Medical Records

WeHeal, Inc.'s Professional Staff (defined as the individuals retained on WeHeal, Inc.'s behalf who are qualified in healthcare-related professions and whose primary responsibilities, including delivering healthcare services to clients, require the exercise of medical judgment and discretion) and mentors (collectively, the "Practice"), WeHeal, Inc. staff ("Staff") and WeHeal, Inc., a Florida corporation (collectively, with the Practice and Staff, "WeHeal") desire to use and disclose information gathered about its patients to (a) ensure continuous quality improvement, and (b) assist WeHeal, Inc. in marketing services it offers. While information gathered about its patients/clients is not subject to the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"), WeHeal, Inc. would appreciate patient consent to WeHeal, Inc.'s use and disclosure of such information.

The following terms are presented in the first person, from client/patient perspective:

1. I am a patient of the Practice. The Practice has Personal Information (as defined below), including but not limited to my name, address, contact and demographic information, general health status and treatment information, images, individually identifiable health information, and other information related to my health (collectively "Personal Information").
2. I have, in the past, disclosed, and/or may in the future disclose to the Practice, in writing or orally, through audio and/or visual recordings and/or by any other medium, my experience seeking and receiving healthcare services from the Practice ("Patient's Experiences"). I consent to any future taking of photographs, videotapes, digital or audio recordings, and any other method to reproduce or edit such Patient's likeness or image ("Patient's Image or Likeness").
3. The Practice may use and disclose Patient's Personal Information, Patient's Experiences and Patient's Image or Likeness and (collectively "Patient's Record") in connection with the Practice's desire to utilize the Patient's Record for training, education and marketing purposes. The Practice desires to use and disclose Patient's Record in writing, orally, through audio and/or visual recordings and/or by any other medium, in the Practice's internal meetings, on social media platforms and websites, in email marketing campaigns, and in any other way that promotes ensuring continuous quality improvement and assisting the Practice in marketing services it offers, which may incidentally disclose Patient's Record. I acknowledge and understand this authorization to use, release and disclose may apply to individual sessions with the Practice as well as any group sessions that I may participate in with the Practice. This may include the release of Patient's record to other group members.
4. The Practice IS NOT receiving direct or indirect remuneration from any third-party in connection with the use/disclosure of Patient's Record as described in this authorization.
5. I may terminate this authorization at any time to prohibit my Record from being included in any future video or videos distributed by WeHeal, provided, however, that no such video is scheduled for release within 30 days of my revocation request. Any such revocation shall not apply to any videos or other materials WeHeal has created prior to my revocation request and shall only apply to materials that are not within 30 days of release or as otherwise determined by WeHeal. I understand that a revocation is ineffective to the extent the Practice has relied on the use and disclosure of Patient's Record. To terminate this authorization, Patient must send written notice to the Practice at the following address or to the following email address:

   Address: WeHeal, Inc. 4058 13th Street #1066 St. Cloud, FL 34769
   Email: matthew.lederman@WeHeal.health

6. I understand that, except as otherwise provided in this authorization, the Practice may use or disclose Patient's Record in accordance with Provider's Notice of Privacy Practices and information disclosed pursuant to this authorization is not protected by the HIPAA.
7. The Practice does not condition treatment or payment on the signing of this form. Patient will not be entitled to any payment or other form of remuneration from the Practice because of any use of Patient's Record.
8. Patient releases, discharges and holds harmless WeHeal, owners, providers, employees, agents, contractors, and assigns from any and all rights, claims, defenses, causes of action, liabilities, losses, damages and costs that Patient may have of any nature whatsoever, whether known, suspected or unknown, whether in law or in equity, which Patient had or now has or may claim to have had or to have or which may hereinafter accrue or otherwise be acquired, upon by reason of or arising out of, use/disclosure of Patient's Record. Patient further agrees that if despite this authorization, Patient, or anyone on Patient's behalf, makes a claim against WeHeal, Patient will indemnify, save, defend and hold harmless the Practice, WeHeal Inc. or WeHeal Inc. staff from any litigation expenses, attorney fees, loss, liability, damage, or cost incurred as the result of such claim.

