ADVANTAGECARE TELE-HEALTH 2 HOME IS A SOFTWARE COMPANY THAT BUILT A PLATFORM TO OFFER ITS CLIENTS THE ABILITY TO MATCH THEIR CONCERNS AND ISSUES TO THE BEST SUITED LICENSED HEALTHCARE PROVIDER WITH THE PROPER SKILL SET AND BACKGROUND AND ALLOW FOR COMMUNICATION WITH THAT LICENSED HEALTHCARE PROVIDER USING MOBILE DEVICES AND OTHER DIGITAL MEANS. ADVANTAGECARE TELE-HEALTH 2 HOME DOES NOT OFFER HEALTHCARE SERVICES DIRECTLY TO CLIENTS.
DISCLAIMER OF MEDICAL LIABILITY
THE PLATFORM IS NOT INTENDED FOR MEDICAL DIAGNOSIS OR DRUG PRESCRIPTION OR ADVICE CONCERNING WHICH DRUGS OR TREATMENT THAT MAY BE APPROPRIATE FOR YOU, AND YOU SHOULD DISREGARD ANY SUCH ADVICE IF DELIVERED THROUGH THE PLATFORM.
AdvantageCare Tele-Health 2 Home does not employ the licensed healthcare providers matched through this site. Licensed healthcare providers act as INDEPENDENT CONTRACTORS to AdvantageCare Tele-Health 2 Home. AdvantageCare Tele-Health 2 Home carefully screens licensed healthcare provider applicants using licensed experts in the healthcare field and insists on evidence of the applicant’s credentials. The licensed healthcare providers are neither our employees nor agents nor representatives. Furthermore, we assume no responsibility for any act, omission or wrongdoing of any licensed healthcare provider. While the site will help Client match with a licensed healthcare provider and will help Client find a new licensed healthcare provider if the match is unsuccessful, the Site makes no representation or warranty whatsoever as to whether you will find the Healthcare Services relevant, useful, correct, satisfactory or suitable to your needs.
ALL ADVANTAGECARE TELE-HEALTH 2 HOME LICENSED HEALTHCARE PROVIDERS PRACTICE INFORMED CONSENT. CLIENT WILL BE MATCHED TO A LICENSED HEALTHCARE PROVIDER IN YOUR STATE OF RESIDENCE AS CLIENT HAS CONFIRMED IT. THE LICENSED HEALTHCARE PROVIDER WILL CONFIRM TO YOU THEIR STATE OF LICENSURE AND LOCATION AND THE RISKS AND BENEFITS OF USING REMOTE AND/OR DIGITAL DEVICES FOR HEALTHCARE SERVICES. BY USING THE SERVICES OF ADVANTAGECARE TELE-HEALTH 2 HOME, YOU ARE AGREEING THAT ANY REMOTE SESSION CONDUCTED IS LEGALLY TAKING PLACE IN THE SITE OF LOCATION OF THE LICENSED HEALTHCARE PROVIDER AS SUCH STATE IS CONFIRMED TO YOU.
While AdvantageCare Tele-Health 2 Home does research and verify certain documents of the licensed healthcare providers using the site, we do not guarantee the verification of degrees, qualifications, licensure, certification, credentials, competence or background of any licensed healthcare provider. Client’s relationship relating to the licensed healthcare provider services is strictly with the licensed healthcare provider. AdvantageCare Tele-Health 2 Home is not involved with the actual substance of that relationship and we do not validate or control any of the licensed healthcare provider Services. You are advised to exercise a high level of care and caution in the use of the AdvantageCare Tele-Health 2 Home. You agree, confirm and acknowledge that you are aware of the fact that in some cases, AdvantageCare Tele-Health 2 Home’s offered services MAY not be completely substitute for a face-to-face session by a licensed healthcare provider. You should never rely on or make health or well-being decisions purely on use of AdvantageCare Tele-Health 2 Home. Never disregard, avoid, or delay in obtaining medical advice from your doctor or other qualified healthcare licensed healthcare provider, or by traditional face-to-face appointment; because of information or advice you received through AdvantageCare Tele-Health 2 Home.
