Good Faith Exam

Protocol for Midlevel Providers, Examiners, for the Good Faith Exam

1. Prior to Good Faith Examination (GFE) of Patient, the Examiner will:

a) be appropriately and professionally dressed for the GFE. Examiner will also

b) must ensure that the patient has signed consent forms, HIPPA forms, etc

c) will ensure that the patient is currently located in Texas during the telehealth exam,

as our license does not cover for out of state exams. A simple question of “Are you

currently in the state of Texas?” is sufficient. If they are not in the state of Texas,

then the exam cannot proceed and must be rescheduled. If they are in the State of

Texas, then you may proceed with the GFE

d) perform the GFE with both Examiner and patient in view on video call.

e) will be stationary in their location, not driving, or performing other tasks not

associated with the GFE currently taking place at the time of the video call.

f) provide 100% of their time and attention to the patient during the entirety of the

GFE.

2. During the GFE, the Examiner:

a) will ask the patient what services they are requesting to be performed by an

injector.

b) will have the full GFE questionnaire in front of them, whether in electronic or paper

form, and re-ask the patient all questions that the patient had previously answered

on-line. This will ensure no changes have occurred since the patient answered those

questions previously and to ensure all yes answers are addressed with patient.

Clarify what exactly the patient has answered yes to as there are multiple parts to a

specific question.

c) will document in the notes section of the GFE form all guidance, advice, and/or,

comments given to patient concerning all yes answers given on the GFE

questionnaire, or oral answers of “yes” upon re-questioning the patient.

d) will discuss plan with the patient including, diagnosis, recommended treatment plan

including max number of units allowed for each area being treated, instructions for

emergency and follow-up care. (Please see below in Exhibit A for specific details of

emergency and follow-up care).

e) will notify the patient of risks to the procedures being requested. Please see specific

risks of each procedure below in Exhibit B.

f) will ask the patient if they understood all the information given to the patient.

Examiner will also ask the patient if they have any concerns or questions about any

of the content covered during the GFE prior to ending the call with the patient.

3. After the GFE with the Patient, the Examiner will:

a) Contact the medical director, via email, phone call, or text, for any questions or

concerns about a patient and their good faith exam content, questions or answers

that the examiner was unable to answer or is unsure about.

b) document on the patients GFE form 1) approval or rejection of services requested

and the reason why if they are rejected 2) any and all yes answers given during the

Last Updated 8/5/2022 ©2022JeremyDrollinger 1GFE and the content covered and discussed with the patient for each yes answer,

3) an entire detailed treatment plan, including the areas to be treated, max number

of units for each area being treated, and that all risks, cautions of the procedure

were discussed and all questions by the patient were answered.

Exhibit A

In the event of an emergency, the patient should be told to:

1. call 911 for any and all serious and life-threatening events, including but limited to,

severe allergic reaction, including difficulty breathing, swelling of throat and face, chest

pain, arrhythmias, and severe bleeding that can’t be stopped, loss of consciousness,

vision changes and eye pain, any of which that develops during or after the injection

takes place.

For all other non-emergent, non-life-threatening situations, the patient should be told to:

1. Contact their injector and discuss with them their specific concerns

2. Seek medical care for all concerns for infection, which include increased swelling not

expected from the procedure, redness around injection sites, discharge of pus from

injection sites, fever.

3. Seek medical care for all concerns of vision changes, difficulty swallowing, rash, itching

Exhibit B

Risks associated with all injections, irrespective of the location of treatment, include:

1. Allergic reaction

2. Muscle weakness

3. Undesired results

4. Swelling

5. Bleeding

6. Bruising

7. Hematoma

8. Infection

Last Updated 8/5/2022 ©2022JeremyDrollinger 2Absolute contraindications to the injection of any neuromodulator include:

1. Any Neuromuscular disorder such as but not limited to, Myasthenia Gravis, Lambert

Eaton

2. Infection at any site of injection or near any site of injection

3. Pregnancy or breastfeeding

4. Allergy to albumin

5. Anyone opposed to the injection of blood products, which includes albumin, for any

reason

6. Significant Neurological disorder such as, but not limited to, Guillain Barre, Multiple

Sclerosis (MS)

