Releaf Specialists Consent to Treatment
Consent to Treatment for PA, OH & WV
Releaf Specialists values your business, and we want to ensure the utmost transparency in our services. We work hard to maintain a high quality of patient care. We value every patient who elects our services to begin their journey to peace and comfort.
Below you will find information pertaining to our Liability Waiver, Patient Rights, and Patient Responsibilities. In order for us to render treatment/services to you, we will need you to confirm that you have read and understand these sections.
PATIENT RIGHTS:
- Each patient will be treated with respect and dignity. Our staff will provide a courteous and professional atmosphere without discriminations to race, religion, ethnicity, disability, or sexual orientation.
- Each patient will participate in the decision-making process regarding your healthcare treatment and verification process.
- Each patient will be provided with a safe environment.
- Each patient will have appropriate suitable privacy regarding communication and medical records.
- Each patient’s medical information is protected by HIPAA.
- Each patient will be informed of the name and credentials of the person interacting with them.
- Each patient may refuse participation in the verification process through Releaf Specialists at any point of their encounter.
- Each patient has the right to voice a grievance and/or suggestion without the fear of restraint or discrimination.
- Prior to obtaining and releasing confidential medical records, the patient must consent and release information as indicated.
PATIENT RESPONSIBILITIES:
- Patient must provide accurate and complete medical information regarding his/her health status, prior illnesses, medications, and other matters that are pertinent for the verification process.
- Patient should voice their concerns to staff regarding eligibility in the verification process for the use of medicinal marijuana.
- Patient must comply with the regulations established through Releaf Specialists and the Commonwealth of Pennsylvania, State of Ohio, and State of West Virginia.
- Staff and Patients are mandated to report abuse, neglect, or exploitations to the Pennsylvania, Ohio, or West Virginia Department of Children and Family Grievances.
- Patients are to provide and authorize the release of necessary records from appropriate sources.
- Patient needs to act in respectful and considerate manner to the staff of Releaf Specialists.
- Patient needs to ask questions and seek clarifications in areas of concern.
- Patient must fulfill financial obligations at the time services are rendered through Releaf Specialists.
- Credit Card transaction will display as RS3, LLC on banking statement. Should a dispute resulting in take back of payment for services rendered, certification will be terminated within 48-hours of notice provided by Releaf Specialists, LLC of said issue.
- Patient understand Releaf Specialists may make any changes to the patient’s treatment plan during their validation period, and Releaf Specialists reserves all rights to terminate patient’s treatment. Releaf Specialist is not responsible for any actions or liabilities caused from terminating patient treatment.
LIABILITY WAIVER:
I hereby acknowledge that I have been instructed about the risks associated with utilizing medical marijuana. These include, but are not limited to:
~ Releaf Specialists
- I understand that the physician is providing me with a certificate/prescription to medicate with medical marijuana per the guidelines of the Pennsylvania Department of Health’s Medical Marijuana Program (PA DOH MMP), and understand that the PA DOH MMP is the governing agency for the medical program in which I will adhere to their guidelines for participation. (PA DOH MMP Website – https://www.pa.gov/guides/pennsylvania-medical-marijuana-program/) – PA RESIDENT
- I understand that the physician is providing me with a certificate/prescription to medicate with medical marijuana per the guidelines of the Ohio Medical Marijuana Control Program (OH MMJ CP), and understand that the OH MMJ CP is the governing agency for the medical program in which I will adhere to their guidelines for participation. (OH MMJ CP Website – www.MedicalMarijuana.Ohio.gov) – OH RESIDENT
- I understand that the physician is providing me with a certificate/prescription to medicate with medical marijuana per the guidelines of the West Virginia Office of Medical Cannabis Program (MEDCAN WV), and understand that the MEDCAN WV is the governing agency for the medical program in which I will adhere to their guidelines for participation. (MEDCAN WV Website – https://dhhr.wv.gov/bph/Pages/Medical-Cannabis-Program.aspx) – WV RESIDENT
- I will consult with a legal professional regarding questions or concerns regarding firearms and medical marijuana use.
- I understand that operating a vehicle, machinery, or other motorized vehicle can be hazardous to myself and others while using medical marijuana. I understand that if I am operating a vehicle while utilizing medical marijuana, I may be found under the influence according to state and/or federal law.
- I understand that utilizing medical marijuana may provide possible side effects, as with any other medication, and hereby hold harmless Releaf Specialists for any personal actions I pursue while utilizing medical marijuana.
- I understand that although I may possess medical marijuana legally with a medical card, I must still adhere to my employer’s company policy regarding medical marijuana and controlled substances. Each company’s policy is different, and I may be subject to disciplinary actions or termination if using medical marijuana is against said policy. I.e. Federal employees, truck drivers, etc.
- I understand medical marijuana is legal to possess and use medically in Pennsylvania, Ohio and/or West Virginia, and that crossing state lines with medical marijuana is federally illegal. Medical Marijuana is still considered illegal on federal property within Pennsylvania, Ohio and/or West Virginia. I.e. federal buildings and federal parks or forest.
~ Releaf Specialists