IF YOU ARE THINKING ABOUT SUICIDE OR IF YOU ARE CONSIDERING TAKING ACTIONS THAT MAY CAUSE HARM TO YOU OR TO OTHERS OR IF YOU FEEL THAT YOU OR ANY OTHER PERSON MAY BE IN ANY DANGER OR IF YOU HAVE ANY MEDICAL EMERGENCY, YOU MUST IMMEDIATELY CALL AN EMERGENCY SERVICE NUMBER AND NOTIFY THE RELEVANT AUTHORITIES.
While AdvantageCare Tele-Health 2 Home protects and honors your Privacy, Independent Contracting Licensed healthcare providers’ practicing through AdvantageCare Tele-Health 2 Home retain a “Duty to Warn” as regulated by their State Ethics and License Regulations and Client acknowledges that any solicitation of advice from AdvantageCare Tele-Health 2 Home does diminish that duty which may include transmittal of Client’s location, IP address or personal identification to proper authorities.
Understanding that such consent may impact privacy protections of Client, Client affirmatively consents that AdvantageCare Tele-Health 2 Home’s Clinical Oversight Personnel will, as needed, review particular Client for the following purposes:
To review a Client complaint about a particular issue/instance that Client reported about Licensed healthcare provider.
For Client Safety Concerns or complaints of Unethical Licensed healthcare provider.
For a quality assurance concern of Client.
Client affirmatively grants permission to AdvantageCare Tele-Health 2 Home to have their matched Independent Licensed healthcare provider provide clinical records of Clients to AdvantageCare Tele-Health 2 Home.
Client affirmatively consents to the above review of Client’s otherwise HIPAA protected communications by AdvantageCare Tele-Health 2 Home when the above.
All de-identified data, meta-data and research data collected by AdvantageCare Tele-Health 2 Home through Client’s of AdvantageCare Tele-Health 2 Home remains the sole property of AdvantageCare Tele-Health 2 Home and its owners. Client has no rights to the ownership, removal or deletion of data on the Platform. All data kept by AdvantageCare Tele-Health 2 Home and stored as part of Agreement with licensed healthcare provider and Client will be securely stored in at least HIPAA level secure storage systems.
Proper Use of the Site
Client agrees that AdvantageCare Tele-Health 2 Home and its affiliates shall not be liable to Client or anyone else for any loss or injury caused in whole or in part by relying upon, using, or interpreting the content or any other information obtained through use of AdvantageCare Tele-Health 2 Home. In no event will AdvantageCare Tele-Health 2 Home or its affiliates be liable to Client or anyone else for any incidental, consequential, indirect, special or exemplary damages or lost profits arising out of the use or inability to use the content, the website or any other information obtained through the website, even if AdvantageCare Tele-Health 2 Home, its affiliates, its licensors, agents or representatives know or have been advised of the possibility of such damages.
Any link (including a hyperlink, button or referral device of any kind) used on AdvantageCare Tele-Health 2 Home or on the mobile AdvantageCare Tele-Health 2 Home Application is provided for your use and convenience. The appearance of a link does not constitute an endorsement, recommendation or certification by us, nor should the presence of a link in any way be construed as a suggestion that any third party website has any relationship to AdvantageCare Tele-Health 2 Home. AdvantageCare Tele-Health 2 Home does not endorse the content on any third-party websites. AdvantageCare Tele-Health 2 Home is not responsible for the content of linked third-party websites or third-party advertisements, and does not make any representations regarding its content or accuracy. AdvantageCare Tele-Health 2 Home does not knowingly link to websites that may infringe on valid and existing trademarks, service marks, copyrights or patents. Client’s use of third-party websites is at Client’s own risk and subject to the terms and conditions of use for such websites.
