THIS PAGE IS FOR REFERENCE ONLY, AND IS EXECUTED WITH THE PATIENTS SIGNATURE DURING THEIR INITIAL VISIT.
I. Acknowledgement of Payment And Cancellation Policy
By my signature below, I understand, acknowledge, and agree that I am fully responsible for payment of services provided to me by VITALIS METABOLIC HEALTH, PLLC (“Vitalis”) and that co-pays and deductibles or self-pay payment must be made in full by cash or credit card at or before the time of service.
I understand that treatment and services provided by Vitalis may not be covered by my insurance. If this occurs, Vitalis will provide information to me to assist me in my claim for reimbursement to my insurance carrier but will not submit claims to insurers on my behalf. I further acknowledge and agree that if I choose to submit any bill or itemized receipt to an insurance carrier for reimbursement for these services, that Vitalis is exempt from any dispute regarding reimbursement.
Please remember that you are 100 percent responsible for all charges incurred: your physician’s referral and our verification of your insurance benefits are not a guarantee of payment. We highly recommend you also contact your insurance carrier and check into your coverage for medical weight loss treatment. Do not assume that you will not owe anything if you have more than one insurance policy.
To fairly and effectively serve patients who wish to receive treatment, the following cancellation policy has been implemented. By your signature below you acknowledge and agree to the following cancellation policy:
Office visits must be cancelled at least 24 hours in advance. Any cancellations with less than 24 hours advance notice, or not arriving to your appointment before 15 minutes after the scheduled start time, will count as a No Show. You will be given three No Shows. After the third No Show we will terminate our physician-patient relationship and no longer provide you services. Communications regarding this policy will be made over the phone during the cancellation or via phone or email after a no show occurs. This termination will be sent to you via certified mail to the address we have on file.
II. Consent to Email And Electronic Communication
It may become useful during the course of treatment to communicate by email, text, or other electronic methods of communication. Be informed that these methods, in their typical form, are not confidential means of communication. If you use these methods to communicate with Vitalis and its staff, there is a reasonable chance that a third party may be able to intercept and eavesdrop on those messages. Parties that may intercept these messages include, but are not limited to:
• People in your home or other environments who can access your phone, computer, or other devices that you use to read and write messages;
• Your employer, if you use your work email to communicate with us;
• Third parties on the Internet such as server administrators and others who monitor Internet traffic.
If you are concerned about methods of communication that are more secured, please talk with Vitalis Metabolic Health staff about ways to keep your communications safe and confidential. If you are willing to communicate electronically, with the understanding that it is unsecured and that your information may be accessed or intercepted by others, please proceed with signing the consent below.
III. Consent for Transmission Of Protected Information By Non-Secure Means
I consent to allow Vitalis and its staff to use unsecured email, text, or other means of unsecured electronic communication to transmit to me protected health information as authorized in the Medical Information (HIPAA) Release Form on Page 6 of this packet. The information to be released may include the following:
• Information related to the scheduling of meetings or other appointments
• Information related to billing and payment
• Completed forms, including forms that may contain sensitive, confidential information
• Information of a therapeutic or clinical nature, including discussion of personal material relevant to my treatment
• My health record, in part or in whole, or summaries of material from my health record
I understand that the information to be released may also include the following: diagnoses and/or treatment for alcohol, drug or substance abuse; psychological or psychiatric conditions; AIDS/AIDS Related Complex (ARC) diagnoses and treatment; HIV test results; cancer diagnoses or sickle cell anemia. I have been informed of the risks, including but not limited to my confidentiality in treatment, of transmitting my protected health information by unsecured means. I also understand that I may terminate this consent by providing written notice at any time, but that this authorization will terminate no later than when my treatment relationship with Vitalis. has ended.
IV. Primary Care Disclaimer
At Vitalis, we focus exclusively on improving health through weight loss or weight maintenance with a focus in healthy lifestyle changes and do not offer primary care services. Unlike most primary care offices, we focus on behavior, nutrition, activity, medication, surgery, and disordered eating. As part of our services, we co-manage medical conditions when they are an associated disease or co-morbid complication of excess weight (e.g. diabetes) but would not perform preventive screenings or sick visits. We encourage all our patients to enlist with a primary care physician, as this is an integral aspect of receiving the care you deserve. We do our best to work closely with your primary care physician and have an open line of communication with him or her.
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.
