AUTHORIZATION TO USE AND DISCLOSE MY MEDICAL INFORMATION AND CONSENT TO TELEHEALTH
OPEN PAYMENTS NOTICE
Last updated: January 1, 2025
Clinical services available through Locklab are provided by independent professional entities, including US Health and Wellness, Locklab Provider Group, and other affiliated professional entities that may be formed or engaged in the future (collectively, the “Medical Groups”). Lock Lab LLC itself does not provide medical care.
BY CLICKING “I AGREE,” CHECKING A RELATED BOX TO SIGNIFY YOUR ACCEPTANCE, USING ANY OTHER ACCEPTANCE PROTOCOL PRESENTED THROUGH THE SERVICE, OR OTHERWISE AFFIRMATIVELY ACCEPTING THIS CONSENT, YOU ACKNOWLEDGE THAT YOU HAVE READ, ACCEPTED, AND AGREED TO BE BOUND BY THIS CONSENT. IF YOU DO NOT AGREE TO THIS CONSENT, DO NOT CREATE AN ACCOUNT OR USE THE SERVICE. YOU HEREBY GRANT AGENCY AUTHORITY TO ANY PARTY WHO CLICKS ON THE “I AGREE” BUTTON OR OTHERWISE INDICATES ACCEPTANCE TO THIS CONSENT ON YOUR BEHALF.
IF YOU ARE EXPERIENCING A LIFE-THREATENING SITUATION SUCH AS CONTEMPLATING SUICIDE, CALL 911 OR THE 988 SUICIDE & CRISIS LIFELINE AT 988.
By signing this Authorization, I authorize Lock Lab LLC (“Locklab”), US Health and Wellness, Locklab Provider Group, and any other affiliated Medical Groups and their respective agents (“Receiving Entities”) to use and disclose my Medical Information, including Protected Health Information (“Personal Information”), for the following purposes:
Authorized Recipients:
Medical Information Scope: I understand that my medical information may include my medical history and information relevant to the treatment of hair loss.
Right to Revoke Authorization: I understand that I have the right to revoke this authorization, except to the extent that Locklab, US Health and Wellness, Locklab Provider Group, or any affiliated Medical Group has already used or disclosed my information in reliance on this authorization. To revoke, I must contact Locklab at help@locklab.co.
Re-Disclosure: I understand that if my Medical Information is disclosed pursuant to this authorization, it may be re-disclosed by the recipient and may not be protected by applicable privacy laws.
Not Required to Sign: I understand that I may refuse to sign this authorization without affecting my ability to obtain treatment or services provided by Locklab or the Medical Groups.
Copy of Authorization: If I agree to sign this authorization, I will be provided a copy upon request.
Expiration Date: This authorization will remain in effect unless and until I revoke it in writing, except where otherwise required by applicable state law.
Purpose
This consent form provides you with information about telehealth and obtains your informed consent to the use of telehealth in the delivery of healthcare services by physicians, physician assistants, or nurse practitioners (“Providers”) affiliated with US Health and Wellness, Locklab Provider Group, or any other affiliated Medical Groups, using the online platforms owned and operated by Lock Lab LLC and branded to patients as Locklab (the “Service”).
Use of Telehealth
Telehealth involves the delivery of healthcare using electronic communications between a provider and a patient who are not in the same location. It may be used for evaluation, prescribing oral medications, follow-up, and/or patient education, and may include transmission of medical records, photos, personal health information, or live audio/video consultations.
Affiliated Provider Groups
You understand and agree that your medical care through Locklab may be provided by one or more affiliated professional entities (“Affiliated Medical Groups”) and their licensed clinicians, including physicians, nurse practitioners, and physician assistants. These Affiliated Medical Groups may include US Health and Wellness, Locklab Provider Group, as well as other entities that may be formed or engaged in the future to ensure you receive care from providers licensed in your state. By signing this consent, you agree to receive telehealth services from any current or future Affiliated Medical Group working with Locklab, and from the licensed clinicians practicing through them. All such providers are subject to the same professional, legal, and regulatory standards of care.
Anticipated Benefits
Potential Risks
Telehealth carries risks, including but not limited to: technology failures, errors in transmission, limited diagnostic ability compared to in-person visits, privacy breaches, data loss, delays in treatment, or miscommunication.
Emergency Situations
If you are experiencing an emergency, call 911. Telehealth is not appropriate for all situations, and you must seek in-person care in emergencies.
Data Privacy
The Service incorporates security protocols to protect privacy. However, no system is entirely secure. Electronic communications may be susceptible to unintended disclosure. Personal information will not be shared with third parties without your consent, except as required by law.
Open Payments Notice
The federal Physician Payments Sunshine Act requires information about certain payments from manufacturers to physicians and teaching hospitals to be made publicly available. This can be viewed at https://openpaymentsdata.cms.gov.
By clicking “I Agree,” you consent to:
California: Physicians and midwives are licensed and regulated by the Medical Board of California. To confirm a license or file a complaint, visit www.mbc.ca.gov or call (800) 633-2322.
The California Board of Behavioral Sciences handles complaints regarding marriage and family therapists, licensed educational psychologists, clinical social workers, and professional counselors. Visit www.bbs.ca.gov or call (916) 574-7830.