Client Responsible for All Posts and Communication
Neither AdvantageCare Tele-Health 2 Home nor its affiliates are under any obligation to respond to messages posted to AdvantageCare Tele-Health 2 Home. If Client posts any information or material to AdvantageCare Tele-Health 2 Home he is responsible for such information or material and the consequences of the message. If Client chooses to post material, Client agrees to do so solely for lawful purposes and in compliance with all applicable laws. AdvantageCare Tele-Health 2 Home reserves the right to edit or delete any material posted on AdvantageCare Tele-Health 2 Home. AdvantageCare Tele-Health 2 Home does not endorse any opinions expressed by third parties or other Clients on AdvantageCare Tele-Health 2 Home. Client acknowledges that any reliance on content posted by others on AdvantageCare Tele-Health 2 Home, and Client use of that content, is done so at Client’s own risk.
Modifications, Termination, Interruption and Disruptions to AdvantageCare Tele-Health 2 Home
Client confirms and acknowledges that AdvantageCare Tele-Health 2 Home may modify, suspend, disrupt or discontinue AdvantageCare Tele-Health 2 Home or any part of the AdvantageCareH2H.com website or the use of the mobile applications, whether to all Clients or to Client specifically, at any time with or without notice. Client agrees and acknowledges that AdvantageCare Tele-Health 2 Home will not be liable for any of the aforementioned actions or for any losses or damages that are caused by any of the aforementioned actions.
The AdvantageCare Tele-Health 2 Home technology is technically complicated and is dependent on third party engineering and hosting in part, and on various factors such as software, hardware and tool, either our own or those owned and/or operated by our contractors and suppliers. AdvantageCare Tele-Health 2 Home does not guarantee that the website or mobile applications will be uninterrupted or that it will be secure, consistent, timely or error-free.
Forbidden Uses of AdvantageCare Tele-Health 2 Home
All Clients expressly agree not to post any material that:
Is defamatory, libelous, abusive, or obscene, including, without limitation, material which encourages conduct that would constitute a criminal offense, give rise to civil liability or otherwise violate any applicable local, state, federal, or international law;
Infringes on the copyright or any other proprietary right of a third party;
Would invade the privacy of any other person;
Is intended to advertise to or solicit others without our express permission;
Constitutes charity solicitations, chain letters or pyramid schemes;
Contains a virus, worm, Trojan horse, time bomb, or any other harmful program or component; or
Interfere with or disrupt networks connected to the website, or used for purposes of delivering the content (or violate the regulations, policies or procedures of such networks);
Attempt to gain unauthorized access to restricted areas of the website, other accounts, computer systems or networks connected to the website, through password mining or any other means; or
Interfere with another Client’s use and enjoyment of the website.
AdvantageCare Tele-Health 2 Home Copyright and Trademarks
Client hereby grants to AdvantageCare Tele-Health 2 Home a non-exclusive, worldwide, royalty-free, perpetual license, with right to sublicense, to reproduce, distribute, transmit, create derivative works of, publicly display and publicly perform any materials and other information Client submits to the website by all means and in any media now known or hereafter developed for any use or purpose. This only refers and applies to content posted via open communication tools as described, and does not refer to information that is provided as part of the registration process for a password or username, if any or to content posted during healthcare session. AdvantageCare Tele-Health 2 Home only purports to use names, logos or marks appearing in this site in those territories in which it or its affiliates are entitled to do so, whether by virtue of pending or registered trademarks, licenses, or otherwise. For the avoidance of doubt, AdvantageCare Tele-Health 2 Home does not purport to use any name, logo or mark in any territory in which it is not so entitled, and will not supply or offer to supply products and/or services bearing any such name, logo or mark into any such territory. The use of these trademarks or any other content on this site, except as provided in these terms and conditions or in the site content, is strictly prohibited. All content and materials available on AdvantageCare Tele-Health 2 Home, including but not limited to text, graphics, domain names, code, images and logos are the intellectual property of AdvantageCare Tele-Health 2 Home, and are protected by applicable copyright and trademark law. Any inappropriate use, including but not limited to the reproduction, distribution, display or transmission of any content on this site is strictly prohibited. “AdvantageCare Tele-Health 2 Home” and “advantagecareh2h.com” are copyright terms. All rights reserved.