Telehealth terms

Telehealth involves the use of advanced telecommunications technology or other means which may include the use of interactive audio, video or other electronic media to enable a healthcare provider and a patient at different locations to communicate and share individual patient health information for the purpose of rendering care. Telemedicine involves the real-time evaluation, diagnosis, consultation on and treatment of a health condition using the same secure, advanced telecommunications technology. There are potential risks to this technology, including interruptions, unauthorized access and technical difficulties. I, the undersigned Patient”), understand I can ask questions and seek clarification of the procedures and telehealth technology at any time.

1. Consent to telemedicine services and treatment:I voluntarily request WeHeal, Inc.’s Professional Staff (defined as the individuals retained on WeHeal,Inc.’s behalf who are qualified in healthcare-related professions and whose primary responsibilities, including delivering healthcare services to clients, require the exercise of medical judgment and discretion) to participate in my healthcare through the use of telemedicine.
2. I understand that the Professional Staff may practice in a different location than where I present for medical care, (ii) may not have the opportunity to perform an in-person physical examination and (iii) rely on information provided by me. I acknowledge that it is my responsibility to provide information about my medical history, condition and care that is complete and accurate to the best of my ability. I further acknowledge my failure to accurately and completely relay information about my medical history, condition and care may adversely impact the Professional Staff’s diagnosis, advice, recommendations or decisions about my care. I understand that the practice of medicine is not an exact science and that no warranties or guarantees are made to me as to result or cure.
3. I understand that if the Professional Staff determines in its reasonable professional judgment that telemedicine services will not adequately address my medical needs, the Professional Staff may discontinue such telemedicine services and I may be required to complete an in-person medical evaluation.I also understand that in the event the telemedicine session is interrupted due to a technological problem or equipment failure, alternative means of communication may be implemented, or an in-person medical evaluation may be necessary. Finally, if I experience an urgent matter during or after a telemedicine session, such as a bad reaction to a treatment, I should alert my treating physician and, in the case of emergencies, call 911 or go to the nearest hospital emergency department.

Limitations on telemedicine services and treatment. I understand and agree that it is my responsibility to inform WeHeal, Inc. staff in advance, in writing or at the beginning of the telemedicine session if:

1. I am not going to be, or am not, (i) present in Texas, when participating in telemedicine sessions with Dr. Neesha Kurian, MD;
2. I am not present in Florida or California, when participating in telemedicine sessions with Dr. Alona Pulde Lederman, MD; or
3. Not present in Florida, California or Texas when participating in telemedicine sessions with Dr. Matthew Lederman, MD; because I understand that such persons cannot practice medicine (including, but not limited to diagnosing, giving medical advice, offering treatment and providing treatment) outside of the states in which they are licensed to practice medicine.

I understand and agree that it is my responsibility to inform WeHeal, Inc. staff in advance, in writing or at the beginning of the telemedicine session, if I am not going to be, or am not, (1) present in Texas or Idaho, when participating in telemedicine sessions with Dr. Dane Mosher, DO, (2) present in Texas, when participating in telemedicine sessions with Dr. Neesha Kurian, MD, (3) present in Florida or California, when participating in telemedicine sessions with Dr. Alona Pulde Lederman, MD, or (4) present in Florida, California or Texas when participating in telemedicine sessions with Dr. Matthew Lederman, MD, because I understand that such persons cannot practice medicine (including, but not limited to diagnosing, giving medical advice, offering treatment and providing treatment) outside of the states in which they are licensed to practice medicine. I understand that for scheduled telemedicine services and treatment occurring in states in which, Dr. Dane Mosher, Dr. Neesha Kurian, MD, Dr. Alona Pulde Lederman, MD, and/or Dr. Matthew Lederman, MD are not licensed, WeHeal, Inc. staff will automatically default to providing telehealth therapeutic Coaching (as defined in the WeHeal, Inc. Patient Consent to Mentor Services and Coaching form which I have executed, or if I have not, I agree to execute). I understand that if I have completed the WeHeal, Inc. Patient Consent to Treatment form and WeHeal, Inc. Patient Health Information forms, but am proceeding with Coaching, WeHeal, Inc. will keep such documents on file, in the event they are needed in the future.

