TREATMENT CONSENT

Effective Date: 03/01/2025

This Treatment Consent Form (“Consent”) outlines your agreement to receive medical and behavioral health services from DRGMED INC through GloriaONeill.com. These services may be provided via telehealth or in-person visits.

By navigating this Consent, you confirm that you have read, understood, and agree to the terms below.

1. CONSENT TO TREATMENT

I voluntarily consent to receive medical, psychiatric, and/or behavioral health treatment from healthcare professionals affiliated with DRGMED INC. This consent applies to both telehealth and in-person services, including medical evaluations, diagnosis, and treatment, medication management, psychiatric and mental health treatment, behavioral health counseling, substance use disorder (SUD) and Medication-Assisted Treatment (MAT) for Opioid Use Disorder (OUD), and preventive care and wellness screenings.

I understand that treatment may involve diagnostic procedures, medication prescriptions, therapy, and recommendations for further medical interventions as deemed necessary by my provider.

I understand that my treatment plan may change over time based on my progress and response to care.

2. TELEHEALTH CONSENT

If I choose to receive telehealth services, I understand that telehealth involves remote consultations via video, phone, or electronic communication. My provider will rely on the information I provide to make medical decisions and may not be able to perform a physical examination as they would in person. Telehealth is subject to limitations, including technology disruptions and the inability to assess certain conditions.

I must be physically located in the state of New Mexico at the time of my telehealth appointment. Prescriptions for controlled substances will only be issued in compliance with federal, state, and DEA regulations, and I may be required to complete an in-person evaluation before receiving certain medications. I may be required to follow up with an in-person visit if my provider determines that remote care is insufficient. My telehealth visit may be documented and stored in my electronic medical record (EMR).

3. IN-PERSON SERVICES CONSENT

If I receive in-person treatment, I acknowledge that my provider may conduct physical exams, lab tests, and in-office procedures as part of my treatment. I will comply with clinic policies, including appointment attendance, behavioral expectations, and safety guidelines. I may be required to follow COVID-19 or other public health precautions when receiving in-person care. If my provider deems necessary, I may be referred to a specialist or hospital for further evaluation.

4. RISKS & BENEFITS OF TREATMENT

I understand that, as with any medical treatment, there are both risks and benefits to the services I receive.

Potential Benefits: Improved health outcomes with proper diagnosis and treatment, access to care via telehealth when in-person visits are not feasible, medication management and behavioral therapy to address psychiatric or substance use disorders.

Potential Risks: Possible side effects from medications or treatments, limited assessment capabilities with telehealth (e.g., no physical examination), unexpected medical complications that require further intervention, technology-related issues during telehealth visits.

5. CONFIDENTIALITY & PRIVACY

I understand that my medical information is protected under HIPAA and other privacy laws. My health records will be kept confidential and only shared as required by law or with my consent. My telehealth consultations will not be recorded without my written permission. My provider may disclose information if legally required (e.g., in cases of abuse, self-harm, or public health risks).

6. APPOINTMENTS, CANCELLATIONS & PAYMENTS

I understand that I am responsible for scheduling and attending my appointments. If I need to cancel or reschedule, I must provide at least 24 hours’ notice to avoid a cancellation fee. If I do not attend a scheduled appointment without prior notice, I may be charged a no-show fee. I understand that I am responsible for any applicable co-pays, deductibles, or self-pay fees if my insurance does not cover my treatment.

7. PRESCRIPTIONS & MEDICATION MANAGEMENT

If my provider prescribes medication, I agree to follow all usage instructions and notify my provider of any side effects. Certain medications, including controlled substances, will only be prescribed after an appropriate evaluation. Controlled substances will be prescribed in compliance with DEA, federal, and state regulations. I may be required to undergo random drug screenings if receiving medication for substance use disorder.

8. PATIENT RESPONSIBILITIES

I agree to provide accurate and complete medical history to my provider. I will follow the treatment plan provided by my healthcare professional. I will notify my provider of any medication side effects or worsening symptoms. I will respect all staff, providers, and other patients in clinical settings. I will follow up with in-person care if required by my provider.

