Established February 1, 2026

​

I understand and consent to using telehealth, SMS and email communication at RX14 Health PLLC and partners. I authorize my credit card to be charged the day of the appointment and be kept on file. I understand no shows and late cancellations of less than 48 hours will be charged for the full visit.

 

EPRESCRIBING CONSENT

ePrescribing is defined as a medical providers ability to electronically send a prescription directly to a pharmacy. Benefits data are maintained for health insurance companies by organizations known as Pharmacy Benefits Managers (PBM). PBM’s are third party administrators of prescription drug programs whose primary responsibilities are processing and paying prescription drug claims. By checking the box below you are agreeing that RX14 Health can request and use your prescription medication history from other healthcare providers and/or third party Pharmacy Benefits Managers for treatment purposes.

​

COACHING SERVICE AGREEMENT

All coaching services and communication email or otherwise, delivered by RX14 Health are meant to help you identify the areas in your life and in your thinking that may be standing in your way. I understand that all comments and ideas offered by my Coach are solely for the purpose of aiding me in achieving my defined goals. I understand that to the extent our work together involves career or business, my Coach is not promising outcomes included but not limited to increased clientele, profitability and or business and/or personal success. The client also agrees to disclose details of the past or present psychological or psychiatric treatment. Coaching and counseling are not the same. Likewise, therapy and other modes of professional or medical

psychological examination shall not be considered equivalent to coaching. I understand that the coaching services I will be receiving from my Coach are not offered as a substitute for professional mental health care or medical care and are not intended to diagnose, treat or cure any mental health or medical conditions. I also understand that my Coach is not acting as a mental health provider or a medical professional when performing coaching services. I understand and agree that I am fully responsible for my well-being during my coaching sessions, and subsequently, including my choices and decisions. In entering into the coaching relationship, and signing the agreement, you are agreeing that if any mental health difficulties arise during the course of

the coaching relationship, you will notify me immediately so that I can discuss with you an appropriate referral plan of action. I hereby release, waive, acquit and forever discharge my Coach, any agents, successors, assigns, personal representatives, executors, heirs and employees from every claim, suit action, demand or right to compensation for damages I may claim to have or that I may have arising out of acts or omissions by myself or by my Coach as a result of the advice given by my Coach or otherwise resulting from the coaching relationship contemplated by this agreement. I further declare and represent that no promise, inducement, or agreement not expressed in this agreement has been made to me to sign this agreement. This agreement

shall bind my heirs, executors, personal representatives, successors, assigns, and agents. No assumption of responsibility is made, or given, and the client requesting such advice agrees not to hold RX14 Health responsible or liable in any form or fashion, for such actions taken of their own accord. The method and process by which this advice and direction is given in whatsoever, written or verbal, constitutes an agreement or liability on the part of the provider and is acknowledged to be different in many ways than clinical and medical counseling. I agree that using any of these life coaching services are entirely at your own risk. Life coaching services are provided "as is", without warranty of any kind, either expressed or implied, including without limitation any warranty for information services, coaching, uninterrupted access, or products and services provided through or in connection with the service. This service is requested at the client's own choice and with inherent singular responsibility. Any actions or lack of actions, taken by the client of such advice is done so solely by choice and responsibility of the client and is neither the responsibility nor liability of RX14 Health. Periodically, we may provide links to other web sites or written print material which may be of value, interest, and convenience to you. This does not constitute endorsement of material at those sites or any associated organization product of service. It is the responsibility of the user to make their own informed

decision about the accuracy of the information at those sites and print material including their privacy policies. In no event shall RX14 Health, be liable for any incident or consequential damages resulting from use of the material.

​

PATIENT FINANCIAL RESPONSIBILITY ACKNOWLEDGEMENT

Payment is required at the time services are rendered. This includes co-payments and payments for services not covered or denied by your insurance company. Cancellations are required 48 hours prior to the appointment. Appointments not cancelled 48 hours in advance will result in being charged for the full appointment time. This fee must be paid before a new appointment is scheduled. Declined or Returned Payments: A $100 charge will be applied to your account for any checks rejected by the bank for any reason. If a pre-arranged credit card payment plan is established and a payment declines, you may be charged $25 per

declined transaction. Please ensure that there are sufficient funds on the stored credit card to cover these payments prior to setting up payment arrangements and contact our office immediately with any changes regarding your stored card. Additional fees may be charged by your financial institution. We offer the convenience of securely storing credit or debit card numbers on file with our office. Please be assured that this payment method will in no way compromise your ability to dispute charges or question your company’s determination of payment. If you have questions about this payment method, do not hesitate to ask. I

acknowledge full financial responsibility for services rendered by RX14 Health. Should this account become delinquent, I agree to pay all collection and court costs, including attorney’s fees. All past due amounts may accrue interest at the rate of 1.5% per month, 18% per annum if the balance is not paid within 60 days. I certify that this information is true and correct to the best of my knowledge and will notify the office of any changes to my information, such as, but not limited to change in address, telephone numbers, insurance coverage, etc. I have read, understand, and agree to abide by the Financial Policy.

​

WRITTEN ACKNOWLEDGEMENT FORM

Our Notice of Privacy Practices provides information about how we may use and disclose medical information about you. As provided in our notice, the terms of our notice may change. If we change our notice, you may receive a revised copy. I have been provided with a copy of RX14 Health's Notice of Privacy Practices. I have had the opportunity to read the Notice of Privacy Practices located at: https://www.rx14health.com/privacypolicy I understand that I may ask questions to RX14Health if I do not

understand any information contained in the Notice of Privacy Practices.

 

MEDIA RELEASE CONSENT

We love to be able to congratulate our clients on a job well done and support their career via social media, education and publication. By signing below, I consent for photographs and/or video images to be used for purposes of marketing (website, print, digital or social media). By consenting to photographs and/or video images I understand I will not be compensated from any party. I authorize the release of the following information like first and last name, location, title, services used, testimony as well as public information to be used. I further acknowledge that my participation is voluntary and agree that use of any photographs and/or video images confers no rights of ownership or royalties whatsoever. I hereby release RX14 Health and

Amanda Miller and its employees, and any third parties involved in the creation of or publication of educational or marketing materials, from liability for any claims by me or any third party in connection with my participation. I confirm understanding of this consent. If I wish to withdraw my consent in the future, I may do so via written request submitted to RX14 Health or by completion of a new form.

​

DISCLOSURE TO PRIVATE HEALTH INFORMATION

Information related to my health may be disclosed as needed for payment of health care services. I understand that RX14 Health will only disclose information relevant to my current treatment that is critical for processing.

​

I understand and agree with the above notices, and consent to using telehealth services at RX14 Health.