Terms, Conditions, Practice Policies:
Evergreen Women’s Wellness, LLC
Terms Conditions and Telehealth Conducted Visits / Practice Terms & Policies
PRACTICE POLICIES New Jersey, and Pennsylvania
APPOINTMENTS AND CANCELLATIONS
The standard meeting time for Evergreen Women’s Wellness telehealth wellness practice. The
number to contact use for any reason is 843-471-0020, and once your schedule an appointment
patients can reach the practice/provider via the patient portal. If there is equipment failure during
the telehealth video visit, or a loss of sound, the practitioner will call the patient on the patients
provided phone number/cell phone number. Evergreen Women’s Wellness, LLC will make every
attempt to reconnect to the telehealth video visit in the event of technological or equipment
failure, or disruption of service due to severe weather where either party is located.
Telehealth video visits vary depending on program, visit type, or as determined necessary by the
provider and can be 90 minutes, 60 minutes, or 30 minutes. Patients do not have input on, nor
can they choose appointment times. Patients have the opportunity to repurchase package options
for extended treatment(s), which is sometimes recommended and or necessary. Payment (for Ask
Me Anything single visit and there is no payment plan offered, that full payment is due at time of
booking) is required at time of booking appointment. Deposit for all programs or packages is
required at time of booking appointment, and each monthly payment is required before the next
visit thereafter, or visits are cancelled until payment is made in full. No further treatment will be
provided until account is up to date including prescription refills.
Cancellations and re-scheduled visits will be subject to a full charge for whatever length of the
time the visit is for, ie 90 minutes, 60 minutes, or 30 minutes, non-refundable in addition to your
package/program regularly expected payments for your package/program if NOT RECEIVED
AT LEAST 48 HOURS IN ADVANCE. This is necessary because a time commitment is made
to you and is held exclusively for you, which stops the provider from seeing any other patient
at that time. It is therefore a loss of the providers time and income which patient will be
held responsible for it did not cancel in the time frame above. If you are late for an
appointment, you WILL lose some of the allotted time for that appointment because other
patients are scheduled behind you and it is not there problem if you arrived to your appointment
late. Your card will automatically be billed 24 hours prior to your appointment if payment is not
received.
TELEPHONE ACCESSIBILITY
If you need to contact Evergreen Women’s Wellness, LLC,
between sessions, please send us a message through the patient portal or call 843-471-0020
during normal business hours with are Monday through Friday 9 am to 4 pm. We are closed from
1pm to 2 pm every day. We have limited weekend appointments, and some evenings, which will
be posted on the appointment scheduling area. We are often not immediately available;
however, we will attempt to return your call or message within 48 hours. Please note that Face-
to-face video visits are required for a telehealth visit meaning your camera and sound must be
on. We do not conduct appointments if patients are in a moving vehicle whether they are the
driver or passenger for legal reasons you will forfeit your appointment in that scenerio. If a true
emergency situation arises, or you are not sure if your situation is an emergency, or you are not
sure, if you require immediate attention, please go to an Urgent Care center, or please call 911 or
go to your local emergency room.
ELECTRONIC COMMUNICATION
We cannot ensure the confidentiality of any form of communication through electronic media,
including, but not limited to, text messages, telephone communication, the Internet, facsimile
machines, and e-mail. By providing an e-mail address and cell phone number on patient intake,
you authorize us to communicate with you by e-mail or text message regarding Your “protected
health information” (PHI). Patient further acknowledges that all such communications may
become a part of the medical record. If you consent to the above means of communication by
participating, you expressly waive the Provider’s obligation to guarantee confidentiality with
respect to same.
Telehealth is broadly defined as the use of information technology to deliver medical services
and information between two parties that are at different locations. The above electronic means
of communication are considered telehealth. Utilizing telehealth services through Evergreen
Women’s Wellness, LLC, is voluntary in nature and you need to understand:
You have the right to withhold or withdraw your consent for telehealth services at any
time. If this occurs, you need to understand that we cannot provide any further care for
you any longer as Evergreen Women’s Wellness, LLC, is strictly a telehealth practice.
