THERAPY CONSENT FORM
General. This document shall serve as informed consent (“Consent”) to receive services from IVNation, LLC (“IVNation”), and must be completed before such services may be rendered. These services include, but are not limited to, the intravenous (IV) infusion of fluids, vitamins, minerals and medications, intramuscular (IM) injection of vitamins, minerals and medications, as well as all other treatments agreed upon by myself and the IVNation medical staff and ordered by the supervising medical practitioner. These services are offered solely under my agreement to the terms and conditions set forth in this Consent and IVNation operating policies. By signing this Consent, I acknowledge agreement to its content without modification, having the opportunity to have my questions addressed regarding services offered, and authorize consent to treatment by IVNation.
Informed Consent. I am aware of my right to be informed about IVNation’s services and treatments, as well as their risks and alternatives. I acknowledge that I have had the opportunity to review this information and ask any questions that I may have before consenting to services provided by IVNation.
Results. I acknowledge that IVNation makes no claims or guarantees with regard to the results of services provided. While there are studies that support possible benefits of such services, I understand that clinical results may vary. Services offered by IVNation are not intended to diagnose, treat, cure or prevent medical diseases and are not an alternative to medical evaluation and treatment by a physician. Rather, the services provided by IVNation may provide patient with symptomatic improvement of certain conditions and/or help them achieve a certain goal with regard to their overall health and wellness.
Medical Disclosure. I have disclosed all medical history requested by IVNation, including, but not limited to, any chronic medical diseases, surgical history, current medications and supplements that I am taking and any known allergies to drugs or substances. I understand that some services offered by IVNation may cause complications with regard to certain medical conditions or history, including, but not limited to:
I am aware that IVNation will not be screening or testing for, diagnosing, treating or curing said medical conditions. My failure to disclose my full medical history to IVNation and /or to accurately answer the questions IVNation asks regarding my health may result in IVNation not being able to make an informed decision as to the appropriate services to be provided to me and such an event could have disastrous effects upon my health.
Risks. Many services offered by IVNation that I may choose to receive involve the administration of fluids and other medications and substances directly into a vein through an IV (intravenous) catheter placed by a licensed health professional. Though uncommon, I do acknowledge understanding that this procedure carries inherent risks, which include, but are not limited to:
I have been given the opportunity to ask any questions regarding the treatments and risks as well as alternatives prior to my consensual receipt of the services.
I recognize that IVNation and its staff cannot anticipate all potential risks and complications but will use their professional judgment during the course of my service should any unforeseen complications arise.
In the event of any complications following receiving services from IVNation, I will call or proceed to the nearest emergency room. I will also provide information to IVNation as to the complications and the follow up care I have received..
Payment And Insurance. I am responsible for payment in full of all services that I choose and receive from IVNation prior to initiation of said services. I acknowledge that IVNation does not accept any medical insurance plans or payments including Medicare, and therefore will not be responsible for providing any assistance in processing my claim unless required by applicable law
Exclusion From Services. I understand that IVNation may refuse rendering of services to me under certain circumstances which include, but are not limited to, my willful misrepresentation of my identity, age or medical history, or my being under the influence of alcohol or illicit drugs or any other reason as determined by IVNation. I acknowledge that fees for any such services that are begun but not completed will not be reimbursed under these circumstances and I will be responsible for payment in full.
Termination Of Services. I understand that I may elect to terminate services provided by IVNation at any time before or during their administration but that I will still be responsible for payment in full for said services. IVNation and its staff reserve the right to terminate service(s) at any point, with or without cause and without prior notice if deemed appropriate in their professional judgment.
Attestation. By signing below, I acknowledge that I have received this Consent and reviewed it in its entirety. I have had the opportunity to ask all questions pertaining to this Consent, IVNation services and policies, as well as to consider my receiving of consensual inclusion in the services offered by IVNation. I am aware of the potential risks posed by receiving these services After review, I consent to receive the service(s) agreed upon by myself and IVNation.
Printed Name of Patient: _________________________
Print Name of Person Signing Consent (if not patient): _________________________
Relationship to Patient (Parent/Guardian): _________________________
Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
This Notice of Privacy Practices (“Notice”) describes the privacy practices of IVNation, LLC (“We” or “IVNation”). While IVNation is not a “covered entity” under the privacy and security rules adopted pursuant to the federal Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and therefore is not required to comply with HIPAA, but is required to comply with other applicable laws governing the privacy of your health information (“Protected Health Information” or “PHI”), IVNation is taking steps to provide privacy protections to your Protected Health Information.
