Last updated: Sept 24, 2025

By clicking “I Agree,” checking a box, or otherwise electronically indicating acceptance, you (“you” or “Patient”) acknowledge and agree to the terms of this Consent to Treatment (“Consent”) with respect to services provided through the TakeBack Health, LLC (“TakeBack Health”) platform.

1. Purpose

The purpose of this Consent is to authorize the provision of medical evaluation and treatment services by licensed healthcare professionals (“Providers”) affiliated with independent professional entities (“Medical Group(s)”) accessible via the TakeBack Health platform (“Platform”). This Consent applies to all medical services delivered via telehealth or other electronic means, and may include diagnosis, testing, prescription, counseling, and treatment.

2. Acknowledgement of Provider Relationship

You understand and agree that:

• The medical services you receive through the Platform will be provided by licensed Providers who are independent contractors or employees of a professional Medical Group.
  
  
• TakeBack Health is not a healthcare provider and does not practice medicine. It provides administrative and technical support as a Management Services Organization (MSO).
  
  
• Your treatment relationship is solely with the Provider and/or Medical Group, and not with TakeBack Health.
  
  

3. Nature of Treatment

You consent to receive routine medical assessment and treatment, which may include:

• Reviewing your health history and current conditions
  
  
• Receiving medical advice, diagnosis, or care plans
  
  
• Prescriptions for medications or labs, if clinically appropriate
  
  
• Educational information about your condition or treatment
  
  

You understand that:

• No guarantees are made as to the outcome or effectiveness of treatment
  
  
• Prescriptions are issued only when deemed appropriate by a licensed Provider
  
  
• You may decline specific recommendations or discontinue care at any time
  
  

4. Voluntary Participation and Alternatives

Your participation in this care is voluntary. You may decline or withdraw consent at any time by providing written notice. You understand that:

• You may seek in-person care from another provider at your discretion
  
  
• Withdrawal of consent will not affect any care provided before the withdrawal
  
  
• Providers on the Platform may not offer in-person services
  
  

5. Risks and Limitations

You acknowledge that all medical care involves some level of risk, including but not limited to:

• Misdiagnosis or delayed diagnosis
  
  
• Adverse reactions to medications
  
  
• Unintended side effects or outcomes
  
  
• Limits of telehealth technologies in identifying certain conditions
  
  

Providers may determine that your condition is not appropriate for treatment via this Platform and may refer you to an in-person provider or specialist.

6. Financial Responsibility

You understand and agree that:

• All services are provided on a direct-pay basis (out-of-pocket)
  
  
• Neither TakeBack Health nor its Medical Groups bill insurance or federal payors (e.g., Medicare/Medicaid)
  
  
• You are solely responsible for payment of all services, consultations, and prescriptions you receive through the Platform
  
  

You also understand that using this Platform may limit your ability to submit claims for reimbursement to insurers or health plans.

7. Consent to Communication and Data Use

You authorize:

• The Provider to communicate with you via electronic means, including secure messaging, email, SMS (with your opt-in), and video calls
  
  
• The collection, storage, and use of your personal and health information for treatment, care coordination, and administrative purposes
  
  
• The use of partner pharmacies or labs unless you request to use a provider of your choice
  
  

Your data will be protected according to applicable laws and privacy notices provided by the Medical Group or Provider.

8. Agreement

By accepting this Consent:

• You confirm that you have read, understood, and agreed to the above
  
  
• You consent to receive medical services from Providers via the TakeBack Health Platform
  
  
• You agree to comply with the Provider’s instructions, ask questions when clarification is needed, and update your health information as needed
  
  

Contact Us
For questions about this Consent, please contact:
TakeBack Health, LLC