Informed Consent Pilot Program WellStart Health

The user agrees to voluntarily enroll in a health improvement program administered by WellStart Health, Inc. I consent to the following:

The user consents to receive treatment from a physician assigned to me through WellStart Health. I will receive text messages, emails, and phone calls from said physician, as well as an assigned Registered Dietitian and health coach.

The user understands that their assigned physician may make recommendations regarding medication doses (if they become too strong); The user understands that these are only recommendations. It is the users responsibility to follow up with their primary care provider for ongoing medical management. The user understands that changing their diet and activity levels may decrease my blood pressure or blood sugar rapidly, which may necessitate changes in medications. If the user finds themselves in an urgent medical situation, they promise to seek medical care at either their primary physician’s office, an urgent care, or an emergency department, and will not rely solely on the availability of any WellStart physicians, dietitians, or health coaches in an emergency situation.

The user consents to their biometrics being tested twice over the course of the 12 week program. The user consents to the having the results reviewed by their assigned physician with identifying information attached to the data. The users data ( including age, sex, blood sugar levels, blood pressure, cholesterol and triglyceride levels, weight, and body mass index) will be de-identified when viewed by statisticians who analyze the data. The user will maintain access to, and be able to view their own data immediately. The user consents to having their de-identified data shown to whomever WellStart Health, Inc. deems necessary. The user understands that their de-identified data will not contain their name, birthdate, home address, telephone number, email address, or social security number.

The user understands that they may not bill their insurance for this program, and that WellStart Health, Inc. will not provide “superbills” or information for insurance claims.

The user consents to being in a “virtual group” for discussions. The user understands that any personal information they reveal is at their own discretion, and that it is not required to divulge any personal information inside of the group. The user understand that any decision to do so is completely voluntary.

The user understands that their deposit fee for the program will not be refunded if the user does not complete the program in its entirety. This means the user must read all program materials, respond to group discussions, complete both biometric screenings, and evaluate the program. The user understands that evaluation of the program will be ongoing, and their feedback will be solicited multiple times.

The user agrees to fully and to the best of their ability, participate in the program, by engaging in all aspects of the program and making their best effort to follow program recommendations.

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