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TELEMEDICINE CONSULTATION
Medical Liability Waiver & Acknowledgment 

This medical liability waiver form covers the following:

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I (“Patient”), authorize Nathaniel Arnatt, NP-C ("Nurse Practitioner" and/or "Provider"), while

operating through the medical office Simply Sweet Health, LLC DBA Elevated Certs

("Practice"), to seek, obtain, and consent for diagnosis and treatment of a medical condition(s)

as a licensed medical professional in the State of Virginia to practice medicine deems

necessary. This authorization is for the period I am in the care of Nathaniel Arnatt, NP-C, my

medical certificate issuer, and is effective for a period of 365 days from the date of 2025-09-18

or until I revoke it.

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Agreement

1. This Is Not Health Insurance. This agreement does not provide comprehensive health

insurance coverage. It provides only the provision of primary care as specifically

described in this agreement. This agreement acknowledges that SIMPLY SWEET HEALTH,

DBA ELEVATED CERTS or its Nurse Practitioner, does not provide health insurance. It

provides only the provision of a one-time medical service as specifically described in this

Agreement. The Patient understands that this Agreement does not replace any existing or

future health insurance or health plan coverage that Patient may carry. The Agreement does

not include hospital services, or any services not personally provided by the Practice, or its

employees. The Patient acknowledges that The Practice has advised the patient to obtain or

keep in full force, health insurance that will cover the Patient for healthcare not personally

delivered by the Practice, and for hospitalizations and/or catastrophic events.

2. Communications. The Patient acknowledges that although The Practice shall comply with

HIPAA privacy requirements, communications with the Nurse Practitioner using e-mail,

facsimile, video chat, cell phone, texting, and other forms of electronic communication can

never be absolutely guaranteed to be secure or confidential methods of communications. As

such, Patient expressly waives the Nurse Practitioner’s obligation to guarantee

confidentiality with respect to the above means of communication. Patient further

acknowledges that all such communications may become a part of the medical record.

3. By providing an e-mail address and phone number during enrollment, the Patient authorizes

the Practice, and its Nurse Practitioner to communicate with Patient(s) by e-mail, text, or

phone, regarding the Patient’s “protected health information” (PHI). The Patient further

acknowledges that:(a) E-mail and texting are not necessarily secure mediums for sending or receiving PHI

and, there is always a possibility that a third party may gain access;

(b) Although the Nurse Practitioner will make all reasonable efforts to keep e-mail

communications confidential and secure, neither the Practice, nor the Nurse Practitioner can

assure or guarantee the absolute confidentiality of e-mail communications;

(c) At the discretion of the Nurse Practitioner, e-mail communications and texts may be

made a part of Patient’s permanent medical record; and,

(d) You understand and agree that e-mail and/or texting is not an appropriate means of

communication in an emergency, for time-sensitive problems, or for disclosing sensitive

information.

(e) In an emergency, or a situation that You could reasonably expect to develop into

an emergency, You understand and agree to call 911 or the nearest Emergency room,

and follow the directions of emergency personnel.

(f) Email Usage. If You do not receive a response to an e-mail message within 24

hours, You agree that You will contact the Nurse Practitioner by telephone or other

means.

(g) Technical Failure. Neither the Practice, nor the Nurse Practitioner will be liable for any

loss, injury, or expense arising from a delay in responding to Patient, when that delay is

caused by technical failure. Examples of technical failures (i) failures caused by an internet

service provider, (ii) power outages, (iii) failure of electronic messaging software, or e-mail

provider (iv) failure of the Practice computers or computer network, or faulty telephone or

cable data transmission, (iv) any interception of e-mail communications by a third party

which is unauthorized by the Practice; or (v) Patient failure to comply with the guidelines for

use of e-mail described in this Agreement.

4. Change of Law. If there is a change of any relevant law, regulation or rule, federal, state or local,

which affects the terms of this Agreement, the parties agree to amend this Agreement to comply with

the law.

5. Severability. If any part of this Agreement is considered legally invalid or unenforceable by a

court of competent jurisdiction, that part will be amended to the extent necessary to be enforceable

and the remainder of the contract will stay in force as originally written.

6. Reimbursement for services rendered. If this Agreement is held to be invalid for any reason,

and the Practice is required to refund fees paid by You, You agree to pay the Practice an amount

equal to the fair market value of the medical services You received during the time period for which

the refunded fees were paid.

7. Amendment. No amendment of this Agreement shall be binding on a party unless it is in writing

and signed by all the parties. Except for amendments made in compliance with Section 12, above.16. Assignment. This Agreement, and any rights You may have under it, may not be assigned or

transferred by You.