Privacy Officer: Bryan Luff, Practice Manager
2. Notice of Privacy Practices:
3. Assigning Privacy and Security Responsibilities:
Specific individuals at Vitalis Metabolic Health, PLLC are assigned the responsibility of implementing and maintaining the HIPAA Privacy and Security Rules’ requirements. At a minimum, Vitalis Metabolic Health, PLLC will designate the Practice Manager as the privacy official.
4. Deceased Individuals:
Vitalis Metabolic Health, PLLC privacy protections extend to information concerning deceased individuals.
5. Minimum Necessary Use and Disclosure of Protected Health Information:
Vitalis Metabolic Health, PLLC will ensure that for all routine and recurring uses and disclosures of PHI (except for uses or disclosures made for treatment purposes; to or as authorized by the patient; or as required by law for HIPAA compliance) such uses and disclosures of PHI must be limited to the minimum amount of information needed to accomplish the purpose of disclosure.
6. Verification of Identity:
Vitalis Metabolic Health, PLLC will ensure that the identity of all persons who request access to protected health information be verified before such access is granted.
Appropriate safeguards will be in place at Vitalis Metabolic Health, PLLC to reasonably protect health information from any intentional or unintentional use or disclosure that is in violation of the HIPAA Privacy Rule. These safeguards include physical protection of premises and PHI, technical protection of PHI maintained electronically and administrative protection of PHI. These safeguards will extend to the oral communication of PHI and to PHI removed from Vitalis Metabolic Health, PLLC.
8. Business Associates:
Vitalis Metabolic Health, PLLC will ensure business associates comply with the HIPAA Privacy Rules to the same extent as Vitalis Metabolic Health, PLLC, and that they be contractually bound to protect health information to the same degree as set forth in this policy. Business associates permitted to receive PHI include, for example Vitalis Metabolic Health, PLLC’s billing service (e.g. Bailey Medical Billing), patients’ health insurers, and other healthcare providers with whom we consult and coordinate patients’ care or to whom we refer patients for specialized care.
9. Training and Awareness:
Vitalis Metabolic Health, PLLC will ensure that all employees are trained on the policies and procedures governing protected health information and how Vitalis Metabolic Health, PLLC complies with the HIPAA Privacy. New employees will receive training within a reasonable time of employment.
Vitalis Metabolic Health, PLLC will ensure that sanctions will be in effect for any member of the workforce who intentionally or unintentionally violates any of these policies or any procedures related to the fulfillment of these policies. Such sanctions will be recorded in the individual’s personnel file.
11. Retention of Records:
Vitalis Metabolic Health, PLLC will adhere to the HIPAA Privacy records retention requirement of six years. All records designated by HIPAA in this retention requirement will be maintained in a manner that allows for access within a reasonable period of time. This records retention time requirement may be extended at Vitalis Metabolic Health, PLLC’s discretion to meet with other governmental regulations or those requirements imposed by our professional liability carrier.
Vitalis Metabolic Health, PLLC will investigate and resolve all complaints relating to the protection of health in a timely fashion. All complaints will be directed to Practice Manager, who is duly authorized to investigate complaints and implement resolutions.
13. Prohibited Activities-No Retaliation or Intimidation:
No employee or contractor of Vitalis Metabolic Health, PLLC may engage in any intimidating or retaliatory acts against persons who file complaints or otherwise exercise their rights under HIPAA regulations. No employee or contractor may condition treatment or payment on the provision of an authorization to disclose protected health information.
14. Cooperation with Privacy Oversight Authorities:
Vitalis Metabolic Health, PLLC will ensure that oversight agencies such as the Office for Civil Rights of the Department of Health and Human Services will receive cooperation in any investigation relative to protection of health information within Vitalis Metabolic Health PLLC. All personnel will cooperate fully with all privacy reviews and investigations.
15. Investigation and Enforcement:
In addition to cooperation with Privacy Oversight Authorities, Vitalis Metabolic Health, PLLC will follow procedures to ensure that investigations are supported internally and staff of Vitalis Metabolic Health, PLLC will not be retaliated against for cooperation with any authority. It is our policy to attempt to resolve all investigations and avoid any penalty phase if at all possible.
VI. Consent To Treat
I give permission for VITALIS Metabolic Health, PLLC to give me medical treatment.
I allow VITALIS Metabolic Health, PLLC to file for insurance benefits to pay for the care I receive.
I understand that:
• VITALIS Metabolic Health, PLLC will have to send my medical record information to my insurance company.
• I must pay my share of the costs.
• I must pay for the cost of these services if my insurance does not pay or I do not have insurance.
• I have the right to refuse any procedure or treatment.
• I have the right to discuss all medical treatments with my clinician