Welcome to
Madison Longevity

I authorize the release of all medical information necessary to process insurance claims and that is pertinent to my medical care. This authorization remains in effect until revoked by me in writing. A photocopy of this authorization is to be considered as valid as the original.

I understand that under HIPAA (1996), I have certain rights to privacy regarding my protected health information (PHI). This information will be used to:

• Conduct, plan, and direct my treatment and follow-up among healthcare providers involved in my care.
• Obtain payment from third-party payers.
• Conduct normal healthcare operations such as quality assessments and certifications.

I have been informed of the Notice of Privacy Practices and may request restrictions on how my information is used. I may revoke this consent in writing at any time.

I voluntarily request and consent to examination, evaluation, and medical care by Scott Pearlman, M.D. PLLC, d/b/a Madison Longevity, and by the physicians, nurse practitioners, physician assistants, nurses, and other qualified staff acting under their direction. This may include, but is not limited to, routine office and telehealth visits, physical examinations, laboratory and diagnostic testing, and the preventive, hormonal, and longevity-focused treatments recommended to me and discussed with my provider.

I understand that the practice of medicine is not an exact science, and I acknowledge that no guarantee or assurance has been made to me as to the outcome or results of any examination, test, or treatment. I have had the opportunity to ask questions about my proposed care, and those questions have been answered to my satisfaction.

I understand that, in addition to my primary treating provider, other members of the clinical staff — including nurses, medical assistants, and laboratory personnel — may perform portions of my care under the direction and supervision of my provider.

This general consent to treat does not replace, and is separate from, any procedure-specific informed consent (such as consent for peptide or specialty hormone therapy), which will be obtained separately before that treatment begins.

I seek the medical services of Madison Longevity (Scott Pearlman, M.D. PLLC) and its providers. I am executing this consent to confirm my discussion with Dr. Scott Pearlman and my understanding of the risks, benefits, and alternatives to treatment with peptide therapy. The goal and possible benefits are to prevent, reduce, or control the dysfunction associated with the aging process, through hormonal balancing, control of oxidative stress, and other clinically significant therapeutic agents.

I understand this treatment may be viewed by the mainstream medical community as new, controversial, off-label, experimental, and unnecessary by the FDA.

Possible adverse reactions include: injection site redness, transient high blood sugar, development of antibodies, and water retention. These are dose-related and usually eliminated by adjusting dosage. This therapy should not be used in patients with known cancer.

I understand that my treatment will be prescribed in an effort to prevent side effects but cannot be guaranteed free of adverse reactions. There is no guarantee of satisfactory results. Use of this treatment does not preclude other treatments, though I should inform all practitioners about all treatments I am using.

Patient acknowledges that the physician has made no representation or warranty that the treatment or any portion thereof qualifies or will qualify for reimbursement or assignment under Medicare or any other government program. Patient hereby covenants that he or she shall not submit any claim(s) to Medicare or any other government program for any portion of the treatment at any time, and agrees to indemnify the physician and its members and managers against any claim, action, loss, or suit and associated costs (including attorney fees) which result either directly or indirectly from submission of a claim for any portion of the treatment to Medicare or any other government program.

Patient acknowledges that this agreement was executed before services were rendered, and that the patient is not facing an urgent or emergency health situation. Patient acknowledges that "Medigap" plans will not pay for the treatment as Medicare or any other government program will not pay therefore.

Please complete and sign this form authorizing Madison Longevity (Scott Pearlman, M.D. PLLC) to keep a credit card on file. Charges may include office visits, telehealth visits, telephone consultations, supplement orders, shipping and handling, copying of medical records, and outstanding balances. All information is used solely for billing and will not be released. This process is password-secured.