8. Legal Significance. You acknowledge that this Agreement is a legal document and gives the

parties certain rights and responsibilities. You also acknowledge that You have had a reasonable

time to seek legal advice regarding the Agreement and have either chosen not to do so or have done

so and are satisfied with the terms and conditions of the Agreement.

9. Miscellaneous. This Agreement shall be construed without regard to any rules requiring that it

be construed against the party who drafted the Agreement. The captions in this Agreement are only

for the sake of convenience and have no legal meaning.

10. Entire Agreement. This Agreement contains the entire agreement between the parties and

replaces any earlier understandings and agreements whether they are written or oral.

11. No Waiver. In order to allow for the flexibility of certain terms of the Agreement, each party

agrees that they may choose to delay or not to enforce or the other party’s requirement or duty under

this agreement (for example notice periods, payment terms, etc.). Doing so will not constitute a

waiver of that duty or responsibility. The party will have the right to enforce such terms again at any

time.

12. Jurisdiction. This Agreement shall be governed and construed under the laws of the State of

Virginia. All disputes arising out of this Agreement shall be settled in the court of proper venue and

jurisdiction for the Practice in Orange, Virginia.

13. Service. All written notices are deemed served if sent to the address on file to the party by first

class U.S. mail.

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Services​

1. Medical Services. Medical Services under this Agreement are those medical services that the

Nurse Practitioner is permitted to perform under the laws of the State of Virginia, are

consistent with the Nurse Practitioner’s training and experience, are usual and customary for

family medicine Nurse Practitioners to provide, and include the following when deemed

appropriate and medically necessary by Us:

Each Patient is entitled to an evaluation for the use of medical cannabis, which shall be performed by

the Nurse Practitioner and may or may not include the following, as deemed medically appropriate:

• Detailed review of medical, family, and social history

• Medical diagnosis and treatment plan

• Personalized Health Risk Assessment

• Preventative health counseling

• Recommendations for products and alternative services2. Non-Medical, Personalized Services. the Practice shall also provide patient with the

following non-medical services (“Non-Medical Services”):

• After Hours Access. Patient shall have telephone access to the Nurse Practitioner during our

regular service hours which are Monday through Friday between the hours of 9am-5pm. Any

service hours outside of our regular service hours are used only at the sole discretion of the

Practice.

• Appointments, office visits, telephone calls, texts, and email communication outside of

our regular service hours may be subject to additional fees as determined by a

reasonable standard charge of such medical services. Patient shall be given a phone

number where patient may reach the Nurse Practitioner for guidance regarding concerns that

arise unexpectedly after office hours. Video chat and text messaging may be utilized when the

Nurse Practitioner and Patient agree that it is appropriate. An additional fee may apply.

• Nurse Practitioner Absence. From time to time, due to vacations, illness, or personal

emergency, the Nurse Practitioner may be temporarily unavailable to provide the services

referred to above in this paragraph one. In order to assist Patients in scheduling non-urgent

visits, the Practice will notify Patients of any planned or unexpected/emergent absences as

soon as the dates/times are confirmed. In the event of the Nurse Practitioner’s unplanned

absences, Patients will be given the name of an appropriate provider or office for the Patient to

contact. Any treatment rendered by the substitute provider is not covered under this contract,

but may be submitted to Patient’s health plan.

• E-Mail Access. Patient shall be given the Nurse Practitioner’s e-mail address to which non-

urgent communications can be addressed. Such communications shall be dealt with by the

Nurse Practitioner or staff member of the Practice in a timely manner. Patient understands

and agrees that email and the internet should never be used to access medical care in

the event of an emergency, or any situation that Patient could reasonably expect may

develop into an emergency. Patient agrees that in such situations, when a Patient cannot

speak to the Nurse Practitioner immediately in person or by telephone or text, that Patient shall

call 911 or the nearest emergency medical assistance provider, and follow the directions of

emergency medical personnel.

• Timely Appointments. All reasonable efforts shall be made to assure that the Nurse

Practitioner arrives on time for scheduled appointments. If Nurse Practitioner foresees a delay,

Patient shall be contacted and advised of the projected arrival time.

• Same Day/Next Day Appointments. When Patient calls, texts, or e-mails the Nurse

Practitioner to schedule an appointment, every reasonable effort shall be made to schedule an

appointment with the Nurse Practitioner within three to five business days.

3. Additional Notices. the Practice shall also adhere to the following acknowledgements:• This agreement acknowledges the Patient’s understanding that the Nurse Practitioner does

not offer any covered services in the Practice to Patients who have or are eligible to receive

services through Medicare, and as a result, Medicare cannot be billed for any services

performed for the Patient by the Nurse Practitioner. The Patient agrees not to bill Medicare or

attempt to obtain Medicare reimbursement for any such services.

