DISCLOSURE AND ACCEPTANCE

I understand that my therapist has recommended certain products and supplies for my personal use that will continue my therapy or help relieve my symptoms that are readily available at pharmacies and stores without prescription.  I also understand that my therapist, as a convenience, can provide these products and supplies to me on a direct shipment basis through an automated, internet-based store (“on-line store.”)  My therapist has explained to me that I am not obligated to purchase any recommendation made to me.

Because my use of this service will require disclosure by my therapist of certain health information that is considered private and confidential to me, I understand that I must authorize the disclosure of such information. 

I also understand that my therapist incurs a cost for this service and will receive some payment associated with my use of this service.  I understand there is no other economic interest between my therapist and the on-line store. 

I agree to participate and have access to this on-line store and confirm my authorization and acknowledgement of the following:

1.         I authorize my therapist to disclose, as necessary, information (including products recommended) as necessary to allow me to enroll and access the products that I wish to purchase through the on-line store. I understand that although all efforts will be made to maintain privacy and security, there is always a risk that the information could be disclosed regardless of efforts to keep it secure.

2.         I acknowledge that I have been provided with the option of using this on-line store as a convenience and that I can obtain the recommended products and supplies at any other retail establishment where sold.

3.         I acknowledge that my therapist has disclosed to me the economic relationship with the on-line store and that there is an income generated to my therapist for each product I purchase through the on-line store. 

4.         I understand that I may receive follow up communications from the on-line store for renewal or other products available for purchase.  I understand that I may disenroll or cancel my arrangement with the on-line store at any time.