FRESH INFUSION, LLC CONSENT TO RECEIVE SERVICES The Undersigned hereby consents to the administration of intravenous or intramuscular vitamins, minerals, other nutrients, and/or IV medications. - I understand and acknowledge that the potential side-effects of this service may include, but not otherwise be limited to, the following:
-burning and stinging at the site of infusion or if IV infiltrates into surrounding tissue -allergic reactions (rare) -local thrombophlebitis (rare) -light headedness or fainting -Bruising, ecchymosis, or hematoma at the IV site -Weakness or fatigue - I understand and acknowledge that, prior to receive the service, I must disclose all past and present medical conditions, medications (including any controlled substances and/or illegal drugs) and/or treatments I currently am receiving, as well as answer any additional questions about my health and medical condition. I elect to receive this service without any expectation that it will diagnose, monitor or otherwise provide any care or treatment for any disclosed medical or health condition. I may stop receiving the service at any time.
- I acknowledge that it is my responsibility to contact my primary care physician for any health concerns prior to the infusion treatment(s) or any follow-up care warranted by the primary care physician.
- I understand and acknowledge that this service will not be billed to any insurance program or payor, and I agree not to seek reimbursement directly from any insurer or payor. I agree to be personally responsible for all costs associated with this service and will make payment at the time of service. I understand that, except in emergencies, I must give 24 hours’ notice of intent to cancel or reschedule my appointment. I understand that I will incur the full fee for the service, regardless of amount of product used, due to wasted materials.
THE RISKS INVOLVED AND THE POSSIBILITIES OF COMPLICATIONS HAVE BEEN EXPLAINED TO ME. I FULLY UNDERSTAND AND ACKNOWLEDGE THAT THE NATURE AND PURPOSE OF THE AFOREMENTIONED SERVICES MAY BE CONSIDERED UNPROVEN BY SCIENTIFIC TESTING AND PEER-REVIEWED PUBLICATIONS, AND THEREFORE, MAY BE CONSIDERED MEDICALLY UNNECESSARY OR NOT CURRENTLY INDICATED. I HAVE BEEN GIVEN AN OPPORTUNITY TO ASK QUESTIONS, AND ALL OF MY QUESTIONS HAVE BEEN ANSWERED TO MY SATISFACTION. I AGREE TO THE ASSUMPTION OF ALL RISKS ASSOCIATED WITH RECEIVING THE SERVICE. I EXPRESSLY REPRESENT AND WARRANT THAT I AM NOT A USER OF ILLEGAL DRUGS AND/OR CONTROLLED SUBSTANCES AND AM NOT UNDER THE INFLUENCE OF SAME OR RECOVERING FROM USE OF SAME AT THE TIME OF THE PROVISION OF SERVICES. I ACKNOWLEDGE AND AGREE THAT THE SOLE RISK OF INJURY OR HARM RESULTING IN ANY MANNER FROM CHOOSING TO RECEIVE THIS SERVICE RESTS ENTIRELY WITH ME TO THE EXTENT THAT I DO NOT DISCLOSE ALL HEALTH CONDITIONS, MEDICATIONS OR DRUG USE IN ADVANCE. I ACKNOWLEDGE AND UNDERSTAND THAT THE SERVICES ARE BEING PROVIDED IN RELIANCE UPON THE FOREGOING REPRESENTATIONS AND WARRANTIES. I WAIVE ANY CLAIM IN LAW OR EQUITY FOR REDRESS OF ANY GRIEVANCE THAT I MAY HAVE CONCERNING OR RESULTING FROM THE SERVICES, EXCEPT AS THAT CLAIM PERTAINS TO NEGLIGENT ADMINISTRATION. May 19, 2024 Notice of Privacy Practices 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. WE HAVE THE RIGHT TO MAKE CHANGES TO THIS NOTICE AT ANY TIME UPON NOTICE TO YOU PURPOSE OF THE NOTICE OF PRIVACY PRACTICES This Notice of Privacy Practices is provided to you as a requirement of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). HIPAA is about individual privacy, and you should read this document carefully. It describes how we may use and disclose your protected health information for purposes of 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 (PHI) is information about you, including demographic information, that may identify you and that relates to your past, present or future physical condition and related health care services, or payment for health care services. OUR LEGAL DUTIES REGARDING PROTECTED HEALTH INFORMATION If HIPAA applies to the services provided to you, we are required to follow the terms of this Notice of Privacy Practices. We understand that medical information about you and your health is personal. We are committed to protecting health information about you. In the course of conducting our medical practice business, we will create records regarding you and the treatment and services we provide to you. Your health record is the physical property of the healthcare provider that compiled it, but the content is about you, and therefore, belongs to you. We are required by law to: · Ensure protected health information that identifies you is kept private; · Give you this notice of our legal duties and privacy practices regarding your protected health information; · Follow the terms of the notice that is currently in effect; and · Notify you in the event of a breach of your PHI. HOW WE MAY USE AND DISCLOSE YOUR PROTECTED HEALTH INFORMATION Treatment: We will use and share your health information to ensure you are provided medical treatment and services. For example, we may share your health information with a doctor or hospital that is providing your health care. Payment: When and as appropriate, we may use and disclose medical information about you to determine your eligibility for benefits, to facilitate