• This agreement acknowledges the Patient’s understanding that neither the Practice, nor its

Nurse Practitioner, participate in any health insurance or HMO plans or panels and do not see

any patients who have or are eligible to receive services through Medicare. The fees paid

under this Agreement are not intended or considered to be covered by the Patient’s health

insurance or other third party payment plans. It is the Patient’s responsibility to determine

whether reimbursement is available from a private, non- governmental insurance plan or HSA

and to submit any required billing.

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Telemedicine Consent to Treat

Definition: Telemedicine ("telehealth"), includes the delivery of patient care through real-time

interactive audiovisual technology

I hereby give my consent for the Practice to treat me with the use of telemedicine which includes the

delivery of patient care through real-time interactive audiovisual technology.

I understand and I am informed that, as with all healthcare treatments, results are not guaranteed

and there is no promise of cure or certification expressed or implied.

I certify that I have had the opportunity to discuss with my provider the nature and purpose of

treatments and procedures. I am aware that all existing methods of diagnosis and treatment pose

some level of risk.

I do not expect the Provider to be able to anticipate and explain all risks and complications,

and I wish to rely on the provider to exercise judgment during the course of the treatment

which the provider feels at the time, based upon the facts then known, is in my best interests.

I will immediately inform the Provider if I experience any gastrointestinal upset (nausea, gas,

stomachache, vomiting or similar condition), allergic reactions (hives, rashes, tingling of the tongue,

headache or similar condition), or any unanticipated or unpleasant effects associated with treatment

or supplements prescribed/recommended. I understand that if an emergency medical condition

arises, I am expected to call 9-1-1.

I consent to voluntarily engaging in a telemedicine consultation with the Practice. I understand that

the video conferencing technology will not be the same as a direct patient/health care provider visit:Telehealth consultation has potential benefits, including easier access to care, decreasing costs, and

allowing visits to be performed from the comfort of my home. It also has potential risks including

interruptions, unauthorized access, and technical difficulties. I understand that I can see the Nurse

Practitioner for this appointment at the Practice location for no additional cost during their

normal business hours during an available Patient appointment time of requested.

I understand that my health care provider or I can discontinue the telehealth consult/visit if it is felt

that the videoconferencing connections are not adequate for the situation.

If there is another individual present during the telehealth consultation, I will be informed of their

presence and I will also disclose if there is another individual with myself. It is agreed that these

individuals will maintain confidentiality of the information obtained. I further understand that I will be

informed of their presence in the consultation and thus will have the right to request the following: (1)

omit specific details of my medical history/physical examination that are personally sensitive to me;

(2) ask non-medical personnel to leave the telemedicine examination room: and or (3) terminate the

consultation at any time.

I understand that telemedicine has limitations in regard to the physical examination. I understand that

the physical exam portion of the care provided through the practice will be limited to inspection via

video conferencing and some parts of the exam such as physical tests, examination of certain body

parts, and vital signs may be conducted by individuals at my location at the direction of the consulting

health care provider or not done at all.

Telemedicine services offered through the practice are not an Emergency Service and in the event of

an emergency or urgent medical issue, I will use a phone to call 9-1-1.

To maintain my privacy, I will not share telemedicine login information or video conferencing links with

anyone unauthorized to attend the appointment.

NOTICE OF PRIVACY PRACTICES

As Required by the Privacy Regulations Created as a Result of the Health Insurance

Portability and Accountability Act of 1996 (HIPAA)

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU (AS A PATIENT OF THIS

PRACTICE) MAY BE USED AND DISCLOSED, AND HOW YOU CAN GAIN ACCESS TO YOUR

INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION.

PLEASE REVIEW THIS NOTICE CAREFULLY.

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1. OUR COMMITMENT TO YOUR PRIVACY:

Our practice is dedicated to maintaining the privacy of your individually identifiable health information

(IIHI). In conducting our business, we will create records regarding you and the treatment and

services we provide to you. We are required by law to maintain the confidentiality of health

information that identifies you. We are also required by law to provide you with this notice of our legal

duties and the privacy practices that we maintain in our practice concerning your IIHI. By federal and

state law, we must follow the terms of the notice of privacy practices that we have in effect at the

time.

We realize that these laws are complicated, but we must provide you with the following important

information:

- how we may use and disclose your IIHI

- your privacy rights in your IIHI

- our obligations concerning the use and disclosure of your IIHI

The terms of this notice apply to all records containing your IIHI that are created or retained

by our practice. We reserve the right to revise or amend this Notice of Privacy Practices. Any

revision or amendment to this notice will be effective for all of your records that our practice

has created or maintained in the past, and for any of your records that we may create or

maintain in the future. Our practice will post a copy of our current Notice on our website, and

you may request a copy of our most current Notice at any time.