9. EMERGENCY SITUATIONS

I understand that telehealth and routine medical visits are not a substitute for emergency care. If I experience a medical emergency, I will call 911 or go to the nearest emergency room. My provider may refer me to in-person care if my condition requires immediate physical evaluation.

10. VOLUNTARY CONSENT & RIGHT TO WITHDRAW

I acknowledge that this Consent is voluntary, and I may withdraw it at any time by notifying my provider in writing. I understand that withdrawing consent does not affect prior treatments or obligations. My provider may discontinue treatment if they determine that telehealth or in-person care is not appropriate for my condition.

11. RIGHT TO PHOTOGRAPHY / VIDEOTAPING AND AUDIO RECORDING

I/We, the above-named client, authorize the facility, its successors, subsidiaries and other personnel to use my name and picture for purposes of identification by the staff of the facility. I/We understand that one [1] picture may be taken upon admission, or at any time during treatment, for the purpose of familiarization of my face and name by the Treatment Team members during my treatment at the facility. The picture is part of permanent medical record. 

I hereby give my consent for photography, filming, videotaping and/or audio recording or other means of capturing my image or voice and/or being quoted in the media or printed materials (including social media websites) at DRGMED INC.
I authorize DRGMED INC to disclose to media representatives and/or public affairs/relations representatives the above information checked by me. I understand that the purpose of this disclosure has been selected by me above.
I understand that my information can be used in publications, fundraising, advertising, marketing, research/educations programs, publicity, promotion, education or publication in print, broadcast and electronic media, including social media according to my selection above. This authorization includes my likeness on photo, videotape and digital media.
I consent to the taking and use of photographs, films, audio and/or videotapes, or other materials as described above. I understand that I may be identified in the above described materials. I realize that I will not be compensated in any way for the taking or use of photographs, films, audio and/or videotapes, or the publishing thereof. I understand and agree that I can revoke this authorization at any time in written, but if I do, it will not have any effect on any actions taken prior to receiving the revocation. 
I understand that once my health information is used or disclosed, it is no longer protected by state or federal law.
I understand that DRGMED INC can’t make me sign this authorization as a condition for getting treatment, making payments on any bills, or gaining enrollment or eligibility in any health insurance plan, unless Federal Privacy Regulations allow it.
I have a right to inspect and copy my own protected health information to be used or disclosed in accordance with the Notice of Privacy Practices. I hereby release, discharge and agree to save harmless DRGMED INC, its affiliates, components, employees, sponsors, agents and assigns of the foregoing, from any liability or claimed liability in connection with the aforementioned use of the photograph, videotape, name, image, likeness or performance; and subsequent publication or broadcast.

12. NOTICE TO RECIPIENT OF INFORMATION

I understand that I may revoke this consent at any time, except to the extent that action has been taken in reliance on my consent. A photocopy of this document is to be considered as valid as the original.

Important rights and other required statements

You can revoke this authorization at any time by writing to the behavioral health provider named above. If you revoke this authorization, we will stop using or disclosing your health information for the reasons covered by your written authorization, unless we have already acted in reliance on your permission.

You do not need to sign this form in order to obtain enrollment, eligibility, payment, or treatment for services.

By federal or state privacy laws, not all persons or entities are required to comply with these laws and may no longer be protected by them once this information is disclosed.

You have a right to a copy of this authorization.

If you have signed, please keep a copy for your records, or you may ask for a copy at any time by contacting your behavioral health provider named above.

Documents were explained to me in my native language

13. NOTICE TO RECIPIENT OF INFORMATION

This information has been disclosed to you from records protected under federal regulations on the confidentiality of alcohol and drug abuse patient records, 42 CFR Part 2. The federal regulations prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2.

A general authorization for the release of medical or other information is NOT sufficient for this purpose. The federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.

14. CONTACT INFORMATION

If I have any questions about my treatment, appointments, or this Consent, I can contact:

DrGmed, Inc

400 Gold Ave SW, Albuquerque, NM 87102

Simms Building (Office # 1060)

Phone: (505) 601-5662

By navigating this Treatment Consent Form, I acknowledge that I have read, understood, and accepted the terms outlined above. Also, you might have to accept other conditions during the consultation, whether through telehealth or in person.