We will protect your protected health information in the same fashion as a brick and
mortar practice. You need to understand though that data breaches can happen, and we
cannot assure your information is 100% protected.
We will not use your protected health information for research purposes unless you give
us consent to do so.
You must be physically located in the State of New Jersey, or Pennsylvania at the time of
service for a telehealth visit to be performed and this state must match the state of your
provider’s license. THIS IS TELELHEALTH FEDERAL LAW. WE WILL NOT RISK OUR LICESNES
FOR ANY PATIENT OUT OF THE STATE AT THE TIME OF THE TELEHEALTH VISIT.
There are potential benefits, risks and subsequent consequences of telehealth. Potential
benefits include, but are not limited to improved access to care, reducing costs, improving
the quality of visits, and reduction of travel time associated with medical visits. The
medical provider will make assessments, diagnoses, and treatment plans based off all the
visual and auditory information provided during the video conference. You must
understand that this is limited and posts potential risks including, but not limited to the
provider’s inability to make complete diagnostic assessments that might require a
physical exam and to see the patient in person. During an in-person encounter, a medical
provider has the ability to see the entire patient including but not limited to their gait,
smell, general appearance, and demeanor. Potential consequences thus include the
provider not being aware of clinically significant information that you may not recognize
as significant to present verbally to the provider.
It is at the provider’s discretion to obtain an in-person physical examination of the patient prior
to initiating treatment. An inspection examination will be performed during the initial video visit.
A physical exam can be done by a local primary care provider or at an urgent care and sent to
Evergreen Women’s Wellness, LLC.
MINORS
We do not treat any patient under the legal age of 18 in the state of New Jersey or Pennsylvania.
Valid ID is required of all patients.
SCOPE OF SERVICES
Evergreen Women’s Wellness, LLC is a telehealth wellness practice. You will be seeing a
Certified Registered Nurse Practitioner (CRNP, also known as an Advanced Practice Registered
Nurse (APRN). You will NOT be seeing a physician. If you desire to see a physician, you will
need to see alternative treatment elsewhere where there is a physician available to you.
I understand that I am voluntarily engaging in a telehealth consultation with the Evergreen
Women’s Wellness, LLC provider, which is a certified registered nurse practitioner, board
certified in women’s health, working under the supervision of “INSERT MD NAME” as
defined by New Jersey Statute In accordance with New Jersey law, our Advanced Practice
Nurses operate under a joint protocol with a collaborating physician, as stipulated in N.J. Rev.
Stat. § 45:11-49 and N.J.A.C. 13:37-7.9, to provide comprehensive and compliant healthcare
services.
In New Jersey, Advanced Practice Nurses (APNs), including Nurse Practitioners (NPs), are
authorized to practice independently within their scope of practice. However, for prescribing
medications and devices, they must establish a joint protocol with a collaborating physician
licensed in New Jersey. This collaborative agreement outlines the parameters for prescribing and
is a requirement under state law.pub.njleg.state.nj.us+6ncsl.org+6njconsumeraffairs.gov+6
The relevant statute governing this practice is N.J. Rev. Stat. § 45:11-49, which details the
conditions under which APNs may prescribe medications and devices, emphasizing the necessity
of a joint protocol with a collaborating physician. Additionally, the New Jersey Administrative
Code, specifically N.J.A.C. 13:37-7.9, provides further regulations on prescriptive practices for
APNs.
Per Pennsylvania state statutes, the board certified nurse practitioner works under the supervision
of a primary physician, “INSERT MD NAME” and per Pennsylvania state statues in the event
the primary physician is not available a secondary physician is required, “INSERT MD
NAME” In accordance with Pennsylvania law, our Certified Registered Nurse Practitioners
(CRNPs) operate under written collaborative agreements with licensed physicians. These
agreements, as mandated by 49 Pa. Code § 21.285 and 63 P.S. § 218.3, delineate the scope of
practice, prescriptive authority, and collaborative responsibilities, ensuring comprehensive and
compliant healthcare services.