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IF YOU HAVE QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT:

SIMPLY SWEET HEALTH, LLC DBA ELEVATED CERTS

32345 Constitution Hwy, Suite H

Locust Grove, Virginia 22508

(540) 760-7457

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WE MAY USE AND DISCLOSE YOUR INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION

(IIHI) IN THE FOLLOWING WAYS:

The following categories describe the different ways in which we may use and disclose your IIHI,

unless you object:

1. Treatment. Our practice may use your IIHI to treat you and may use it for third party scheduling. For example, we may ask you to have laboratory tests (such as blood or urine tests), and we may use the results to help us reach a diagnosis. We might use your IIHI in order to write a prescription for you, or we might disclose your IIHI to a pharmacy when we order a prescription for you. Many of the people who work for our practice—including, but not limited to, our medical providers and nurses—may use or disclose your IIHI in order to treat your or to assist others in your treatment. Additionally, we may disclose your IIHI to others who may assist in your care, such as other healthcare providers, your spouse, your children or your parents.

2. Payment. Our practice may use and disclose your IIHI in order to bill and collect payment for

the services and items you may receive from us. For example, we may use and disclose your

IHII to obtain payment from third parties that may be responsible for such costs, such as family

members. Also, we may use your IIHI to bill you directly for services and items.

3. Health Care Operations. Our practice may use and disclose your IIHI to operate our

business. As examples of the ways in which we may use and disclose your information for our

operations, our practice may use your IIHI to evaluate the quality of care you received from us,

to develop protocols and clinical guidelines, to develop training programs, and to aid in

credentialing, medical review, legal services and insurance. We will share information about

you with such insurers or other business associates as necessary to obtain these services.

4. Appointment Reminders. Our practice may use and disclose your IIHI to contact you and

remind you of an appointment.

5. Treatment Options. Our practice may use and disclose your IIHI to inform you of potential

treatment options or alternatives.

6. Health-Related Benefits and Services. Our practice may use and disclose your IIHI to inform

you of health-related benefits or services that may be of interest to you.

7. Release of Information to Family/Friends. Our practice may release your IIHI to a friend or

family member that is involved in your care, or who assists in taking care of you. For example,a parent or guardian may ask that a babysitter take their child to the pediatrician’s office for

treatment of a cold. In this example, the babysitter may have access to this child’s medical

information.

8. Disclosures Required by Law. Our practice will use and disclose your IIHI when we are

required to do so by federal, state, or local law.

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USE AND DISCLOSURE OF YOUR IIHI IN CERTAIN SPECIAL CIRCUMSTANCES:

The following categories describe unique scenarios in which we may use or disclose your identifiable

health information:

1. Public Health Risks. Our practice may disclose your IIHI to public health authorities that are

authorized by law to collect information for the purpose of:

- maintaining vital records, such as births and deaths

- reporting child abuse or neglect

- preventing or controlling disease, injury, or disability

- notifying a person regarding potential exposure to a communicable disease

- notifying a person regarding a potential risk for spreading or contracting a disease or condition

- reporting reactions to drugs or problems with products or devices

- notifying individuals if a product or device they may be using has been recalled

- notifying appropriate government agency (ies) and authority (ies) regarding the potential abuse

or neglect of an adult patient (including domestic violence); however, we will only disclose this

information if the patient agrees or we are required or authorized by law to disclose this information

- notifying your employer under limited circumstances related primarily to workplace injury or

illness or medical surveillance

2. Health Oversight Activities. Our practice may disclose your IIHI to a health oversight agency for

activities authorized by law. Oversight activities can include, for example, investigations, inspections,

audits, surveys, licensure and disciplinary actions; civil, administrative, and criminal procedures or

actions; or other activities necessary for the government to monitor government programs,

compliance with civil rights laws and the health care system in general.

3. Lawsuits and Similar Proceedings. Our practice may use and disclose your IIHI in response to a

court or administrative order, if you are involved in a lawsuit or similar proceeding. We also may

disclose your IIHI in response to a discovery request, subpoena, or other lawful process by another

party involved in the dispute, but only if we have made an effort to inform you of the request or to

obtain an order protecting the information the party has requested.4. Law Enforcement. We may release IIHI if asked to do so by a law enforcement official:

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- regarding a crime victim in certain situations, if we are unable to obtain the person’s agreement

- concerning a death we believe has resulted from criminal conduct

- regarding criminal conduct at our offices

- in response to a warrant, summons, court order, subpoena or similar legal process

- to identify/locate a suspect, material witness, fugitive or missing person

- in an emergency, to report a crime (including the location or victim(s) of the crime, or the

description, identity or location of the perpetrator)

5. Deceased Patients. Our practice may release IIHI to a medical examiner or coroner to identify a

deceased individual or to identify the cause of death. If necessary, we may also release information

in order for funeral directors to perform their jobs.

