Telehealth Consent & Authorization to Use and Disclose Medical Information

Effective Date: December 10, 2025
By clicking “I Agree,” checking a consent box, or affirmatively accepting this document, you confirm that you have read, understand, and agree to the terms outlined below. If you do not agree, do not use our telehealth services or submit any personal information.

1. Authorization to Use and Disclose Medical Information

By accepting this Consent, you authorize Manna Life, including its licensed healthcare providers, wellness practitioners, clinical support staff, and pharmacy partners, to collect, use, and disclose your medical and personal information—including protected health information (“PHI”)—for purposes related to:

  • Providing telehealth-based medical and wellness services

  • Reviewing your history and developing personalized care plans

  • Communicating with you about appointments, follow-ups, and wellness education

  • Coordinating prescription fulfillment with licensed U.S. pharmacies

  • Processing payments and managing billing

  • Complying with healthcare regulations and legal requirements

Your health information may include—but is not limited to—medical history, wellness assessments, lab results, treatment records, and communications with your provider. Sensitive categories of data, including mental health, reproductive health, substance use, and communicable disease information, may also be disclosed when necessary for your care.
While HIPAA protects your PHI, information disclosed to certain third parties may be subject to re-disclosure and may no longer be protected under federal privacy law.

2. Pharmacy Information & Consent to Fulfill Prescriptions

If a Manna Life provider determines that a prescription is medically appropriate, it may be transmitted to a licensed U.S. pharmacy for fulfillment.

Current Pharmacy Partner

Compounding Pharmacy of America
5710 Kingston Pike, Suite A
Knoxville, TN 37919
Phone: (865) 243-2488
Website: www.compoundingrxusa.com

By agreeing to this Consent, you authorize Manna Life to share your prescription and relevant health information with this pharmacy—or another licensed pharmacy—to prepare, dispense, and ship your medication.

You may request to have your prescription transferred to a pharmacy of your choice at any time by contacting our support team.

3. Consent to Telehealth Services

You consent to receive healthcare and wellness services via telehealth, which may include:

  • Video consultations

  • Audio consultations

  • Secure electronic messaging

  • Remote review of medical records and lab results

  • Wellness coaching and education

Telehealth services may be provided by licensed physicians, nurse practitioners, physician assistants, and other qualified clinical professionals.

You understand that:

  • Telehealth may not replace in-person care in every situation.

  • You may decline or discontinue telehealth services at any time.

  • You are responsible for sharing accurate and complete health information.

  • Providers may not be able to fully examine or evaluate certain conditions remotely.

  • There is no guarantee of outcomes, symptom changes, or treatment success.

Telehealth is designed to enhance access to care but has limitations that may affect decision-making.

4. Data Protection & Privacy

Manna Life uses secure, encrypted, HIPAA-compliant systems to store, transmit, and protect your personal and health data. Measures include administrative, physical, and technical safeguards designed to prevent unauthorized access.
Communications may include appointment reminders, follow-ups, wellness guidance, and service-related updates delivered via:

  • Email

  • Phone or SMS

  • Patient portal messaging

Your Rights Include the Ability to:

  • Request a copy of your health records

  • Update or correct your personal information

  • Revoke this consent at any time by submitting a written request to info@mannalife.com

Revoking consent will not affect actions taken before your request was received.

5. Acknowledgments

By consenting, you confirm that:

  • You are at least 18 years of age

  • You understand and voluntarily agree to receive telehealth services

  • Your provider will use professional judgment to determine when telehealth is appropriate

  • You understand the risks and limitations of telehealth care

  • You may seek in-person care, use a different pharmacy, or engage a different provider at any time

  • You are financially responsible for all services received from Manna Life, which are not submitted to Medicare or insurance

6. Emergencies & Crisis Situations

Telehealth is not appropriate for medical or mental health emergencies.
If you are experiencing an emergency, please immediately:

  • Call 911, or

  • Call the 988 Suicide & Crisis Lifeline

Manna Life does not provide crisis intervention or emergency medical services.

7. Expiration of Consent

This Consent remains valid for one (1) year from the date of acceptance, unless you revoke it in writing sooner. Revoking consent may limit our ability to continue providing care.

Questions or Contact

For questions about this Consent, data privacy, or your rights, contact:

Manna Life
Email: info@mannalife.com
Phone: 509-349-3010