7. Anyone taking the following medications:

a) Aminoglycoside antibiotics (Amikacin, gentamicin, tobramycin, streptomycin,

neomycin

b) Clindamycin

c) Quinidine

d) Cyclosporine

e) Succinylcholine or any other depolarizing or non-depolarizing blockers

f) Anticoagulants such as Warfarin or Lovenox

g) Retinol or Vitamin A skin products on the face within the last 3 months

8. Anyone mentally/psychologically unstable or history of any form of dementia or

Alzheimer’s Disease

9. History of allergic reaction to any previous injection of neuromodulator

10. History of previous neuromodulator injection within the last 2 weeks

Caution should be exercised with patients that:

1. Are taking any prescribed, Over the counter, or supplemental blood thinners such as,

but not limited to: aspirin, Motrin, ibuprofen, Toradol or ketorolac, any other NSAID,

Warfarin, Lovenox, Vitamin E, Ginkgo Biloba, cayenne peppers, garlic. Blood thinners

increase risk of bleeding, bruising, and hematoma formation and should be told to the

patient. Advise to apply more pressure than normal to areas of bleeding after injection

until bleeding stops. Ice may be applied to the area to help prevent bleeding and

bruising.

2. Have Diabetes Type 1 or Type 2 due to increased risk of infection. This increased risk of

infection should be discussed with the patient.

3. History of Cardia Disease including arrhythmias. Pts with this medical history are at

increased risk of cardiac events including heart attack and arrhythmias in the extremely

rare event that there is systemic spread of neuromodulator. This increased risk should

be discussed with the patient.

4. Have rods, screws, or any other hardware in the face. Location of this hardware should

be taken into consideration and avoided during injections.

5. History of herpes infection including Herpes 1, Herpes 2, Herpes zoster or shingles on

the face. Anyone with a history of these conditions should be advised to take

Last Updated 8/5/2022 ©2022JeremyDrollinger 3medication prescribed form their physician prior to injection in order to avoid a

breakout.

6. History of Keloids. Pt should be notified that keloids can form after skin injection and

there is an increased risk of keloid formation at the sites of injection. Keloids can occur

after any skin injury, such as with needle injection.

Any and all cautions specific to the patient should be discussed with patient. Discussion of these

risks and cautions is part of informed consent. This is a very important step in the process of

any medical procedure and cannot be skipped, minimized or glossed over. Your discussion with

the patient about their specific risks and cautions they should take also needs to be

documented in their record. If it isn’t documented, then it did not take place in the eyes of the

court in the case of litigation.

The above protocol must be followed by all midlevel providers who are providing Good Faith

Exams (GFE). The above protocol was written and approved by Dr. Jeremy Drollinger, Medical

Director. This protocol will be reviewed, at a minimum annually, and updated as the need arises

as part of the Quality Assurance Protocol.

Medical Director

Signature Date: 8/1/2022

Last Updated 8/5/2022 ©2022JeremyDrollinger 4

S & V Consulting LLC DBA Skys The Limit Wellness established in 2025. 

At Sky's The Limit Wellness Site ("we," or "us"), we value the privacy of individuals who use our websites and related services (collectively, our "Services"). This Privacy Notice explains how we collect, use, and share the personal information of users of our Services ("users," "you," or "your"). By using our Services, you agree to the collection, use, disclosure, and processing of your information as described by this Privacy Notice.

Personal information is information that identifies or could be used to identify a specific person. Personal information does not include deidentified information (anonymized or pseudonymized) or aggregated information derived from personal information.

We may collect a variety of personal information and other information about you or your devices from various sources, as described below.

Registration Information. If you sign up for an account, register to use our Services, or sign up for emails or other updates, we may ask you for basic contact information, such as your name, email address, phone number, and/or mailing address. We may also collect certain demographic information when you register for our Services, including your age, gender, personal interests, income, and/or marital status.

Communications. If you contact us directly, we may collect additional information from you. For example, when you reach out to our customer support team, we may ask for your name, email address, mailing address, phone number, or other contact information so that we can verify your identity and communicate with you. We may also store the contents of any message or attachments that you send to us, as well as any information you submit through any of our forms or questionnaires.

Events. If you register for an event that we host, whether in-person or online, we may collect relevant information such as your name, address, title, company, phone number, or email address, as well as specific information relevant to the event for which you are registering.