6. Organ and Tissue Donation. Our practice may release your IIHI to organizations that handle

organ, eye or tissue procurement or transplantation, including organ donation banks, as necessary to

facilitate organ or tissue donation and transplantation if you are an organ donor.

7. Research. Our practice may use and disclose your IIHI for research purposes in certain limited

circumstances. We will obtain your written authorization to use your IIHI for research purposes

except when: (a) our use or disclosure was approved by an Institutional Review Board or a Privacy

Board; (b) we obtain the oral or written agreement of a researcher that (i) the information being

sought is necessary for the research study; (ii) the use or disclosure of your IIHI is being used only

for the research and (iii) the researcher will not remove any of your IIHI from our practice; or (c) the

IIHI sought by the researcher only relates to decedents and the researcher agrees either orally or in

writing that the use or disclosure is necessary for the research and, if we request it, to provide us with

proof of death prior to access to the IIHI of the decedents.

8. Serious Threats to Health or Safety. Our practice may use and disclose your IIHI when

necessary to reduce or prevent a serious threat to your health and safety or the health and safety of

another individual or the public. Under these circumstances, we will only make disclosures to a

person or organization able to help prevent the threat.

9. Military. Our practice may disclose your IIHI if you are a member of U.S. or foreign military forces

(including veterans) and if required by the appropriate authorities.

10. National Security. Our practice may disclose your IIHI to federal officials for intelligence and

national security activities authorized by law. We may also disclose your IIHI to federal officials inorder to protect the President, other officials or foreign heads of state, or to conduct investigations.

11. Inmates. Our practice may disclose your IIHI to correctional institutions or law enforcement

officials if you are an inmate or under the custody of a law enforcement official. Disclosure for these

purposes would be necessary: (a) for the institution to provide health care services to you, (b) for the

safety and security of the institution, and/or (c) to protect your health and safety or the health and

safety of other individuals.

12. Workers’ Compensation. Our practice may release your IIHI for workers’ compensation and

similar programs.

E. YOUR RIGHTS REGARDING YOUR IIHI:

The health and billing records we maintain are the physical property of Simply Sweet Health.

The information in it, however, belongs to you. You have a right to:

1. Confidential Communications. You have the right to request that our practice communicate with

you about your health and related issues in a particular manner or at a certain location. For instance,

you may ask that we contact you at home, rather than work. In order to request a type of confidential

communication, you must make a written request to the Privacy Officer, specifying the requested

method of contact, or the location where you wish to be contacted. Our practice will accommodate

reasonable requests. You do not need to give a reason for your request.

2. Requesting Restrictions. You have the right to request a restriction in our use or disclosure of

your IIHI for treatment, payment or health care operations. Additionally, you have the right to request

that we restrict our disclosure of your IIHI to only certain individuals involved in your care or the

payment for your care, such as family members and friends. We are not required to agree to your

request; however, if we do agree, we are bound by our agreement except when otherwise required

by law, in emergencies, or when the information is necessary to treat you. In order to request a

restriction in our use or disclosure of your IIHI, you must make your request in writing to the Privacy

Officer. Your request must describe in a clear and concise fashion:

(a) the information you wish restricted;

(b) whether you are requesting to limit our practice’s use, disclosure or both; and

(c) to whom you want the limits to apply.

3. Inspection and Copies. You have the right to inspect and obtain a copy of the IIHI that may be

used to make decisions about you, including patient medical records and billing records, but not

including psychotherapy notes. You must submit your request in writing to the Privacy Officer in orderto inspect and/or obtain a copy of your IIHI. Our practice may charge a fee for the costs of copying,

mailing, labor and supplies associated with your request. Our practice may deny your request to

inspect and/or copy in certain limited circumstances; however, you may request a review of our

denial. Another licensed health care professional chosen by us will conduct reviews.

4. Amendment. You may ask us to amend your health information if you believe it is incorrect or

incomplete, and you may request an amendment for as long as the information is kept by or for our

practice. To request an amendment, your request must be made in writing and submitted to the

Privacy Officer. You must provide us with a reason that supports your request for amendment. Our

practice will deny your request if you fail to submit your request (and the reason supporting your

request) in writing. Also, we may deny your request if you ask us to amend information that is in our

opinion: (a) accurate and complete; (b) not part of the IIHI kept by or for the practice; (c) not part of

the IIHI which you would be permitted to inspect and copy; or (d) not created by our practice, unless

the individual or entity that created is not available to amend the information.

