Informed Consent For Services
I understand and I am informed that, as is with all Healthcare services, results are not guaranteed and there is no promise or implication to cure. I further understand and I am informed that, as is with all Healthcare services, in the practice of health/lifestyle consulting, primary care, wellness, physical therapy, infusion therapy, and any other health care and medical services we provide, there are some risks to care. I do not expect the provider to be able to anticipate and explain all risks and complications, and I wish to rely on the provider to exercise judgment during the course of the procedure which the provider feels at the time, based upon the facts then known, is in my best interests.
I hereby request and consent to the performance of health/lifestyle consulting and all other healthcare and medical services and/or other educational programs and procedures, including but not limited to Interview (history taking), Physical examination, Common diagnostic procedures (such as diagnostic imaging; laboratory evaluation of blood, urine, stool, and saliva; biofeedback; balance tracking; and movement screenings), Dietary advice and therapeutic nutrition (such as the therapeutic use of foods, dietary plans, nutritional supplements, intravenous and intramuscular injections), Dry Needling (insertion of specialized disposable stainless steel sterilized needles through the skin into underlying tissues at specific points on the body surface), nutraceuticals [also referred to as supplements] (such as the prescribing of various therapeutic substances including plant, mineral, and animal materials. Substances may be given in the forms of teas, pills, creams, powders, tinctures-which may contain alcohol, suppositories, topical creams or other forms.), various modes of physical therapy and any supportive therapies on me (or on the patient named below, for whom I am legally responsible) by the medical providers, therapists, and coaches and/or other licensed practitioners and support staff who now or in the future treat me while employed by, working or associated with or serving as healthcare provider and coach with Doctor Hero, including those working at the clinic or office listed or any other office or clinic where the consultation was performed, whether signatories to this form or not.
I understand and I am informed that in the practice of Functional Medicine, Regenerative, Aesthetics, Corrective Exercise, Health Coaching, Dry Needling, PRP, and Biohacking, as with all healthcare treatments there are risks and benefits with evaluation, diagnosis, and treatment including, but not limited to the following:
Potential Risks: pain, discomfort numbness or tingling near the needling sites that may last a few days, dizziness or fainting, minor bruising from dry needling as well as unusual risks such as spontaneous miscarriage, nerve damage, pneumothorax, allergic reaction to prescribed herbs, supplements, prescription medications, or an aggravation of pre-existing symptoms or conditions.
Potential Benefits: restoration of the body’s maximal functioning capacity, pain relief and symptoms of disease, assistance in injury and disease recovery, and prevention of disease or its progression.
Notice to pregnant women: all female patients must alert the provider if they know or suspect that they are or may be pregnant, since some of the therapies could present a risk to the pregnancy.
I have had an opportunity to discuss with the provider named below and/or with other office or clinic personnel the nature and purpose of care and procedures.
Accordingly, I understand that all payment(s) for treatment(s) are final and no refunds will be issued. However, prorated fees for unused, prepaid treatments will be refunded if I wish to cancel the treatment.
I further understand that there are treatment options available for my condition other than the offered options. I understand and have been informed that I have the right to a second opinion and secure other opinions if I have concerns as to the nature of my symptoms and treatment options.
Consent to TeleMedicine
Telemedicine involves the real-time evaluation, diagnosis, consultation on and treatment of a health condition using advanced telecommunications technology, which may include the use of interactive audio, video or other electronic media. As such, telemedicine allows the provider to see and communicate with the patient in real time. There are potential risks to this technology, including interruptions, unauthorized access and technical difficulties. I understand I can ask questions and seek clarification of the procedures and telemedicine technology at any time.
Consent for treatment: I voluntarily request Doctor Hero and its physicians, nurses, associates, technical assistants and other health care providers as it may deem necessary (collectively the “Practice”) to participate in my medical care through the use of telemedicine.
I understand that the Practice (i) may practice in a different location than where I present for medical care, (ii) may not have the opportunity to perform an in-person physical examination, and (iii) rely on information provided by me. I acknowledge that it is my responsibility to provide information about my medical history, condition and care that is complete and accurate to the best of my ability. I further acknowledge my failure to accurately and completely relay information about my medical history, condition and care may adversely impact the Practice’s advice, recommendations or decisions about my care. I understand that the practice of medicine is not an exact science and that no warranties or guarantees are made to me as to result or cure.