User Content. We may allow you and other Users of our Services to share their own content with others. This may include posts, comments, reviews, or other User-generated content. Unless otherwise noted when creating such content, this information may be shared publicly through our Services. 

Notice of Privacy Practices Including Photography

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND

DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT

CAREFULLY.

Understanding Your Health Record/Information

This notice describes the practices of Jeremy Drollinger, MD and its staff (collectively, "Practice"), and that

of any physician or provider with staff privileges with respect to your protected health information created

while you are a patient at Practice. Practice, physicians with staff privileges and personnel authorized to

have access to your medical chart are subject to this notice. In addition, Practice and physicians with staff

privileges may share medical information with each other for treatment, payment or health care operations

described in this notice.

The Practice utilizes a third-party organization, MySpaLive, LLC, for all administrative work such as, but not

limited to, use of their App for appointments and record keeping, including your protected health information,

use of their website, but MySpaLive, LLC is not directly involved with your medical treatment and care or

any medical decision making.

We create a record of the care and services you receive at Practice. We understand that medical

information about you and your health is personal. We are committed to protecting medical information

about you. This notice applies to all the records of your care at Practice.

This notice will tell you about the ways in which we may use and disclose medical information about you. It

also describes your rights and certain obligations we have regarding the use and disclosure of medical

information.

Your Health Information Rights

Although your health record is the physical property of Practice, the information belongs to you. You have the

right to:

• Request a restriction on certain uses and disclosures of your information for treatment, payment

and health care operations, and as to disclosures permitted to persons, including family members

involved with your care and as provided by law. However, we are not required by law to agree to a

requested restriction, unless the request relates to a restriction on disclosures to your health insurer

regarding health care items or services for which you have paid out of pocket and in full;

• Obtain a paper copy of this notice of information practices;

• Inspect and request a copy of your health record as provided by law;

• Request that we amend your health record as provided by law. We will notify you if we are unable to

grant your request to amend your health record;

• Obtain an accounting of disclosures of your health information as provided by law; and

• Request communication of your health information by alternative means or at alternative locations.

We will accommodate reasonable requests.

You may exercise your rights set forth in this notice by providing a written request to Jeremy Drollinger,

MD:

130 N. Preston Road #330

Prosper, TX 75078

Our Responsibilities

In addition to the responsibilities set forth above, we are also required to:

• Maintain the privacy of your health information;

• Subject to certain exceptions under the law, provide notice of any unauthorized acquisition, access,

use or disclosure of your protected health information, to the extent it was not otherwise secured;

• Provide you with a notice as to our legal duties and privacy practices with respect to information

we maintain about you;

• Abide by the terms of this notice; and

• Notify you if we are unable to agree to a requested restriction on certain uses and disclosures.

We reserve the right to change our practices and to make the new provisions effective for all protected

health information we maintain, including information created or received before the change. Should our

information practices change, we are not required to notify you, but we will have the revised notice available

upon your request at Practice.

Uses and Disclosures of Medical Information That Do Not Require Your Authorization

The following categories describe different ways that we may use and disclose medical information without

your authorization. We will explain what we mean for each category of uses or disclosures, but not every

use or disclosure in a category will be listed. However, all the ways we are permitted to use and disclose

information without your authorization should fall within one of the categories.

We will use your health information for treatment.

• For example: We may disclose medical information about you to doctors, nurses, technicians,

medical students or other personnel who are involved in taking care of you. We may share medical

information about you in order to coordinate different treatments, such as prescriptions, lab work

and x-rays. We also may provide your physician or a subsequent health care provider with copies

of various reports to assist in treating you once you are discharged from care at Practice.

We will use your health information for payment.

• For example: A bill may be sent to you or a third-party payer. The information on or accompanying

the bill may include information that identifies you, as well as your diagnosis, procedures and

supplies used.

We will use your health information for regular health care operations.

• For example: We may use the information in your health record to assess the care and outcome

in your case and others like it. This information will then be used in an effort to continually improve

the quality and effectiveness of the health care and services we provide.

We will use and disclose your health information as otherwise allowed by law. Examples of those uses and

disclosures follow:

• Business associates: There are some services provided in our organization through agreements

Notice of Privacy Practices

Date last updated: 8/8/2022

2with business associates. Examples include answering services and copy services. To protect your

health information, however, we require business associates to appropriately safeguard your

information.