Terms of service

Healthcare Services. Client understands and agrees that the Professional Staff (defined as the individuals retained on WeHeal’s behalf who are qualified in healthcare-related professions and whose primary responsibilities, including delivering healthcare services to clients, require the exercise of medical judgment and discretion) shall provide healthcare evaluation and treatment (as described in the Patient Consent to Evaluation and Treatment form incorporated herein by reference) to Client. Mentor Services and Coaching. Client understands and agrees that the mentor shall provide Services and Coaching (as are defined in the Patient Consent to Mentor Services and Coaching form incorporated herein by reference) to Client. Client acknowledges and agrees that prior to starting any Mentor or Coaching services, Client’s initial visit must be with Professional Staff. Concierge Program. The Concierge Program provides access to specific Professional Staff only. The Concierge Program includes texting support with your designated staff. Client may send a text at any time (unlimited), however, Professional Staff will do their best to reply to texts within 24 hours of receipt and during business days only. Texts received on a Friday or weekend will be answered on the next business day. Texts are for non-emergency purposes only. Access to the Concierge Program requires payment of the Professional Staff fee in addition to the monthly Concierge Fee. Financial Terms. Fees are provided on Schedule A “Fee Schedule”. WeHeal may modify fees from time to time in its discretion, at which point Client may be provided with an updated Fee Schedule. Payment for any packages or upcoming appointment(s) will be requested in advance at the time of scheduling. Client agrees to complete the electronic payment request no more than 48 hours after receipt of the email.

Prior to the end of a scheduled session, if the mentor is available, the Client can agree to extend a session (in 25-minute increments) beyond the time scheduled. Any additional time spent with the Client beyond what was already billed in advance will be requested after the session. Client agrees to make additional payments within 48 hours of receipt of the email with the additional electronic payment request. Upon the completion of any sale of a product or session, Client is not entitled to any refund.

In the event Client has purchased multiple sessions, or has agreed to a payment plan for programs, Client authorizes WeHeal to automatically charge the Client’s credit card on file, or draw from the Client’s payment account, to pay for such programs or until a program has been paid in full. WeHeal will make such charges on a monthly basis unless otherwise agreed to in writing. Client may not cancel the auto-payment until all owed amounts have been paid in full, even in the event Client ceases to participate in the program. Monthly or recurring payments may only be terminated at least two (2) business days in advance of the monthly or recurring payment. Notice of termination must be given in writing. If notice is not received within the termination time period, Client understands they will be charged for the upcoming payment and no refunds will be given. Termination is approved upon written confirmation by WeHeal.   HIPPA Not Applicable/Privacy. Any and all information gathered by WeHeal about Client is not subject to the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and therefore, HIPAA affords Client no protection. Client understands and agrees to communicate via text or e-mail with the Professional Staff, Mentors, Coaches and any other WeHeal administrators and that communications via text or e-mail are not secure and poses the risk of a breach of confidentiality.  Cancellation/Missed/Unused Appointments.The scheduling of an appointment involves the reservation of time specifically for Client. Client agrees to inform WeHeal of Client’s cancellation at least two (2) business days in advance of the scheduled appointment time and understands that Client will be billed at the above billing rate using the scheduled amount of time for that missed appointment in the event proper cancellation notice is not given to WeHeal. Client understands that failure to utilize an appointment or group session in a recurring or monthly program, for any reason, shall not entitle Client to carry over or accumulate such appointments for future use. Any unused appointments in a recurring or monthly program are forfeited and no refunds shall be owed. DISPUTE RESOLUTION. Mediation. If a dispute arises under this Agreement, the parties agree first to try to resolve the dispute with the help of a mutually agreed-upon mediator in Osceola County, Florida. Any costs and fees other than attorneys’ fees or other expenses incurred by a party for such party’s own benefit associated with the mediation shall be shared equally by the parties.  Arbitration. If the dispute is not resolved through mediation, the parties agree to submit the dispute to binding arbitration in Florida under a mutually agreed-upon arbitrator in Osceola County, Florida and which shall be governed by the laws of the state of Florida. A demand for arbitration must be communicated in writing to all parties. Each party shall select two arbitrators within thirty (30) days. The parties agree to first try to select an arbitrator from the four offered arbitrators within fifteen (15) days. In the event the parties cannot agree on an arbitrator within such a time frame, a neutral arbitrator (“neutral arbitrator”) shall be selected by the arbitrators appointed by the parties within thirty (30) days thereafter. The neutral arbitrator shall then be the sole arbitrator and shall decide the arbitration. Any costs and fees other than attorneys’ fees or other expenses incurred by a party for such party’s own benefit associated with the arbitration shall be shared equally by the parties.  Payment Dispute Exception. Notwithstanding the foregoing, any Client payment-related dispute may be brought in the courts of the state of Florida and shall be governed by the laws of the state of Florida. There are no warranties or guarantees given for these services. I have read this Client Agreement in its entirety and agree to be bound by all of its terms and conditions as described above. I acknowledge and agree that I have been given the opportunity to ask any questions and have either (i) declined the opportunity to do so or (ii) had all my questions answered to my satisfaction.