5. Accounting of Disclosures. All of our patients have the right to request an “accounting of

disclosures.” An “accounting of disclosures” is a list of certain non-routine disclosures our practice

has made of your IIHI for non-treatment or operations purposes. Use of your IIHI as part of the

routine patient care in our practice is not required to be documented. For example, the doctor sharing

information with the nurse. In order to obtain an accounting of disclosures, you must submit your

request in writing to the Privacy Officer. All requests for an “accounting of disclosures” must state a

time period, which may not be longer than six (6) years from the date of disclosure and may not

include dates before April 14, 2003. The first list you request within a 12-month period is free of

charge, but our practice may charge you for additional lists within the same 12-month period. Our

practice will notify you of the costs involved with additional requests, and you may withdraw your

request before you incur any costs.

6. Right to a Paper Copy of this Notice. You are entitled to receive a paper copy of our notice of

privacy practices. You may ask us to give you a copy of this notice at any time. To obtain a paper

copy of this notice, contact the Privacy Officer.

7. Right to File a Complaint. If you believe your privacy rights have been violated, you may file a

complaint with our practice or with the Secretary of the Department of Health and Human Services.

To file a complaint with our practice, contact:

SIMPLY SWEET HEALTH, LLC DBA ELEVATED CERTS

32345 Constitution Hwy, Suite H

Locust Grove, Virginia 22508

(540) 760-7457

All complaints must be submitted in writing. You will not be penalized for filing a complaint.

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8. Right to Provide an Authorization for Other Uses and Disclosures. Our practice will obtain

your written authorization for uses and disclosures that are not identified by this notice or permitted

by applicable law. Any authorization you provide to us regarding the use and disclosure of your IIHI

may be revoked at any time in writing. After you revoke your authorization, we will no longer use or

disclose your IIHI for the reasons described in the authorization. Please note: we are required to

retain records of your care.

Again, if you have questions regarding this notice or our health information privacy policies, please

contact the Office listed above.

Acknowledgement:

I hereby acknowledge that I have received and read the Simply Sweet Health HIPAA Privacy

Policy Notice. I understand that I may request additional copies of this notice at any time.

Medical Cannabis Certificate Patient Agreement

Simply Sweet Health, LLC DBA ELEVATED CERTS

Background: SIMPLY SWEET HEALTH, LLC DBA ELEVATED CERTS (Practice) is a Direct Pay

primary care practice (DPC), which delivers primary care services through its nurse practitioner, Mr.

Nathaniel Arnatt (Nurse Practitioner), whose mailing address is 32345 Constitution Hwy, Suite H,

Locust Grove, Virginia 22508. In exchange for certain fees, Simply Sweet Health agrees to provide

You with the Services described in this Agreement on the terms and conditions contained in this

Agreement.

Terms and conditions: I ("Patient") hereby authorize Simply Sweet Health, LLC DBA Elevated

Certs (“Practice”) to charge my designated payment method for all charges incurred for services

received through the participating healthcare provider, Nathaniel Arnatt, NP-C (“Provider”).

I certify under penalty of law that I am the authorized user of the payment method provided. I

understand that I remain personally responsible for all charges, including any additional late fees or

other applicable charges, in the event that an authorized withdrawal from my account is denied,

returned for insufficient funds, or otherwise becomes unavailable.

I further understand and agree that if payment for services is disputed, reversed, or otherwise

challenged after a medical certificate has been issued, the Practice reserves the right to revoke or

invalidate that certificate until full payment is received.

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MEDICAL CANNABIS LIABILITY WAIVER AND RELEASE

In consideration of the medical evaluation of me to be performed by or on behalf of the

Practice, I, my heirs, assigns and anyone acting on my behalf, agree to hold the Practice,

Staff, Providers, and their principals, agents, officers, directors and employees, free and

harmless from any and all claims, damages and causes of action relating to or arising out of:

(1) my use or possession of cannabis, or (2) the denial of my application for a medical

cannabis certificate for any reason.

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I understand and acknowledge that:

1. It is my responsibility to be informed regarding State and Federal laws regarding the possession,

use, sale/purchase and/or distribution of medical cannabis.

2. The Practice is not a Dispensary and cannot provide me with medicinal cannabis or any other

medication.3. An evaluation that results in a provider’s recommendation that I may benefit from the use of

medicinal cannabis does not guarantee that I will in fact be eligible to obtain, possess, or use

medicinal cannabis pursuant to Virginia law.

