Terms & Conditions
Terms and conditions of NP in Family Health On Demand 24/7 PLLC
I understand that participating in intravenous (“IV”) hydration, vitamin/supplement administration, pharmaceutical administration, programs and services made available by NP In Family Health On Demand 24/7, PLLC (“IV DRIPS”) carries risks. Risks include, but are not limited to, injury, bleeding, infection, inflammation/swelling, bruising or scarring from IV infiltration, extraction and extravasation, misplacement of IV lines in the body, air embolism, fluid overload, medication adverse interactions, nerve injuries, lightheadedness or fainting. To the extent that I fail to disclose any of my health conditions, medications or drug use in advance, I acknowledge and agree that the sole risk of injury or harm resulting in any manner from my choosing to participate in such regiment, programs, and services rests entirely with me. I expressly represent to IV DRIPS that I have never been diagnosed with nor treated for any diseases, illnesses or conditions which may result in increased risk when I participate in regimens, programs or services made available by IV DRIPS. In addition, I am not choosing to participate with any expectation that IV DRIPS will screen for, diagnose, monitor, or otherwise provide any care or treatment for such conditions. I acknowledge and understand that IV DRIPS is relying upon the foregoing representations that I am providing to IV DRIPS in choosing to accept me for participation in its program(s) or service(s). I acknowledge that IV DRIPS made no warranties or guarantees as to the results or general success of the IV, vitamin/supplement administration, pharmaceutical administration, programs or any other services made available by IV DRIPS and all expressions made by IV DRIPS relative thereto, are opinions that should not be relied upon. I acknowledge that ancillary damages may occur to my property as a result of participating in IV hydration, vitamin/supplement administration, pharmaceutical administration, or any program/service made available by IV DRIPS. I hereby hold IV DRIPS entirely harmless and will fully indemnify IV DRIPS against all such damages.
I acknowledge that the services provided have not been evaluated by the US Food and Drug Administration. I acknowledge that these products are not intended to diagnose, treat, or cure any disease. I expressly represent and guarantee to IV DRIPS that I am not a user of illegal drugs or controlled substances and I am not under the influence of or recovering from any drugs or controlled substances at the time of any service provided to me by IV DRIPS. In the event of an emergency, I will be sure to call 911 or proceed to the nearest emergency room.
Acknowledgement: I confirm that I have read this form and fully understand its contents. I acknowledge that no guarantees or assurances have been made to me concerning the results intended from the sessions and programs offered by IV DRIPS. I understand the nature of the sessions and programs and that participating in them carries risks. I have been given an opportunity to ask questions, and all of my questions have been answered fully and to my satisfaction. I assume all risks associated with my participation.
Patient Authorization for Use and Disclosure of Protected Health Information: By signing this form, I authorize IV DRIPS to use or disclose certain personal information, if necessary. IV DRIPS may disclose (not limited to) the following: date(s) of service(s), type of service(s), any data source, age, gender, and, vital signs. The information will be used or disclosed for (i) research data to reflect growth, and (ii) any type of service requested by IV DRIPS’ current or prospective clients. This authorization expires one year from the date of service. IV DRIPS will not receive payment or other remuneration from a third-party in exchange for personal information. I understand I am not obligated to sign this authorization. When my information is used or disclosed pursuant to this authorization, it may be subject to redisclosure by the recipient and may no longer be subject to the HIPAA Privacy Rule when adhering to certain protocol. I hereby give IV DRIPS, and any employees or agents of IV DRIPS, the right and permission to use or publish any photographs taken of me for art or promotional purposes including, but not limited to, advertising, publicity, or commercial/display of use. I also authorize my pictures to be posted on social media (e.g., Facebook, Twitter, TikTok), including IV DRIPS’ website. I hereby release and discharge IV DRIPS and any related employee/agent from any legal or equitable claim originating from, but not limited to, (i) blurring of any image(s), (ii) alteration, (iii) distortion or use in composite form, (iv) libel, (v) invasion of privacy, or (vi) any claim based on the production or publishing of any material resulting from a service provided by IV DRIPS. I consent to IV DRIPS using my name, image or quote for any promotion and I understand all proprietary rights (e.g., property rights) is owned by IV DRIPS. I consent to using my name, image or quotes as determined by IV DRIPS in, but not limited to, media content (e.g., website or Facebook Page for IV DRIPS). consent to being enrolled in IV DRIPS Loyalty Program; Converted points can only be redeemed with drip purchase except free drip of choice. Redemption of rewards cannot be combined with other promotions. NAD+ and Ketamine excluded from 10% and 15% off reward. Loyalty Program benefits are non transferable.