I acknowledge that no controlled substances such as narcotic pain medications will be prescribed
via telehealth visit per federal law requiring in-person visit.
I acknowledge that no medications termed “obesity medications” will be prescribed.
We do not bill health insurance or any other third parties for services included in the
periodic fee.
This agreement is not health insurance and does not meet any individual health insurance
mandate that may be required by law.
An initial set of blood work, and specialty testing is free for you and included in our
program/packages. If any additional follow up blood work is needed, which often times is
needed to manage certain health conditions, you can call your private insurance and ask if wit
will be covered using your insurance, if not you will have the option to pay out of pocket to
cover the costs. An estimate of testing fees will be provided. The costs of imaging such as pelvic
ultrasounds, pelvic MRIs, mammograms, etc, and prescriptions are not included in in any of
what we charge. Those are outside fees you are responsible for. However, you may use your own
insurance to cover these costs which are often times are covered. If you do not have insurance,
you have the option of speaking with your local radiology facility(s) for cost comparison or their
payment options, as well as calling your pharmacy for price checks. Evergreen Women’s
Wellness, LLC does not call/shop pharmacies for costs, that is patient responsibility. We have
contracted agreements with several blood draw companies and may be able to get additional
blood work labs at a discounted price.
ADDITIONAL FEES
Patient will be invoiced by Evergreen Women’s Wellness, LLC for cost of Evergreen Women’s
Wellness, LLC discounted labs, if not using insurance and qualify per state law. A $25 lab
interpretation fee is included with these labs.
DURATION OF AGREEMENT AND AUTOMATIC PAYMENT PROVISIONS
I acknowledge and understand that I am required to provide a credit card (to be kept on file) to
participate in Evergreen Women’s Wellness, LLC telehealth visits and or packages/programs or
pay for them in full.
I acknowledge and understand that Evergreen Women’s Wellness, LLC fees are automatically
charged, and it is my responsibility to notify Evergreen Women’s Wellness, LLC of any changes
with my credit card information.
I acknowledge and understand that fees incurred outside of my Evergreen Women’s Wellness,
LLC programs/packages or visits are due at the time of service.
I acknowledge and agree to pay required downpayment at the initial appointment scheduling and
the recurring fees as outlined in the equal payment options offered at scheduling. I acknowledge
that my appointments will be terminated for non-payment.
I acknowledge and understand that Evergreen Women’s Wellness, LLC may add or discontinue
included services without notice.
I acknowledge and understand that Evergreen Women’s Wellness, LLC may change my monthly
fee at any time (but no more than once per calendar year), and that I will be given at least sixty-
day notice of such fee schedule changes.
I acknowledge and understand that I am responsible for any charges incurred for health care
services outside of Evergreen Women’s Wellness, LLC including but not limited to emergency
room, urgent care, hospital and specialty services, imaging, labs, and pharmaceuticals.
RISKS AND BENEFITS:
I acknowledge and understand that Evergreen Women’s Wellness, LLC does not guarantee
curative treatment, at times even through thorough testing, it may not be possible to
diagnose/uncover some or certain health conditions with limited conditions of telehealth video
visit capacity limitations, and that when deemed necessary by the nurse practitioners assessment,
patients will be referred to and not limited to specialty care such fertility specialists, allergies
specialists, rheumatology, endocrinology, primary care, infectious disease, or surgical practice as
needed.
I acknowledge and understand that Evergreen Women’s Wellness, LLC does not guarantee and
cannot diagnose all medical conditions via telehealth visit’s limited capacity and that it may be
deemed necessary for a patient to be seen in-person by a gynecologist, including urgent
situations or other non-urgent but necessary regardless. Scheduling of in-person visits with
outside providers is the responsibility of the patient. Evergreen Women’s Wellness, LLC is not
required to find said specialists, it is the responsibility of the patient to contact their insurance to
find a participating specialist. When possible, Evergreen Women’s Wellness, LLC may suggest a
referral to a particular practice.