Staff and practitioner privacy

WeHeal, Inc. is committed to providing outstanding client support and is based on a collaborative model which integrates different levels of support into the care environment. In addition to its Professional Staff (defined as the individuals retained on WeHeal, Inc.'s behalf who are qualified in healthcare-related professions and whose primary responsibilities, including delivering healthcare services to clients, require the exercise of medical judgment and discretion) who provide medical diagnosis, treatment and advice to clients, WeHeal, Inc. provides additional support to its patients by offering mentor Services (as defined herein) (collectively, the "Practice").

WeHeal, Inc. is based on a collaborative model. WeHeal, Inc. expects that a mentor will (as needed): (1) help clients articulate agendas for upcoming visits with the Professional Staff (as defined herein), (2) review Professional Staff recommendations to ensure client comprehension, (3) assess whether clients accept their health plans, (4) support clients' efforts in adopting healthy behaviors, and (5) function as a cultural bridge, point of access, and support for clients, and undertake any other action within their scope, to support client support ("Services"). WeHeal, Inc. defines "Professional Staff" as the individuals retained on WeHeal, Inc.'s behalf who are qualified in healthcare-related professions and whose primary responsibilities, including delivering healthcare services to clients, require the exercise of medical judgment and discretion.

WeHeal, Inc. also expects that a mentor will (as needed): provide client coaching, which involves direct and personal conversations conducted via scheduled face-to-face, video, or phone appointments, which may include, but is not limited to, one or more of the following: creation/development of personal, professional, emotional, spiritual, mental, physical and lifestyle goals; methods to carry out a strategy/plan for achieving those goals; identification and addressing of specific personal struggles, professional issues or general physiological conditions; value clarification, brainstorming, identification of plans of action, examining modes of operation in life, asking clarifying questions and making empowering requests or suggestions for action (collectively, "Coaching").

WeHeal mentors may NOT exercise independent medical judgment or discretion or provide medical advice, diagnosis, or treatment recommendations and may only perform non-clinical tasks. Examples of non-clinical tasks include, but are not limited to, education & coaching, empathy & companionship support, transcribing notes, taking information from the client and/or communicating such information to the Professional Staff, and bringing to the attention and/or discussing with the Professional Staff any items of concern that have been disclosed to the mentor by the client.

I understand that the Services and Coaching I will be receiving under this agreement are not offered as a substitute for mental health care and are not psychological or medical care services. I also understand that my mentor is not acting as a mental health practitioner, licensed healthcare professional, dietician or nutritionist and does not purport to offer such care, and nothing communicated to me by the mentor shall constitute the practice of such fields. If my mentor believes that medical care services may be helpful, my mentor may provide a referral.

I am fully responsible for my well-being during my sessions with my mentor, and subsequently, including my choices and decisions.

All comments and ideas offered by my mentor are solely for the purpose of educating me and aiding me in achieving my defined goals. I am entering into this agreement knowingly and voluntarily, and hereby give my consent to my mentor to assist me in achieving such goals.

My mentor will endeavor to maintain the confidentiality of our communications to the extent allowed by law.

I understand that the sharing of any of my confidential information outside of WeHeal, whether made at my request or not, is done at my own risk.

I, the undersigned, do hereby request and consent to Services and Coaching provided by a mentor. I understand any questions I may have regarding diagnosis, treatment or advice will be directed to a Professional Staff member during my evaluation and course of treatment. I request and consent to be transported by the Practice and/or emergency medical services to a hospital or emergency medical facility in the event of a medical emergency during my treatment at the Practice. I intend this consent to cover the entire course of treatment.

I have read this WeHeal, Inc. Patient Consent to mentor Services and Coaching in its entirety and agree to be bound by all of its terms and conditions as described above. I acknowledge and agree that I have been given the opportunity to ask any questions and have either (i) declined the opportunity to do so or (ii) had all my questions answered to my satisfaction.