.
Refills of medications as prescribed by Jennifer Roelands, as long as the Member is compliant with the recommended appointment and testing frequency.
Non-urgent email access within delineated boundaries set forth (Monday-Friday)
Access to nutraceutical products at discounted rates.
Access to specialty testing at wholesale cost, as recommended by Dr. Jennifer Roelands

ELECTRONIC COMMUNICATION:

You, (The Member) understand and agree that E-mail communications (outside of the secure Member portal), facsimile, video chat, instant messaging, and cell phone are not guaranteed to be encrypted, secure, or confidential methods of communications.
Any communications made outside of the Member portal are made at the Member’s risk.
The use of electronic communication outside of the secure Member Portal has inherent limitations, including possible breach of privacy or confidentiality, difficulty in validating the identity of the parties, and possible delays in response. Dr. Jennifer Roelands delivers medical services in various convenient ways to help support the Members. This allows members the opportunity to communicate via secure email, phone, online Zoom meetings, and CHAM Health.

Transmitting confidential health information by electronic means, however, has several risks, both general and specific, that should be considered before use.
1. Risks:
a. General email risks are the following: e-mail can be immediately broadcast worldwide and be received by many intended and unintended recipients; recipients can forward the e-mail to other recipients without the original sender(s) permission or knowledge; users can easily misaddress an email; e-mail is easier to falsify than handwritten or signed documents; backup copies of e-mail may exist even after the sender, or recipient has deleted his/her history.
b. Specific email risks are the following: e-mail containing information pertaining to diagnosis and/or treatment must be included in the protected personal health information; all individuals who have access to the protected personal health information will have access to the e-mail messages; the Members who send or receive email from their place of employment risk having their employer read their email.

2. It is the policy of Precision Health that all e-mail messages sent or received that concern the diagnosis, or treatment, of the Member, will be a part of the Member’s protected personal health information, and we will treat such e-mail messages, or internet communications, with the same degree of confidentiality as afforded other portions of the protected personal health information. Precision Health MD will use reasonable means to protect the security and confidentiality of e-mail or Internet communication. Because of the risks outlined above, we cannot, however, guarantee the security and confidentiality of e-mail or internet communications.

3. The Members must consent to the use of email for confidential medical information after having been informed of the above risks. Consent to the use of e-mail includes an agreement with the following conditions:
a. All e-mails to or from the Members concerning diagnosis and treatment will be made a part of the protected personal health information. As a part of the protected personal health information, other individuals, Jennifer Roelands, MD, physicians, nurses, other healthcare practitioners, insurance coordinators, and upon written authorization, other healthcare providers and insurers will have access to e-mail messages contained in protected personal health information.
b. The office may forward e-mail messages within the practice as necessary for diagnosis and treatment. We will not, however, forward the email outside the practice without the consent of the Member as required by law.
c. We at Well Woman MD / Precision Health MD will endeavor to read e-mail promptly but can provide no assurance that the recipient of the e-mail will read the e-mail message promptly. Therefore, an e-mail must not be used in a medical emergency.
d. Because some medical information is so sensitive that unauthorized disclosure can be very damaging, e-mail should not be used for communications concerning the diagnosis or treatment of AIDS/HIV infection; other sexually transmissible, or communicable diseases, such as syphilis, gonorrhea, herpes, and the like; Behavioral health, Mental health, or developmental disability; or alcohol and drug abuse.
e. Precision Health MD cannot guarantee that electronic communications will be private. However, we will take reasonable steps to protect the confidentiality of e-mail or Internet communication. However, Dr. Roelands and her team are not liable for improper disclosure of confidential information not caused by its employee’s gross negligence or wanton misconduct.
f. If consent is given for the use of e-mail, it is the responsibility of the Member to inform Well Woman MD staff of any type of information you do not want to be sent by email.
g. It is the responsibility of the Member to protect their password or other means of access to an e-mail sent or received, from Precision Health MD, to protect confidentiality.
Precision Health MD and Dr. Jennifer Roelands are not liable for breaches of confidentiality caused by the Member.
Informed Consent Regarding E-mail or the Internet Use of Protected Personal Information Any further use of e-mail initiated by the Member that discusses diagnosis, or treatment, constitutes informed consent to the foregoing. I understand that my consent to the use of e-mail may be withdrawn at any time by e-mail, or written communication to doctorjen@wellwomanmd.com
Dr. Jennifer Roelands (Practice) may send regular email updates to private patient members with exciting information and tips. Still, she will not respond to these emails or other messages that contain sensitive medical information.