I understand that if the Practice determines in its reasonable professional judgment that telemedicine services will not adequately address my medical needs, I may be required to complete an in-person medical evaluation. I also understand that in the event the telemedicine session is interrupted due to a technological problem or equipment failure, alternative means of communication may be implemented, or an in-person medical evaluation may be necessary. Finally, if I experience an urgent matter after a telemedicine session, such as a bad reaction to a treatment, I should alert my treating physician and, in the case of emergencies, dial 911 or go to the nearest hospital emergency department.
Release of information: To facilitate the provision of care and/or treatment through telemedicine, I voluntarily request and authorize the disclosure of my Personal Information (defined below) to the Practice. I understand this disclosure may include my name, address, contact and demographic information, general health status and treatment information, images, individually identifiable health information or protected health information, and other information related to my health or condition (collectively “Personal Information”).
I understand that the disclosure of my Personal Information to the Practice, including the audio and/or video, will be by electronic transmission. Although precautions are taken to protect the confidentiality of this information by preventing unauthorized review, I understand that electronic transmission of data, video images and audio is new and developing technology and that confidentiality may be compromised by failures of security safeguards or illegal and improper tampering.
Right to withdraw consent: I understand that I have the right to withdraw my consent to the use of telemedicine in the course of my care at any time.
I have read this Telemedicine Consent in its entirety and agree to be bound by all of its terms and conditions as described above. I acknowledge and agree that I have been given the opportunity to ask any questions and have either (i) declined the opportunity to do so, or (ii) had all my questions answered to my satisfaction.
Off-Label Medication Consent
The off-label use of a medication is defined as the use of a medication, currently approved for use by the FDA, in a manner that is different than its approved use. Many medications are commonly used off-label. An example of this would be using certain blood pressure medications for controlling migraine headaches or treating acne.
Off-label use of medication is a legal and common practice for healthcare providers. Approximately 1 in 5 medications are prescribed off-label. You may be prescribed a medication for off-label use while you are under our care. In addition to this general information on off-label prescribing, you will receive specific instructions about any medication you may be prescribed and the intended use.
I have read and understand the information above. I have had the opportunity to ask questions, and if I had questions, they were answered to my satisfaction. I understand that any treatment by staff at Doctor Hero is voluntary and that I have the right to decline treatment or services. I acknowledge that by taking an off label medication or by participating in a treatment or services with off-label medications or devices, I am consenting to their use.
Consent To Share Images And Content
I, as the patient, identified above or the legal representative of such patient (“Patient”), have consented to the taking of photographs, videotapes, digital or audio recordings, and/or images of Patient, and any other method to reproduce or edit such Patient’s likeness or image now known or hereafter developed (collectively “Photography”), by Doctor Hero and its staff (collectively the “Practice”) which will be part of my medical record. I also understand that the Photography that identifies the Patient can be released and/or used outside the Practice only upon written authorization from me.
The Practice desires to utilize the Photography for purposes of professional publications, training, education, or clinical evaluation as well as on social media, including posting on social media accounts, including, but not limited to the Practice’s website and social media platforms (“Social Media”) and including such use in the Practice’s email marketing campaigns, both of which will result in the publication and distribution of protected health information to the general public. The Practice IS NOT receiving direct or indirect remuneration from a third party in connection with the use/disclosure of the protected health information described in this authorization.
I understand that the Photography will be used on the Practice’s website, social media, and email marketing, in which I have agreed to participate as a patient of the Practice. I further understand that the use of the Photography in Social Media and marketing may incidentally disclose additional protected health information related to my treatment, condition, procedure, or other protected health information associated with such use, and I authorize such disclosure. I also understand that the use of the Photography can be released and/or used outside the Practice only with my written authorization.
I understand that I have the right to revoke this authorization, in writing, at any time by sending such written notification to the Practice’s privacy officer. I understand that a revocation is not effective to the extent that the Practice has relied on the use or disclosure of the protected health information. I understand that, except as otherwise provided in this authorization, the Practice may use or disclose my protected health information in accordance with the Practice’s Notice of Privacy Practices. I understand that information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) or other applicable laws or regulations.