—

Gloria O’Neill

DNP, APRN, FNP, PMHNP-BC 

TREATMENT CONSENT

Effective Date: 03/01/2025

This Treatment Consent Form (“Consent”) outlines your agreement to receive medical and behavioral health services from DRGMED INC through GloriaONeill.com. These services may be provided via telehealth or in-person visits.

By navigating this Consent, you confirm that you have read, understood, and agree to the terms below.

1. CONSENT TO TREATMENT

I voluntarily consent to receive medical, psychiatric, and/or behavioral health treatment from healthcare professionals affiliated with DRGMED INC. This consent applies to both telehealth and in-person services, including medical evaluations, diagnosis, and treatment, medication management, psychiatric and mental health treatment, behavioral health counseling, substance use disorder (SUD) and Medication-Assisted Treatment (MAT) for Opioid Use Disorder (OUD), and preventive care and wellness screenings.

I understand that treatment may involve diagnostic procedures, medication prescriptions, therapy, and recommendations for further medical interventions as deemed necessary by my provider.

I understand that my treatment plan may change over time based on my progress and response to care.

2. TELEHEALTH CONSENT

If I choose to receive telehealth services, I understand that telehealth involves remote consultations via video, phone, or electronic communication. My provider will rely on the information I provide to make medical decisions and may not be able to perform a physical examination as they would in person. Telehealth is subject to limitations, including technology disruptions and the inability to assess certain conditions.

I must be physically located in the state of New Mexico at the time of my telehealth appointment. Prescriptions for controlled substances will only be issued in compliance with federal, state, and DEA regulations, and I may be required to complete an in-person evaluation before receiving certain medications. I may be required to follow up with an in-person visit if my provider determines that remote care is insufficient. My telehealth visit may be documented and stored in my electronic medical record (EMR).

3. IN-PERSON SERVICES CONSENT

If I receive in-person treatment, I acknowledge that my provider may conduct physical exams, lab tests, and in-office procedures as part of my treatment. I will comply with clinic policies, including appointment attendance, behavioral expectations, and safety guidelines. I may be required to follow COVID-19 or other public health precautions when receiving in-person care. If my provider deems necessary, I may be referred to a specialist or hospital for further evaluation.

4. RISKS & BENEFITS OF TREATMENT

I understand that, as with any medical treatment, there are both risks and benefits to the services I receive.

Potential Benefits: Improved health outcomes with proper diagnosis and treatment, access to care via telehealth when in-person visits are not feasible, medication management and behavioral therapy to address psychiatric or substance use disorders.

Potential Risks: Possible side effects from medications or treatments, limited assessment capabilities with telehealth (e.g., no physical examination), unexpected medical complications that require further intervention, technology-related issues during telehealth visits.

5. CONFIDENTIALITY & PRIVACY

I understand that my medical information is protected under HIPAA and other privacy laws. My health records will be kept confidential and only shared as required by law or with my consent. My telehealth consultations will not be recorded without my written permission. My provider may disclose information if legally required (e.g., in cases of abuse, self-harm, or public health risks).

6. APPOINTMENTS, CANCELLATIONS & PAYMENTS

I understand that I am responsible for scheduling and attending my appointments. If I need to cancel or reschedule, I must provide at least 24 hours’ notice to avoid a cancellation fee. If I do not attend a scheduled appointment without prior notice, I may be charged a no-show fee. I understand that I am responsible for any applicable co-pays, deductibles, or self-pay fees if my insurance does not cover my treatment.

7. PRESCRIPTIONS & MEDICATION MANAGEMENT

If my provider prescribes medication, I agree to follow all usage instructions and notify my provider of any side effects. Certain medications, including controlled substances, will only be prescribed after an appropriate evaluation. Controlled substances will be prescribed in compliance with DEA, federal, and state regulations. I may be required to undergo random drug screenings if receiving medication for substance use disorder.

8. PATIENT RESPONSIBILITIES

I agree to provide accurate and complete medical history to my provider. I will follow the treatment plan provided by my healthcare professional. I will notify my provider of any medication side effects or worsening symptoms. I will respect all staff, providers, and other patients in clinical settings. I will follow up with in-person care if required by my provider.

