Terms & Conditions

Terms and conditions of NP in Family Health on Demand 24/7 PLLC servicing IVDRIPS

I understand that participating in IVDRIPS which is intravenous (IV) hydration, vitamin/supplement administration, pharmaceutical administration, programs and services made available by NP In Family Health On Demand 24/7, PLLC carries risks. Risks include, but are in no way limited, to the following: injury, bleeding, infection, inflammation/swelling, bruising or scarring resulting 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.

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, to the extent that I fail to disclose any of my health conditions, medications or drug use in advance.

I expressly represent and warrant to NP In Family Health On Demand 24/7, PLLC 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 NP In Family Health On Demand 24/7, PLLC, and I am not choosing to participate with any expectation that NP In Family Health On Demand 24/7, PLLC will screen for, diagnose, monitor or otherwise provide any care or treatment for such conditions.

I acknowledge and understand that NP In Family Health On Demand 24/7, PLLC is relying upon the foregoing representations and warranties that I am providing to NP In Family Health On Demand 24/7, PLLC in choosing to accept me for participation in its programs and services.

I acknowledge that the NP In Family Health On Demand 24/7, PLLC has made no warranties or guarantees as to the results or general success of the intravenous (IV) hydration, vitamin/supplement administration, pharmaceutical administration, programs or any other services made available by NP In Family Health On Demand 24/7 and all expressions made by NP In Family Health On Demand 24/7, PLLC 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, programs and services made available by NP In Family Health On Demand 24/7, PLLC including, but not limited to, damages caused by blood staining my property. I hereby hold NP In Family Health On Demand 24/7, PLLC entirely harmless and fully indemnify NP In Family Health On Demand 24/7, PLLC against all such damages.

I acknowledge that the services provided have not been evaluated by the FDA. I acknowledge that these products are not intended to diagnose, treat or cure any disease. I expressly represent and warrant to NP In Family Health On Demand 24/7, PLLC that I am not a user of illegal drugs and/or controlled substances and I am not under the influence of same or recovering from use of same at the time of the provision of services to me. 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 NP In Family Health On Demand 24/7, PLLC. I understand the nature of the sessions and programs and that participating in them carries risks. I have been given contact information to to ask any questions, and opportunity to ask any questions and all of my questions have been answered fully and to my satisfaction. I agree to my assumption of all risks associated with my participation.

Patient signature:____________________________________________________

Insurance Not Accepted; Client’s Responsibility for Payment.Clients will be BILLED DIRECTLY and shall be personally responsible for payment, regardless of whether clients are reimbursed by their insurance company, managed care plan or other third party payer.

NP in Family Health on Demand 24/7 does NOT diagnose or treat any illness, disease or health condition.

Patient Authorization for Use and Disclosure of Protected Health Information

I authorize NP In Family Health On Demand 24/7, PLLC to use and/or disclose certain protected health information (PHI) about me to carry out treatment, payment and health care operations (TPO). This authorization permits NP In Family Health On Demand 24/7, PLLC to use and/or disclose the following individually identifiable health information about me include, but are not limited to: Date(s) of services, type of services, origin of information, age, gender, and vital signs. The information will be used or disclosed for the following purpose: Obtaining research data to reflect growth, sales, and types of services requested by our client population. The purpose is provided so that I can make an informed decision whether to allow release of the information. NP in Family Health on demand 24/7 PLLC reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to NP in Family Health on demand 24/7 PLLC. With this consent, NP in Family Health on demand 24/7 PLLC may call my home or other alternative location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any calls pertaining to my clinical care, including laboratory test results, among others. With this consent, NP in Family Health on demand 24/7 PLLC may mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements as long as they are marked “Personal and Confidential.” With this consent, NP in Family Health on demand 24/7 PLLC may e-mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements. I have the right to request that NP in Family Health on demand 24/7 PLLC restrict how it uses or discloses my PHI to carry out TPO. The practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.

This authorization will expire two (2) years from date of service. The practice will not receive payment or other remuneration from a third party in exchange for using or disclosing the PHI. l do not have to sign this authorization in order to receive treatment from NP In Family Health On Demand 24/7, PLLC. In fact, I have the right to refuse 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 protected by the federal HIPAA Privacy Rule. I have the right to revoke this authorization in writing except to the extent that the practice has acted in reliance upon this authorization.

HIPPA for NP in Family Health on demand 24/7 PLLC servicing IVDRIPS

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:

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.