payment for the treatment and services you receive from health care providers, to determine benefit responsibility and coverage, or to coordinate your coverage. Health Care Operations: We will use and share your health information for our operations that are authorized by law. For example, we may share your health information with outside contractor to audit the compliance of our operations with regulations. Legal Requirements: We will share health information about you when required to do so by federal or states law. To Avoid Harm: We may use or share your health information to prevent a serious threat to your health and safety or the health and safety of others such as in abuse, neglect, domestic violence situation, or for law enforcement purposes. Health Oversight Activities: We will share health information with a health oversight agency for activities authorized by law. For example, audits, investigations, and inspections. Lawsuits and Disputes: We will share health information in response to a valid judicial or administrative order. Marketing and Sale of Health Information: We will not use or disclose your health information for marketing purposes, or sell your health information, without your written authorization. Business Associates: We may disclose your medical information to our business associates. We may contract with entities (defines as “business associates” under HIPAA) to help us administer our services. We will enter into contracts with these entities requiring them to only use and disclose your health information as we are permitted to do so under HIPAA. Workers’ Compensation: We may release medical information about you for workers’ compensation or similar programs. These programs provide benefits for work related injuries or illness. Disclosure to Others Involved in Your Care: We may disclose medical information about you to a relative, a friend, or to any other person you identify, provided the information is directly relevant to that person’s involvement with your health care or payment for that care. For example, if a family member or a caregiver calls us with prior knowledge of a claim and asks us to help verify the status of a claim, we may agree to help them confirm whether or not the claim has been received and paid. We also may disclose information to your personal representatives. For example, we can disclose information to your appointed health care power of attorney or your legal guardian. Military and Veterans: If you are a member of the armed forces, we may release medical information about you as required by military command authorities. We may also release medical information about foreign military personnel to the appropriate foreign military authority. YOUR RIGHTS REGARDING YOUR PHI The 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. Right to Confidential Communications: You have the right to request that our practice communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, at work, or email. In order to request a type of confidential communication, you must make a written request to our Privacy Official specifying the requested method of contact, or the location where you wish to be contacted. Our practice will accommodate reasonable requests. Right of Access to Inspect and Copy: You have the right to obtain and inspect a copy of your health information and billing records by a written request to Fresh Infusion. We may charge you a fee to obtain a copy of your records. Right to Correcting Health Information: If you believe that information about you is incorrect or incomplete, you can ask to amend the information by making a written request. We may say “no” to your request to correct a record if the information was not created or kept by us or if we determine the record is complete and correct. Right to a List of Certain Disclosures of Information: You have the right for a list of every time we shared medical information about you, other than certain circumstances, such as for treatment, payment, health care operations or where you have given us written permission for the sharing. Your request must be in writing to us. Right to Request That We Not Use or Share Your Health Information: You have the right to request that we not use or share your health information for treatment, payment, or health care operations. This would include your right to request that we not share your information with persons involved in your care except when specifically authorized by you. Your request must be given to us in writing, but we may not be legally required to agree to your request. For More Information or To Report a Problem: If you have a question about your privacy rights, would like additional information about content in this notice, or would like to file a complaint because you feel your privacy right have been violated you may contact Fresh Infusion directly. You will not be penalized for filing a complaint. You also may contact the U.S. Department of Health and Human Services, as follows: Centralized Case Management Operations U.S. Department of Health and Human Services 200 Independence Avenue, S.W. Room 509F HHH Building Washington, D.C. 20201 Email: OCRComplaint@hhs.gov Fax: (202) 619-3818 TDD: (800) 537-7697 This Notice is effective as of September 1, 2018
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