• Notification: Unless you object, we may use or disclose information to notify or assist in notifying

a family member, a personal representative or another person responsible for your care about your

location and general condition.

• Individuals involved in your care: Unless you object, we may disclose to a family member,

another relative, a close personal friend or another person you identify the health information that

is directly relevant to that person's involvement in your health care or payment for your health care.

If you are not able to agree or object to such disclosure, we may disclose the information as

necessary if we determine it is in your best interest in our professional judgment.

• Disaster relief: We may use or disclose your health information to public or private disaster relief

organizations to coordinate your care or to notify your family or friends of your location or condition

in a disaster. We will provide you with an opportunity to agree or object to these disclosures when

practical.

• Research: We may disclose information to researchers when their research has been approved

by an institutional review board that has established protocols to protect the privacy of your health.

• Communications regarding treatment alternatives and appointment reminders: We may

contact you to provide appointment reminders or information about treatment alternatives or other

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

• Food and Drug Administration (FDA): We may disclose to the FDA health information relative to

adverse events with respect to food, medications, devices, supplements, products and product

defects, or post marketing surveillance information to enable product recalls, repairs or

replacement.

• Worker's compensation: We may disclose health information to the extent authorized by and to

the extent necessary to comply with laws relating to worker's compensation or other similar

programs established by law.

• Public health: As required by law, we may disclose your health information to public health or legal

authorities charged with preventing or controlling disease, injury or disability.

• Abuse, neglect or domestic violence: As required by law, we may disclose health information to

a governmental representative authorized by law to receive reports of abuse, neglect or domestic

violence.

• Judicial, administrative and law enforcement purposes: Consistent with applicable law, we

may disclose health information about you for judicial, administrative and law enforcement

purposes.

• Health oversight activities: We may disclose health information to a health oversight agency for

activities authorized by law, such as audits, investigations, inspections and licensure.

• Threats to health or safety: We may use or disclose health information as allowed by law if we

believe in good faith that it is necessary to prevent or lessen a serious and imminent threat to the

health or safety of a person or the public, or for law enforcement authorities to identify or apprehend

an individual involved in a crime.

• Special government functions: We may disclose health information to authorized federal officials

for intelligence, counterintelligence and other national security activities authorized by law, or for

protective services to the President of the United States or certain other government officials. If you

are a member of the military, we may disclose health information to military authorities under some

circumstances. If you are an inmate of a jail, prison or other correctional facility or in the custody of

law enforcement personnel, we may disclose health information necessary to maintain your health

and the health and safety of others.

 Required or allowed by law: We will disclose medical information about you when required or

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

• Electronic Health Information Exchange: Practice uses a third party to maintain our electronic

medical records (EMR). Practice stores electronic health information about you in the EMR.

Practice monitors who can view your EMR.

When We Need Your Written Authorization

We will not use or disclose your health information without your written authorization, except as described

in this notice. Additional circumstances that might require your additional written authorization are not

common, but an example would be uses and disclosures for marketing purposes.

Photographs, videotapes, digital or audio recordings, and/or images of the Patient, and any other method

to reproduce or edit such Patient’s likeness or image now known or hereafter developed (collectively,

“Photography”), taken by the Practice, will be recorded to document and assist with the Patient’s care and

to assist with Practice’s health care operations.

I understand that the Photography or a portion of the Photography may become part of my medical

record and therefore be protected, used and/or disclosed in accordance with Practice’s Notice of

Privacy Practices. I further understand that Practice will own the Photography and I will not receive

any payment for such Photography, but that I will be allowed to access or view the Photography or

to obtain copies of any portion of the Photography that becomes part of my medical record.

For More Information or to Report a Problem

If you have questions and would like additional information, you may contact Practice at 832-305-5668.

If you believe your privacy rights have been violated, you can send a complaint to the Director of Practice

at 130 N. Preston Road #330, Prosper, TX 75078 or to the Secretary of Health and Human Services.

There will be no retaliation for filing a complaint.

This notice is effective on the following date: 8/8/2022

We may change our policies and this notice at any time and have those revised policies apply to all the

protected health information we maintain. If or when we change our notice, we will post the new notice on

the MySpaLive Website where it can be viewed.

Notice of Privacy Practices

Date last updated: 8/8/2022

S & V Consulting LLC DBA Skys The Limit Wellness established in 2025.