TELEMEDICINE CONSENT

Dr. Jennifer Roelands at Precision Health MD utilizes Telemedicine Services. By signing below, you affirm that you are seeking the telemedicine consultation services for your own purposes and not on behalf of any third party. You are a participant in the decision-making process and are free to decline services or treatments at any time. You retain the option to withhold or withdraw consent at any time without affecting your right to future care or treatment nor risking the loss or withdrawal of any program benefits to which I would otherwise be entitled. You acknowledge that Dr. Jennifer Roelands may, in her sole discretion, determine whether the nature of your consultation is inappropriate for telemedicine and may require you to come in for an in-person consultation. You agree to bring to the attention of Dr. Jennifer Roelands at Precision Health MD if, at any time, you have any lack of understanding of such risks, benefits, and alternatives and inquire of Dr. Roelands for a further explanation until you have a full understanding before giving consent to any treatment or services.

Nature of Telemedicine Consultation. Telemedicine involves the use of audio, video, or other electronic communications to interact with you, consult with your healthcare provider, and/or review your medical information for the purpose of diagnosis, therapy, follow-up, and/or educational purposes. During your telemedicine consultation, details of your medical history and personal history information may be discussed with other health professionals using interactive video, audio, and telecommunications technology. Additionally, a physical examination of you may take place, and video, audio, and/or photo recordings may be taken.

Risks, Benefits, and Alternatives. The benefits of telemedicine include access to medical specialists and additional medical information and education without traveling outside your local healthcare community. Additional benefits are that patients may be diagnosed and treated earlier, contributing to improved outcomes and less costly treatments. Potential risks of telemedicine include that because of your specific medical condition or due to technical problems, a face-to-face consultation may still be necessary after the telemedicine appointment.

Precision Health MD and Dr. Jennifer Roelands have taken the following steps to ensure the privacy of the telemedicine consultation:
We use only HIPAA-compliant software through our Electronic Medical Record (EMR), teleconferencing, and other HIPAA electronic service providers.
We have taken steps to encrypt data stored on local devices if any.
We use password-protected screen-savers and data files, and
We use other reliable authentication techniques and safeguards, both electronically and physically, to reduce the likelihood of patient data or privacy breaches.

In rare instances, technology failure may lead to the loss of information provided through telemedicine consultations. Additionally, in rare instances, security protocols could fail to cause a breach of patient privacy. In rare cases, a lack of access to complete and/or accurate medical records or information may result in adverse drug reactions, allergic reactions, or other judgment errors. You agree to hold Provider and Practice harmless from any such information loss, and any resulting judgments or decisions, due to technical failures outside of their agency or control. The quality of transmitted data may also affect the quality of the services provided via telemedicine consultation. The alternative to telemedicine consultation is a face-to-face visit with a physician.

Medical Information and Records. All laws concerning patient access to medical records and copies of medical records apply to telemedicine. Dissemination of any patient-identifiable images or information from the telemedicine consultation shall not occur without your consent.

Confidentiality. All existing confidentiality protections under federal and state law apply to information used or disclosed during your telemedicine consultation. However, there are both mandatory and permissive exceptions to confidentiality, which may allow or require disclosure of information used or disclosed during the telemedicine consultation. You will be informed of any parties who will be present from the Practice during your telehealth consultation and will have the opportunity to exclude anyone from attending the consultation.

Rights. You may withhold or withdraw your consent to a telemedicine consultation at any time before and/or during the consultation without affecting your right to future care or treatment or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled. You have the right to be informed of and object to videotaping or another recording of the telehealth consultation.