4. A provider's recommendation that I may benefit from the use of medicinal cannabis does not

guarantee that the use of medicinal cannabis will be effective at alleviating my pain; or any other

medical condition.

5. I acknowledge that my employer or occupation may prohibit me from the use of medical cannabis

even though I have a state certification.

6. Should an approval be made for my medicinal use of medical cannabis, there is a renewal date

specified by the State. It is my responsibility to see the provider to assess the possible continuance

of medical cannabis use beyond the term of the approval and not the responsibility of the Practice.

7. I certify I am a resident of Virginia, I am at least 18 years of age, and have not misrepresented any

information to the Practice. If I am under 18 years of age, I am not suitable or allowed to be certified

by the Practice.

8. I acknowledge that I am not recording any portion of my visit with the Practice. I understand that

the Practice does not allow any recordings. Any such action is a direct violation of HIPAA regulations,

patient/provider confidentiality, and that of the Practice.

9. I acknowledge that cannabis, even if used for medical purposes, is illegal under Federal law.

10. I acknowledge that the use of medical cannabis can affect coordination, motor skills and

cognition, i.e., the ability to think, judge and reason. While using marijuana I should not drive, operate

heavy machinery, or engage in any activities that require me to be alert and/ or respond quickly. I

understand that if I drive while under the influence of medical marijuana, I can be arrested for "driving

under the influence”.

11. I understand that using cannabis while under the influence of alcohol is not recommended.

Additional side effects may become present when using both alcohol and cannabis.

12. I acknowledge that the Practice does not provide any legal advice or provide any legal counsel.

PATIENT INFORMED CONSENT, CONTRAINDICATIONS, & SIDE EFFECTS ACKNOWLEDGMENT

I understand that medical marijuana is considered a medicine and is to be used in treating the

suffering caused by serious and debilitating medical conditions. Serious and debilitating medical

conditions include, but are not limited to:

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Acquired Immune Deficiency Syndrome (AIDS) Amyotrophic Lateral Sclerosis (ALS)

Human Immunodeficiency Virus (HIV) Glaucoma

Agitation of Alzheimer’s Disease Hepatitis C

Cachexia or Wasting Syndrome Severe Nausea

Post-Traumatic Stress Disorder (PTSD) Severe and Chronic Pain

Seizures, including epilepsy characteristics Crohn's Disease

Insomnia Anxiety

Depression Cancer

Severe or persistent muscle spasms Multiple Sclerosis

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If I begin to experience respiratory problems or any other ill effects I will discontinue the use of

medical cannabis and dial 9-1-1.

The Nurse Practitioner is addressing one specific aspect of my medical care for medical cannabis

certification and, unless otherwise stated, is not establishing themself as my primary care provider

unless specifically requested and the proper paperwork is completed.

The Provider is not advising nor condoning the discontinuation of treatment or medication that I am

currently taking.

​

I give my consent to have my name, date of visit, and other required information released for the

legal verification of my certification as needed.

I have had the opportunity to discuss these matters with the Provider and to ask questions regarding

anything I may not understand or that I believe needed to be clarified.

I understand that smoking cannabis may cause respiratory harm such as bronchitis. Some

researchers believe that cannabis smoke contains chemicals that can cause lung disease and that

smoking cannabis may increase the risk of respiratory illness and disease of the lungs, throat, mouth,

and tongue.I understand that potential dangers to fetuses cause by smoking or ingesting cannabis while

pregnant or to infants while breastfeeding. I also understand that the use of cannabis during

pregnancy may result in a risk of being reported to the Department of Child Safety during pregnancy

or at the birth of the child by persons who are required to report.

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Possible side effects of medical marijuana may include, but are not limited to:

Anxiety Inability to concentrate

Difficulty in completing complex tasks Sedation

Alterations in the perception of time and space Low blood pressure

Impairment of motor skills, reaction time, & Dizziness

physical coordination

Increased talkativeness Euphoria

Impairment of short-term memory Confusion

Tachycardia and heart palpitations Cough

Bronchitis General Apathy

Suppression of the body's immune system Paranoia

Psychotic symptoms Sore throat

Cannabinoid Hyperemesis Syndrome Laryngitis

​

I understand that side effects, while rare, may occur while I am using medical marijuana. These side

effects have been explained to me.

The potency and effects of medical marijuana varies. Estimating the proper marijuana dosage is very

important. Some patients may become dependent on marijuana and could experience withdrawal

symptoms when they stop.