I. INTRODUCTION. Certain laws provide you with certain basic rights and protections in connection with health information maintained about you. IVNation is required by law to maintain the privacy of your Protected Health Information and is providing you with notice of its legal duties and privacy practices with respect to your Protected Health Information. Some examples of Protected Health Information may include information about your past, present or future physical or mental health condition, or information about your health care benefits under an insurance plan, each when combined with identifying information such as your name, address, social security number or phone number. (Please note that not all of such information will necessarily be maintained by IVNation about you.) While IVNation may voluntarily follow some of the HIPAA requirements (as IVNation is not required to comply with HIPAA), IVNation shall comply with any other federal or state law requirements that may govern your Protected Health Information. IVNation reserves the right to change, modify or otherwise revise this Notice at any time. Please note that IVNation has decided to use some terms from HIPAA and such terms will be identified as having the same definition under HIPAA for convenience even though IVNation is not required to comply with HIPAA.
II. USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION. There are some situations when We do not need your written authorization before using your Protected Health Information or sharing it with others as briefly explained below.
Treatment: We may use and disclose your PHI to provide, coordinate, or manage your health care and any related services. For example, your Protected Health Information may be provided to a treating provider to ensure that the provider has the necessary information to diagnose or treat you.
Payment: Your Protected Health Information may be used, as needed, to obtain payment for your health care services after IVNation has treated you. For example, we may submit information for collecting payment for services provided.
Healthcare Operations: We may use or disclose your Protected Health Information in order to support the business activities of IVNation. For example, IVNation may use your Protected Health Information for quality assessment, employee review, training of providers, licensing, and conducting or arranging for other business activities of IVNation.
Business Associates: We may disclose your Protected Health Information to contractors, agents and other “business associates” (As such term is defined under HIPAA) who need the information in order to assist us with obtaining payment or carrying out our business operations. For example, an accounting firm that provides professional advice to us are considered that involves Protected Health Information would be our business associate.
General Uses and Disclosures: We may use or disclose your Protected Health Information to the extent that law requires the use or disclosure including but not limited to the following purposes: (i) public health activities and purposes to a public health authority; (ii) to a person/company subject to the jurisdiction of the U.S. Food and Drug Administration (“FDA”); (iii) to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition; (iv) to a public health authority that is authorized by law to receive reports of abuse or neglect; (v) to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections; (vi) in the course of a judicial or administrative proceeding in response to an order of a court or administrative tribunal; (vii) for law enforcement purposes; (viii) to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law; (ix) if We believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public; (x) use or disclose the Protected Health Information of individuals who are Armed Forces personnel and to disclose your Protected Health Information to authorized federal officials for conducting national security and intelligence activities; (xi) to comply with workers’ compensation laws and other similar legally established programs and/or as may be required by your workers compensation insurance coverage; (xii) if you are an inmate of a correctional institution or under the custody of a law enforcement official to such institutions; (xiii) for research purposes; (xiv) to provide legally required notices of unauthorized access to or disclosure of your Protected Health Information that may include appropriate governmental agencies; (xv) to the Secretary of the Department of Health and Human Services to investigate or determine IVNation’s compliance with the requirements of applicable law and regulations; and (xvi) if you need emergency treatment or if We are required by law to treat you. While We will take reasonable steps to safeguard the privacy of your Protected Health Information, certain disclosures of your Protected Health Information may occur during or as an unavoidable result of our otherwise permissible uses or disclosures of your Protected Health Information.
III. USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION PERMITTED WITHOUT AUTHORIZATION BUT WITH AN OPPORTUNITY FOR YOU TO OBJECT. We may use or disclose your Protected Health Information for any of the purposes described in this section unless you affirmatively object to or otherwise restrict a particular release. Please direct any written objections or restrictions to the Privacy Officer.
Appointment Reminders and Health-related Benefits and Services: We may use or disclose your Protected Health Information, as necessary, to contact you to remind you of your appointment [To discuss] and inform you about treatment alternatives or other health-related benefits and services that may be of interest to you. If We use or disclose your Protected Health Information for fundraising activities, We will provide you the choice to opt out of those activities. You may also choose to opt back in.
Messages: In order to communicate with you regarding your health care, We may leave messages on your answering machine or with family or friends who may answer your phone with some of your Protected Health Information. [To discuss]
Treatment Alternatives/Health-Related Benefits: We may use and disclose your Protected Health Information to tell you about or recommend possible treatment options or alternatives that may be of interest to you and about health-related benefits or services that may be of interest to you.
Individuals Involved in Your Care or Payment for Your Care: We may release your Protected Health Information about you to any person We determine in IVNation’s reasonable discretion, to be involved in your care and/or payment. In addition, We may disclose Protected Health Information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location.