9. EMERGENCY SITUATIONS

I understand that telehealth and routine medical visits are not a substitute for emergency care. If I experience a medical emergency, I will call 911 or go to the nearest emergency room. My provider may refer me to in-person care if my condition requires immediate physical evaluation.

10. VOLUNTARY CONSENT & RIGHT TO WITHDRAW

I acknowledge that this Consent is voluntary, and I may withdraw it at any time by notifying my provider in writing. I understand that withdrawing consent does not affect prior treatments or obligations. My provider may discontinue treatment if they determine that telehealth or in-person care is not appropriate for my condition.

11. RIGHT TO PHOTOGRAPHY / VIDEOTAPING AND AUDIO RECORDING

I/We, the above-named client, authorize the facility, its successors, subsidiaries and other personnel to use my name and picture for purposes of identification by the staff of the facility. I/We understand that one [1] picture may be taken upon admission, or at any time during treatment, for the purpose of familiarization of my face and name by the Treatment Team members during my treatment at the facility. The picture is part of permanent medical record. 

I hereby give my consent for photography, filming, videotaping and/or audio recording or other means of capturing my image or voice and/or being quoted in the media or printed materials (including social media websites) at DRGMED INC.
I authorize DRGMED INC to disclose to media representatives and/or public affairs/relations representatives the above information checked by me. I understand that the purpose of this disclosure has been selected by me above.
I understand that my information can be used in publications, fundraising, advertising, marketing, research/educations programs, publicity, promotion, education or publication in print, broadcast and electronic media, including social media according to my selection above. This authorization includes my likeness on photo, videotape and digital media.
I consent to the taking and use of photographs, films, audio and/or videotapes, or other materials as described above. I understand that I may be identified in the above described materials. I realize that I will not be compensated in any way for the taking or use of photographs, films, audio and/or videotapes, or the publishing thereof. I understand and agree that I can revoke this authorization at any time in written, but if I do, it will not have any effect on any actions taken prior to receiving the revocation. 
I understand that once my health information is used or disclosed, it is no longer protected by state or federal law.
I understand that DRGMED INC can’t make me sign this authorization as a condition for getting treatment, making payments on any bills, or gaining enrollment or eligibility in any health insurance plan, unless Federal Privacy Regulations allow it.
I have a right to inspect and copy my own protected health information to be used or disclosed in accordance with the Notice of Privacy Practices. I hereby release, discharge and agree to save harmless DRGMED INC, its affiliates, components, employees, sponsors, agents and assigns of the foregoing, from any liability or claimed liability in connection with the aforementioned use of the photograph, videotape, name, image, likeness or performance; and subsequent publication or broadcast.

12. NOTICE TO RECIPIENT OF INFORMATION

I understand that I may revoke this consent at any time, except to the extent that action has been taken in reliance on my consent. A photocopy of this document is to be considered as valid as the original.

Important rights and other required statements

You can revoke this authorization at any time by writing to the behavioral health provider named above. If you revoke this authorization, we will stop using or disclosing your health information for the reasons covered by your written authorization, unless we have already acted in reliance on your permission.

You do not need to sign this form in order to obtain enrollment, eligibility, payment, or treatment for services.

By federal or state privacy laws, not all persons or entities are required to comply with these laws and may no longer be protected by them once this information is disclosed.

You have a right to a copy of this authorization.

If you have signed, please keep a copy for your records, or you may ask for a copy at any time by contacting your behavioral health provider named above.

Documents were explained to me in my native language

13. NOTICE TO RECIPIENT OF INFORMATION

This information has been disclosed to you from records protected under federal regulations on the confidentiality of alcohol and drug abuse patient records, 42 CFR Part 2. The federal regulations prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2.

A general authorization for the release of medical or other information is NOT sufficient for this purpose. The federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.

14. CONTACT INFORMATION

If I have any questions about my treatment, appointments, or this Consent, I can contact:

DrGmed, Inc

400 Gold Ave SW, Albuquerque, NM 87102

Simms Building (Office # 1060)

Phone: (505) 601-5662

By navigating this Treatment Consent Form, I acknowledge that I have read, understood, and accepted the terms outlined above. Also, you might have to accept other conditions during the consultation, whether through telehealth or in person.

—

Gloria O’Neill

DNP, APRN, FNP, PMHNP-BC