I acknowledge and understand that Evergreen Women’s Wellness, LLC will NOT be required to
reimburse me for any charges that I may incur for any care outside of the Evergreen Women’s
Wellness, LLC Telehealth Practice.
TERMINATION
Both the patient and provider may terminate the agreement by giving the other party at least 30
days’ advance written notice. There will be no refunds of any deposits if appointments have
already been conducted. The only refund will be for visit(s) left in the package program that have
not been conducted. The cost refunded will be less the costs of included blood work and
specialty testing, and not more than one equal payment plan payment.
The agreement may provide for immediate termination due to a violation of the physician-patient
relationship or a breach of the terms of the agreement. We will not terminate the medical
relationship with you without first discussing and exploring the reasons and purpose of
terminating. If treatment is terminated for any reason, we will provide you with a list of qualified
providers to continue your care. You may also choose someone on your own or from another
referral source. Should you fail to not show up for your follow up appointments, not obtain lab
work in a timely fashion or are non-compliant with treatment, unless other arrangements have
been made in advance, for legal and ethical reasons, we must consider the professional
relationship discontinued.
PROVIDER ABSENCE
From time to time, due to vacations, illness, conflicting obligations, or personal emergency, the
provider may be temporarily unavailable to provide the services referred to above in this
paragraph one. In order to assist patients in rescheduling, Evergreen Women’s Wellness, LLC
will notify patients of any planned provider absences as soon as the dates are confirmed.
AFTER HOURS ACCESS
Evergreen Women’s Wellness, LLC, is a non-urgent wellness practice, not an urgent care clinic
or environment. We do not handle urgent health care matters, issues, conditions. Patient will
make all reasonable efforts to provide telephone and text access to the provider after hours for
urgent needs. Patients are to call our main office number 843-471-0020, where patient may
leave a message for the provider for guidance regarding concerns that arise unexpectedly after
office hours. For true medical emergencies, call 911 immediately, do not wait for a call back go
directly to your emergency room for medical emergencies.
INSURANCE POLICIES
Neither the Practice, nor its Provider, participate in any health insurance or HMO plans or
panels.
This agreement is not an insurance plan or a substitute for health insurance. This agreement does
not replace any existing or future health insurance or health plan coverage that you may carry.
The Agreement does not include hospital services, or any services not personally provided by
Evergreen Women’s Wellness, LLC or its staff. You acknowledge that we have advised you to
obtain or keep in full force, an in-person primary care provider who manages your overall health,
a routine gynecologist you can see you for in-person visits, and health insurance that will cover
you for hospitalizations, catastrophic events, and all other healthcare not personally provided by
Evergreen Women’s Wellness, LLC.
Due to regulatory restrictions, services are not available to patients who are eligible for or
enrolled in:
Medicare, Medicaid, or other government healthcare programs. By signing below, you deny
that you are currently enrolled in Medicare or Medicaid. You understand that if you should enroll
in Medicare or Medicaid, we will no longer be able to provide you services. If Patient becomes a
Medicare beneficiary Patient has a responsibility to inform Evergreen Women’s Wellness, LLC
of that change in status. Patient acknowledges and accepts this responsibility.
I acknowledge and understand that Evergreen Women’s Wellness, LLC does not guarantee
reimbursement for any Evergreen Women’s Wellness, LLC service or fees from any third-party
health plans, including insurance plans and savings accounts (health savings or flexible
spending).
This agreement is not health insurance, and the provider will not file any claims against the
patient’s health insurance policy or plan for reimbursement of any care services covered by
the agreement. This agreement does not qualify as minimum essential coverage to satisfy the
individual shared responsibility provision of the Patient Protection and Affordable Care Act, 26
U.S.C. s. 5000A. This agreement is not workers’ compensation insurance and does not replace
an employer’s obligations under chapter 440. This is not a Health Maintenance Organization
(HMO) defined by any state law as an organization that provides comprehensive health service
plans to maintain good health. An annual physical exam is necessary to maintain comprehensive
health services. As a telehealth only practice, we do not provide this service.
BY SIGNING BELOW, I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND
AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.