Credit/Debit Card Authorization: By signing this form, I authorize IV DRIPS to debit my credit card provided for any product/service rendered and understand the authorization to be valid.
I consent to the above terms:
Print:________________ Sign:________________ Date:________________
HIPAA for NP in Family Health on demand 24/7 PLLC servicing IV DRIPS
This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present or future practitioner or mental health or condition and related health care services.
We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice, at any time. The new notice will be effective for all protected health information that we maintain at that time. Upon your request, we will provide you with any revised Notice of Privacy Practices. You may request a revised version by accessing our website, or calling the office and requesting that a revised copy be sent to you in the mail or asking for one at the time of your next appointment.
1. Uses and Disclosures of Protected Health Information
Your protected health information may be used and disclosed by your practitioner, our office staff and others outside of our office who are involved in your care and treatment for the purpose of providing health care services to you. Your protected health information may also be used and disclosed to pay your health care bills and to support the operation of your practitioner’s practice.Following are examples of the types of uses and disclosures of your protected health information that your practitioner’s office is permitted to make. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by our practice.
Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with another provider. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. We will also disclose protected health information to other practitioners who may be treating you. For example, your protected health information may be provided to a practitioner to whom you have been referred to ensure that the practitioner has the necessary information to diagnose or treat you. In addition, we may disclose your protected health information from time-to-time to another provider who, at the request of your practitioner, becomes involved in your care by providing assistance with your health care diagnosis or treatment to your practitioner.
Payment: Your protected health information will be used and disclosed, as needed, to obtain payment for your health care services provided by us or by another provider. This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services we recommend for you such as: making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities.
Health Care Operations: We may use or disclose, as needed, your protected health information in order to support the business activities of the practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, and licensing.
We will share your protected health information with third party “business associates” that perform various activities (for example, billing or transcription services) for our practice. Whenever an arrangement between our office and a business associate involves the use or disclosure of your protected health information, we will have a written contract that contains terms that will protect the privacy of your protected health information.We may use or disclose your protected health information, as necessary, to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you. You may contact our Privacy Officer to request that these materials not be sent to you.Other Permitted and Required Uses and Disclosures That May Be Made Without Your Authorization or Opportunity to Agree or Object.
We may use or disclose your protected health information in the following situations without your authorization or providing you the opportunity to agree or object. These situations include:
- Required By Law: We may use or disclose your protected health information to the extent that the use or disclosure is required by law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, if required by law, of any such uses or disclosures.
- Health Oversight: We may disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections.
- Additional situations include but not limited too: Abuse and neglect,. Criminal Activity, Workers’ Compensation, Communicable disease, Research approved by IRB, Public health, and Legal proceeding
Other uses and disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law as described below. You may revoke this authorization in writing at any time. Please understand that we are unable to take back any disclosures already made with your authorization.
Other Permitted and Required Uses and Disclosures That Require Providing You the Opportunity to Agree or Object
We may use and disclose your protected health information in the following instances. You have the opportunity to agree or object to the use or disclosure of all or part of your protected health information. If you are not present or able to agree or object to the use or disclosure of the protected health information, then your physician may, using professional judgment, determine whether the disclosure is in your best interest.
Others Involved in Your Health Care or Payment for your Care: Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your protected health information that directly relates to that person’s involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose protected health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition or death. Finally, we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care.
2. Your Rights
Following is a statement of your rights with respect to your protected health information and a brief description of how you may exercise these rights.You have the right to inspect and copy your protected health information. This means you may inspect and obtain a copy of protected health information about you for so long as we maintain the protected health information. You may obtain your medical record that contains medical and billing records and any other records that your practitioner and the practice uses for making decisions about you. As permitted by federal or state law, we may charge you a reasonable copy fee for a copy of your records. Depending on the circumstances, a decision to deny access may be reviewable. In some circumstances, you may have a right to have this decision reviewed. You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or health care operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.Your practitioner is not required to agree to a restriction that you may request. If your practitioner does agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment. With this in mind, please discuss any restriction you wish to request with your practitioner.You have the right to request to receive confidential communications from us by alternative means or at an alternative location. We will accommodate reasonable requests. We will not request an explanation from you as to the basis for the request. Please make this request in writing to us. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice electronically. You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. We will not retaliate against you for filing a complaint.
I read, acknowledge and agree to the above.