IV. USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION THAT REQUIRE YOUR AUTHORIZATION. All other uses and disclosures of your Protected Health Information not covered by the preceding categories or as permitted or required under applicable law will be made only with your written authorization. Examples of some uses and disclosures requiring your authorization include: (i) sale of your health information (except as permitted under the law; and (ii) other uses or disclosures not permitted or required as set forth in this Notice or as required under applicable law.
V. PATIENT RIGHTS.
Right to Inspect and Copy Records: You have the right to inspect and copy your Protected Health Information that is contained in a “Designated Record Set” (as defined under HIPAA). To inspect and copy your Protected Health Information, you must submit your request in writing to the Privacy Officer. If you request a copy of your Protected Health Information, We may charge a fee for the costs of copying, mailing and other supplies associated with your request as permitted by applicable law. We may deny all or part of your request to inspect and copy your Protected Health Information in certain very limited circumstances as set forth under applicable state or federal law.
Right to an Electronic Copy of Electronic Medical Records: You have the right to request that an electronic copy of your record be given to you or transmitted to another individual or entity. We will make every reasonable effort to provide access to your Protected Health Information in the form or format you request if it is readily producible in such form or format. Ask the Privacy Officer what is required to make the request. We will provide the copy within thirty (30) days of your request. We may charge a reasonable, cost based fee as permitted under applicable law.
Right to Amend Records: If you feel that any of the information We have about you is incorrect or incomplete, you may ask IVNation to amend such information. Ask IVNation’s Privacy Officer how to make such a request. We may deny your request under certain conditions permitted under applicable law but we will notify you the reason why within sixty (60) days of your request.
Right to an Accounting of Disclosures: You may request an “accounting of disclosures” of your Protected Health Information except for disclosures made with you or your personal representative’s written authorization for purposes of treatment, payment, healthcare operations; required by law, or six (6) years prior to the date of the request (or the lesser period of time if IVNation has not provided services to you for at least six (6) years). To obtain a request form for an accounting of disclosures, please write to IVNation’s Privacy Officer. You may receive an accounting of certain disclosures of your Protected Health Information made by IVNation in the six (6) years prior to the date on which the accounting is requested request (or the lesser period of time if IVNation has not provided services to you for at least six (6) years). Such accounting may be subject to other conditions set forth under applicable law. We will provide one (1) accounting free of charge per every twelve (12) months. We may charge a reasonable, cost based fee for any additional accountings provided within a twelve (12) month period.
Right to Receive Notification of a Breach: You have the right to be notified no later than sixty (60) days (or sooner as required under applicable law) of the discovery of a breach of your unsecured Protected Health Information in accordance with applicable law.
Right to Request Restrictions: You have the right to request restrictions or limitations on the Protected Health Information We use or disclose about you for treatment, payment or health care operations we will agree to such restrictions or limitations to the extent reasonable and required under applicable law. Your request for restrictions should be made in writing to the Privacy Officer.
Right to Request Confidential Communications: You have the right to request that We communicate with you about health matters by alternative means or at alternative locations. Any such request must be made in writing to the Privacy Officer and must specify how or where you wish to be contacted. We will not ask you the reason for your request and will accommodate all reasonable requests.
Right to Have Someone Act on Your Behalf: You have the right to name a personal representative who may act on your behalf to control the privacy of your Protected Health Information.
Right to Obtain a Copy of Notices: If you are receiving this Notice electronically, you have the right to a paper copy of this Notice. Also, you may ask IVNation to give you a copy of this Notice at any time.
Use and Disclosures Where Special Protections May Apply: Some kinds of information, such as alcohol and substance abuse treatment, HIV-related, mental health, psychotherapy, and genetic information, are considered so sensitive that state or federal laws provide special protections for them. Therefore, some parts of this general Notice may not apply to these types of information if other federal or state laws require additional restrictions or other requirements and IVNation members shall comply with all such applicable laws and this Notice shall be deemed to include the additional protections required by such laws.
VI. COMPLAINTS. If you believe your privacy rights have been violated, you may file a complaint with IVNation or with the New Jersey State Board of Medical Examiners. To file a complaint with IVNation, contact the Privacy Officer listed below. All complaints must be submitted in writing. You will not be penalized for filing a complaint. Neither IVNation nor any of its personnel shall retaliate against you for filing such a complaint. The New Jersey State Board of Medical Examiners can be contacted at:
P.O. Box 183
Trenton, NJ 08625
|For Delivery Services
140 East Front Street
Trenton, New Jersey 08608
|Telephone (609) 826-7100
Fax (609) 826-7117
VIII. PRIVACY OFFICER CONTACT INFORMATION. Questions, comments and requests regarding the matters described in this Notice should be directed to Privacy Officer:
attn: Howard Wilensky
100 Springdale Road, Suite 3
Cherry Hill, NJ 08003
IVNATION CANCELLATION POLICY