ELECTRONIC MESSAGING ETIQUETTE

Suppose a question or request is deemed by Dr. Roelands or one of the staff members to be too complicated or involved for us to respond via message. In that case, the ability of Members to communicate via email becomes abused or habitual beyond reasonable time limitations set by our practice, or if we determine that your condition requires an in-person exam or evaluation, we may require that the member schedule a phone, telemedicine or in-person visit instead of responding via email and/or text. The member may use one or part of an included visit or pay a fee according to the time needed to consult with the client. The open messaging service is a benefit to maintaining the trust and positive dialogue we find helpful. At any time during membership, this feature can be re-defined to exclude or cap the number of texts and emails if it is deemed to be abused by any Member.
If a response is requested, Dr. Jennifer Roelands will respond through the secure Charm member portal. Though it is Practice’s policy only to respond through the Member portal by initiating correspondence through an unsecured and/or unencrypted channel, the Member hereby expressly waives Practice’s obligation to guarantee confidentiality with respect to correspondence using such means of communication. The Member understands and acknowledges that Practice may retain any communications between Practice and the Member and include such communications in The Member’s medical record.
All members’ information will be kept private, and Dr. Jennifer Roelands will not share the Member’s information with any third party unless compelled to by law. Participation in shared group medical visits will be treated with similar HIPAA confidentiality, and all the Members will sign an agreement.
As such, you expressly waive Dr. Jennifer Roelands'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.
The Member understands and agrees that portal messaging or e-mail are not appropriate means of communication regarding an emergency or other time-sensitive issues or for inquiries regarding sensitive information. In the event of an emergency or a situation that The Member reasonably believes could develop into an emergency, The Member shall call 911 or proceed to the nearest emergency room and follow the directions of emergency personnel.

Voicemail and Texting: This is not a preferred method of communication for the Members, as telephone and text messages are not reliably checked.

Charm EMR Portal message: This is to be used for non-urgent messages only, and a response will generally be sent within two (2) business days. By leaving a telephone or portal message, The Member acknowledges and agrees that a prompt reply is NOT required or expected and acknowledges that The Member will not use portal messages to deal with emergencies or other time-sensitive issues.
Dr. Jennifer Roelands at Precision Health MD will substantively respond and answer inquiries seeking to clarify the recommendations made at the most recent medical visit or to answer supplement usage or dosage questions. If at the sole discretion of Practice, The Member’s questions exceed the scope of that limited exception, The Member will be encouraged to come in for an appointment and thus restart active membership with Practice or to seek counsel from their primary care physician.

Online Zoom meetings: are used for educational purposes. You can ask questions that are specific to your medical conditions but understand that others are watching. You must be comfortable with this knowledge.
Dr. Jennifer Roelands expressly disclaims any liability associated with any loss, cost, injury, or expense caused by, or resulting from, a delay in responding to the Member because of any action, inaction, technical issues, or activity outside Practice’s control, including but not limited to,
(i) technical failures attributable to any Internet service provider,
(ii) power outages, failure of any electronic messaging software, or failure to properly address portal messages,
(iii) failure of the Practice’s computers or computer network, faulty telephone or cable data transmission,
(iv) any interception of email communications by a third party; or
(v) The Member’s failure to comply with the guidelines regarding the use of e-mail communications

TELEPHONE CALL POLICY

Our office number is (714) 272-3477. If it is urgent, please call 911 or go to Urgent Care. Our business hours are Monday - Friday 9 am -5 pm PST. We do not check messages/emails Saturday - Sunday (& observed holidays). Please leave a message during non-business hours and allow up to 5 days for a callback.

SUPPLEMENTS

Supplements and nutritional supplements may interfere with prescribed medications. It is important that every physician member of your health team is aware of what combinations of medications and supplements you are taking. All the products recommended by Dr. Jennifer Roelands have been scientifically tested by their manufacturers and independently reviewed for quality by others qualified.
Dr. Roelands has partnered with several companies that provide medical-grade supplements. She has personally reviewed and feels confident in their research, quality, and history. This does not mean these companies are the ONLY ones to use. Dr. Roelands can provide a list of alternatives and will always remain transparent with cost.
Precision Health MD acts as a secondary retailer for the manufacturers of the health-related products it sells. Precision Health MD has decided that it can provide health-related products online through the internet as a convenience to our members. However, if you prefer to purchase these products (or other similar products) elsewhere, please let us know, and we will provide you with information on where they are available.
MOST IMPORTANT: Dr. Roelands may recommend dietary supplements as part of your treatment plan. This is through an online dispensary. However, you are under no obligation to purchase these products from her. You may purchase the same products elsewhere at your own risk, and your quality of medical care in her office will not be affected by your decision to purchase or not purchase products.