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Symptoms of withdrawal, while generally mild, may include:

Feelings of depression, sadness or irritability Unusual tiredness

Insomnia Trouble concentrating

Sleep disturbances Loss of appetite

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I understand that the cannabis plant is not a food crop and therefore is not regulated by the U.S.

Food & Drug Administration and may contain unknown quantities of impurities, active ingredients

and/or contaminants. While under the influence of cannabis, the use of alcohol is not recommended.

The possibility exists that medical cannabis may exacerbate psychotic problems.

Comprehensive Disclosure StatementSimply Sweet Health, LLC DBA Elevated Certs

In compliance with Virginia Code § 54.1-2998. Medical care agreement requirements; disclosures;

disclaimer:

This agreement does not provide comprehensive health insurance coverage. It provides only the

provision of primary care as specifically described in this agreement.

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Your financial rights and responsibilities to our Practice:

1. This agreement is not insurance nor does it express or imply it;

2. The Practice provides only the limited scope of primary care specified in this agreement as it

pertains to the evaluation, diagnosis, and the issuance of a medical cannabis certificate in the state

of Virginia in accordance with its laws and regulations.

3. A patient is required to pay for all services provided by the Practice that are not specified in this

agreement; and

4. The agreement standing alone does not satisfy the health benefit requirements as established in

the federal Patient Protection and Affordable Care Act (P.L. 111-148), as amended.

We encourage all Patients to obtain and maintain insurance for services not provided by this

Practice.

The Practice will not bill a health carrier for services covered under this agreement.

The Practice has further discussed:

I am aware that in the practice of medicine, other unexpected complications and risks my Doctor

didn’t discuss with me might occur. I understand the proposed treatments might reveal unforeseen

conditions. These conditions might result in the processed treatments changing.

I am voluntarily participating in this Treatment. I assume all known and unknown risks of my

participation in these treatments and procedures. I further agree to indemnify, defend, and hold the

medical or healthcare institute and its practitioners harmless against all claims and suits of action

against liability, compensation, damages, or otherwise brought to me, including attorney fees and

related costs.Having read this form and talked with the physicians, my signature below signifies that I give my authorization and consent. This consent is for Nathaniel Arnatt, NP-C and his associates, assisted by

medical center personnel and other trained persons, and with the presence of observers, to perform

the treatments and procedures described above.

​

By signing our Telemedicine Consultation, I agree to these Terms, Conditions, Medical Liability Waiver & Acknowledgment, the practice’s policies on payment, HIPAA privacy, and patient responsibilities. Furthermore, I agree to an evaluation, by Nathaniel Arnatt, NP-C, to determine if I have a medical

condition that qualifies for the use of medical cannabis under Virginia law § 4.1-1601. Certification for

use of cannabis for treatment. I understand that I have requested an evaluation which does not guarantee a product or service which is at the sole medical discretion of the Nurse Practitioner and Practice standards of care. If I am found not eligible, Practice will refund the amount paid minus any credit card fees incurred, not to exceed 10% of the total of each purchase.

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Acknowledgments

1. Understanding of Evaluation Purpose

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• I understand that this evaluation is solely to assess whether I have a qualifying medical condition as

defined by Virginia law for the purpose of applying to the state’s medical cannabis program.

2. No Prescription or Endorsement

• I acknowledge that receiving a certification of a qualifying condition does not constitute a

prescription, recommendation, or endorsement for the use of medical cannabis by Nathaniel Arnatt,

NP-C, or the Practice.

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3. Program Application

• I understand that it is my responsibility to adhere to the laws enacted by the Commonwealth of

Virginia and those regulated by the Virginia Cannabis Control Authority.

​

4. Risks and Benefits

• I have been informed about the potential risks and benefits of medical cannabis use, including

possible side effects and alternative treatment options.

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5. Legal Compliance

• I agree to comply with all Virginia laws and regulations regarding the use, possession, and

acquisition of medical cannabis.

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6. Liability Release

• I release and hold harmless Nathaniel Arnatt, NP-C, and Simply Sweet Health, DBA Elevated Certs

from any and all claims or liabilities arising from my use of medical cannabis.

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Patient Declaration

By agreeing to Terms & Conditions, I declare that I have read and understood the Medical Liability Waiver & Acknowledgment and the information I have provided to the Nurse Practitioner and Practice is accurate and complete to the best of my knowledge. I certify that I have provided true and accurate information today during our visit. Furthermore, I will forfeit my medical certificate if I am found of knowingly or willingly given false information in the attempt to obtain it under false pretenses of which constitutes fraud and abuse punishable by the Laws of The Commonwealth of Virginia. I have had the opportunity to ask questions, and all my questions have been answered to my satisfaction before signing the Medical Liability Waiver & Acknowledgment.

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