I specifically agree that the Practice shall have the right to interview, consult with and examine me at such times as the Practice may reasonably request before, during and after my procedure, and that the Practice shall have the right to use such interviews, consultations, or examinations on Social Media. I understand that such use may result in these interviews, consultations and examinations being disclosed in the public domain.
I understand the Practice does not condition treatment or payment on the signing of this form. I understand that I will not be entitled to any payment or other form of remuneration from the Practice as a result of any use of Photography.
I understand that I may revoke or withdraw this permission at any time to prohibit future use of my information. To do so, I must send written notice to Practice’s privacy officer. I understand that a revocation is not effective to the extent that the Practice has relied on the use or disclosure of the protected health information. This authorization is valid until the earlier or the occurrence of the death of Patient; Patient reaching the age of majority; or permission is withdrawn.
I release and hold harmless the Practice, its officers, staff and employees from any and all claims or causes of action that I may have of any nature whatsoever, which may in any manner result from use of the Photography. I understand that the Practice will not condition my treatment or payment on whether I provide authorization for the requested use.
HIPAA Privacy Standards
Patient Consent for Use and Disclosure of Protected Health Information
I hereby give my consent for Doctor Hero to use and disclose protected health information (PHI) about me to carry out treatment, payment and health care operations (TPO). (The Notice of Privacy Practices provided by Doctor Hero describes such uses and disclosures more completely.)
I have the right to review the Notice of Privacy Practices prior to signing this consent. Doctor Hero 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 Doctor Hero.
With this consent, Doctor Hero 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, Doctor Hero 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, Doctor Hero may e-mail or 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 Doctor Hero 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.
By signing this form, I am consenting to allow Doctor Hero to use and disclose my PHI to carry out TPO.
I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, Doctor Hero may decline to provide treatment to me.
Financial Agreement Health Insurance
We would like to take a moment to welcome you to our office and assure you that you will receive the very best of care available for your condition. In order to familiarize you with the financial policy of this office we would like to explain how your medical bills will be handled.
Explanation of Insurance Coverage:
Many insurance policies do cover clinical services and our office makes a great effort to inquire into your benefits. However, we can not guarantee coverage from our inquiries. Because of the variance from one insurance to another, we require that you, the patient, be personally responsible for the payment of your deductibles, as well as any unpaid balances in this office. We can verify coverage and provide you with the necessary documentation to pursue reimbursement.
Assignment of Benefits:
By signing this form you are authorizing payment of medical benefits to be made directly to this office. If your insurance carrier sends payment to you for services incurred in this office, you agree to send or bring those payments to this office upon receipt. You understand that you are responsible to pay all non-insurance related fees when services are rendered. If you choose to use your insurance you understand that you will be responsible for all “non covered” services and /or coinsurance/co-pays associated with your office visit.
Release of Information:
By signing this form you are also authorizing, upon request from your insurance carrier, the release of any medical or other information necessary to process the claim by this office. You also acknowledge and request payment of government benefits either to myself or to the party who accepts assignment, namely the Practice.
Voluntary Termination of Care:
You may suspend or terminate your care at any time.
We hope this answers any questions you might have concerning the financial policy of this office. Once again we welcome you to our office, and will be glad to answer any further questions that you might have.
Cancellation Policy
When you schedule an appointment with us this appointment time is set aside especially for you and is not available to other patients. Therefore, it is important that you let your practitioner know as soon as possible if you will be unable to come to your scheduled appointment. This allows us to make this time available to other patients.
We request that you give at least 24 hours notice if you need to cancel or reschedule your appointment. Please understand that if you do not provide adequate notice, you will be charged a $50 fee for the missed appointment.
Late Appointments
We do our very best to stay on schedule.
Late appointments are a challenge to maintaining a schedule. Arriving 20 minutes late may result in a cancelled appointment for which we will charge the above mentioned fee. If you know you are going to be late, please let us know, and we will try our best to accommodate.
I, the undersigned, have read and understand the above cancellation policy.
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Communications
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Newsletters
In addition to providing services, our goal is to educate our patients. We would like to invite you to join our newsletter, which covers an array of topics dealing with health and updates on other services we offer
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