CANCELLATION POLICY

Cancellation and Missed Appointment Policy:
 When you schedule an appointment, that time is reserved especially for you. Therefore, we require that cancellations and scheduling changes be made at least 72 business hours for initial appointments and 48 business hours (two business day, M-F) prior to your scheduled appointment. Monday appointments must be cancelled before 5pm the Thursday prior.
 For cancellations made less than 48/72 business hours before your scheduled appointment or after 5pm, two days prior for Monday appointments and no-shows (missed appointments), your credit card on file will be charged the following fee:
o A $75 cancellation fee will be charged to your credit card on file for a late cancellation or no-show on a scheduled IV
o A $100 cancellation fee will be charged to your credit card on file for a late cancellation or no-show of a standard medical visit or aesthetic consultation; $300 no-show fee for New Patient consults.
 Two no-shows (or late cancels within 6 hours of appointment time) within one calendar year without just cause, and Dr. Roelands may exercise the right to refuse continuation of ongoing care.

COLLABORATION WITH TEAM

Dr. Jennifer Roelands has agreements with independent contractors to help with data entry and Member workflow. HIPAA contracts are signed with these supporting staff, and you acknowledge agreement to have staff help with your medical care when necessary (phone calls, answering emails, messaging in the Charm portal).

Compounded HORMONE REPLACEMENT THERAPY or Weight Loss Meds

All medical treatments have potential side effects. I acknowledge and understand that hormone replacement can lead to side effects and I hereby consent to get a full physical exam including PSA lab testing, digital rectal exam, PAP, mammogram, complete wellness panel, or specialized hormonal testing as my doctor recommends, either with them or with your primary care doctor, before initiating, or while taking hormone replacement.

Dr. Roelands may prescribe compounded HRT or other medications from a compounded pharmacy and therefore you as the member understand that the mainstream medical community may view this treatment as new, controversial, off-label, experimental, and unnecessary by the Food and Drug Administration (“FDA”).

AUTHORIZATION FOR CREDIT CARD PAYMENT.

This is to hold an appointment.
The card will not be charged until the appointment is completed. The patient may incur additional charges, these charges include, but are not limited to:
- Full appointment charge for a missed appointment without 24-hour advance notice.
- Any costs associated with the collection of patient balances after insurance processes

The patient shall receive an invoice for the additional costs and payment must be rendered within 30 days of invoice or the card will be charged.

CREDIT CARD ON FILE: All Patients are required to maintain a credit card on file
to hold your scheduled appointments. Please complete the Credit Card Authorization provided. Your credit card information will be held on file and is safely and securely stored into our encrypted merchant system, and we can only see the last 4 digits.
Your credit card on file will be charged for any appointment fees immediately after your appointments are over unless another valid credit card is provided, as well as for late cancellation fees in accordance with our Cancellation and Missed Policy, and any costs associated with the collection of patient
balances after insurance processes.
If payment is not made or if there is a chargeback or billing dispute, you understand that Precision Health MD is authorized to provide the necessary information to the credit card company about the scope of services provided to you as well as a copy of this signed form to obtain payment. Additionally, patients are responsible for the costs of collections if Precision Health MD must hire the services of a collections agency to obtain payment. A holder of this medical debt contract is prohibited by Section 1785.27 of the Civil Code from furnishing any information related to this debt to a consumer credit reporting agency. In addition to any other penalties allowed by law, if a person knowingly violates that section by furnishing information regarding this debt to a consumer credit reporting agency, the debt shall be void and unenforceable (SB 1061).

I/we authorize Dr. Jennifer Roelands, to bill the above credit/debit card for professional services as outlined in the Policies. I will notify Dr. Jennifer Roelands, in writing if I no longer want my credit/debit card billed. FEES WILL BE DUE AT THE TIME OF SERVICE, and this card will be run for fees at the time of service.

Disclaimer

Our Services

About Our Clinic

Request Appointment

OUR LOCATION

CONTACT

OFFICE HOURS