Red Lion Clinic HIPAA Authorization & GLP-1 Treatment Consent
Authorization for Use & Disclosure of Protected Health Information
By signing this Authorization, I consent to the use and disclosure of my Protected Health Information (PHI) as outlined below. This Authorization is voluntary, and my decision to sign or decline will not impact my ability to receive healthcare services through Red Lion Clinic Health VHS LLC (“Red Lion Clinic”).
1. Telehealth Services & Consent
I acknowledge and consent to:
✔️ Receiving medical evaluations, diagnoses, treatments, follow-up care, and prescriptions via telehealth.
✔️ Consulting with a licensed provider electronically, who will determine if telehealth is appropriate for my condition.
✔️ Understanding that some conditions may require in-person visits for proper evaluation and treatment.
2. Risks & Limitations
I understand that:
✔️ Technical issues may occasionally disrupt my telehealth session.
✔️ While privacy measures are in place, electronic data transmission always carries some risk.
✔️ Telehealth is not for emergencies—I will call 911 for urgent medical needs.
3. Privacy & Confidentiality
✔️ My medical records will be securely maintained per HIPAA regulations.
✔️ My information will not be shared without my consent unless required by law.
4. Patient Rights & Responsibilities
✔️ I may withdraw consent at any time.
✔️ I have the right to ask questions and receive clear information about my care.
✔️ I am responsible for providing accurate medical history and following treatment recommendations.
5. Purpose of This Authorization
This Authorization allows Red Lion Clinic to:
✔️ Retain my medical records even if my provider stops offering services.
✔️ Share my PHI with an alternative Red Lion Clinic provider of my choice.
6. Information Retained & Shared
✔️ My complete patient file (including demographics, medical history, and billing records) may be retained if my provider discontinues services.
7. Duration of Authorization
✔️ This Authorization remains valid for five years after I stop receiving services through Red Lion Clinic.
8. My Rights Regarding This Authorization
✔️ Signing is optional and does not affect my ability to receive care.
✔️ I may revoke this Authorization at any time by submitting a written request.
✔️ Red Lion Clinic will continue to protect my PHI under HIPAA guidelines.
GLP-1 Agonist Treatment Consent
Understanding GLP-1 Treatment
Semaglutide and Tirzepatide are GLP-1 receptor agonists that regulate appetite, reduce food intake, and help manage Type 2 Diabetes and Obesity. These medications should be combined with lifestyle changes for long-term success, including nutrition, exercise, and behavioral modifications.
Expected Benefits & Treatment Duration
✔️ GLP-1 treatment can improve weight-related health issues such as blood glucose levels, blood pressure, cholesterol, and cardiovascular risk factors.
✔️ Treatment should be discontinued after 12 weeks if I have not lost at least 5% of my initial body weight.
✔️ My response to treatment may vary, and long-term use may be necessary for sustained benefits.
Patient Responsibilities
✔️ If I have any medical or psychological conditions, I should consult my primary care provider (PCP).
✔️ If I am under another healthcare provider's care, I will inform them of my use of Semaglutide or Tirzepatide.
✔️ I will combine diet, exercise, and behavioral modifications with this treatment for the best results.
Contraindications to Treatment
I confirm that I do not have any of the following conditions that would make GLP-1 treatment unsafe:
❌ Personal or family history of medullary thyroid cancer or multiple endocrine neoplasia syndrome type 2.
❌ Severe kidney impairment (GFR < 15) or history of kidney disease.
❌ Severe liver disease.
❌ Concurrent insulin or sulfonylureas (due to hypoglycemia risk).
❌ History of pancreatitis, gallbladder disease, or diabetic gastroparesis.
❌ Pregnant, breastfeeding, or trying to conceive.
❌ Allergic reaction to Semaglutide, Tirzepatide, or any components of the medication.
Missed Doses & Discontinuation
✔️ If a missed dose is more than 5 days late, I will skip it and resume at the normal time.
✔️ If my therapy is discontinued for more than 2 weeks, I will consult my provider before restarting.
Side Effects & Risks
Common Side Effects
🔹 Nausea (most common when starting, improves over time)
🔹 Decreased appetite
🔹 Constipation, diarrhea, vomiting, or heartburn
🔹 Headache, dizziness, fatigue
🔹 Abdominal pain or injection site irritation
Uncommon & Rare Risks
⚠️ Uncommon: Pancreatitis, tachycardia, urticaria
⚠️ Rare: Renal impairment, allergic reaction, anaphylaxis
Special Warnings & Precautions
⚠️ Thyroid Disease: Semaglutide should be used with caution in patients with thyroid disorders.
⚠️ Gallbladder Issues: Higher risk of gallstones and gallbladder disease, which may require surgery.
⚠️ Birth Control Warning (Tirzepatide Users): Effectiveness may be reduced—alternative contraception is recommended.
Laboratory Testing & Monitoring
✔️ Testing may be required to monitor for potential risks, including:
✔️ Additional blood tests may be necessary for:
Alternative Treatment Options
✔️ Other options for weight management include:
Bariatric surgery
Other weight loss medications (Phentermine, Bupropion, Orlistat)
Lifestyle modifications (diet & exercise)
Treatment Acknowledgment & Consent
By signing below, I confirm that:
✔️ I have read and understand all information provided, including possible side effects, contraindications, and special warnings.
✔️ I acknowledge that GLP-1 treatment is not guaranteed to be effective and may require adjustments or discontinuation.
✔️ I have been informed of alternative treatment options.
✔️ I understand that unforeseen medical complications may arise.
✔️ I understand that if I experience a severe reaction or emergency, I will call 911 or seek immediate medical care—Red Lion Clinic does not provide emergency medical services.
✔️ I understand that medications are non-refundable once dispensed, per FDA Policy Sec. 460.300.
✔️ I agree that payment is required at the time of service.