Age Requirements, Password, Email, Texting and Honesty Policy for AdvantageCare Tele-Health 2 Home
General Legal Terms
Nothing in this Agreement shall be construed as making either party the partner, joint venture, agent, legal representative, employer or employee of the other. Neither party shall have, or hold itself out to any third party as having any authority to make any statements, representations or commitments of any kind, or to take any action that shall be binding on the other, except as provided for herein or authorized in writing by the party to be bound.
This Agreement shall be interpreted only in accordance with the laws of the State of California.
This Agreement will be binding and will inure to the benefit of the legal representatives, successors and assigns of the parties hereto.
No amendment to this Agreement will be effective unless made in writing. The paragraph headings herein are solely for the sake of convenience and will not be applied in the interpretation hereof.
If any provision of this Agreement is held by a court of competent jurisdiction to be illegal, invalid, unenforceable, or otherwise contrary to law, the remaining provisions of this Agreement will remain in full force and effect.
UNLESS OTHERWISE EXPRESSED, ADVANTAGECARE TELE-HEALTH 2 HOME EXPRESSLY DISCLAIMS ALL WARRANTIES AND CONDITIONS OF ANY KIND, WHETHER EXPRESS OR IMPLIED, INCLUDING, BUT NOT LIMITED TO THE IMPLIED WARRANTIES AND CONDITIONS OF MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE AND NON-INFRINGEMENT.
Miscellaneous Terms and Conditions
AdvantageCare Tele-Health 2 Home reserves the right to change these Terms and Conditions from time to time in its sole discretion.
The Personal Data and Browser Data (hereinafter collectively referred to as “Data”), automatically collected from this website (hereinafter the “Site”), by means of automated systems or freely entered by the User of this Site.
We receive a number of different types of information about you, including:
The information that’s required when you sign up for the site, as well as the information you choose to share.
Required information such as your name, email address, birthday, and gender. We use return email addresses to answer the email we receive. Such addresses are not used for any other purpose and are not shared with outside parties.
Usernames and User IDs, which are a way to identify you on AdvantageCare Tele-Health 2 Home. A User ID is a string of numbers and a username generally is some variation of your name.
“Public Information” which means the information you choose to make public, as well as information that is always publicly available.
Parties processing the data
AdvantageCareh2h.com is a “DBA” used by AdvantageCare Tele-health 2 home who runs the site and keeps the Data.
We will keep your information confidential except where disclosure is required or permitted by law (for example to government bodies and law enforcement agencies). Generally, we will only use your information within our company. However, sometimes we use third parties to process your information (for example or payment providers). We will require these third parties to comply strictly with its instructions and we will require that they not use your personal information for their own business purposes.
The use of the collected Data by AdvantageCare Tele-Health 2 Home
We use non-identifying and aggregate information to better design our Web site and to share with advertisers. For example, we may tell an advertiser that X number of individuals visited a certain area on our Web site, or that Y number of men and Z number of women filled out a site survey or form, but we would not disclose anything that could be used to identify those individuals. We only provide data to our partners, if any, after we have removed your name and any other personally identifying information from it, or have combined it with other people’s data in a way that it no longer personally identifies you.
AdvantageCare Tele-Health 2 Home use non-identifying and aggregate information about responses to the clinical outcome assessments (personal assessments), and the frequency of the utilization of the AdvantageCare Tele-Health 2 Home service. These efforts enhance program evaluation.
The anonymous and aggregated data also be published through various media platforms/academic journals. No personal identifying information will be tied to the results, and AdvantageCare Tele-Health 2 Home will not share anything that could be used to identify your account or your private information.
From time to time, we may use customer information for new, unanticipated uses not previously disclosed in our privacy notice. If our information practices change at some time in the future we will contact you before we use your data for these new purposes to notify you of the policy change and to provide you with the ability to opt out of these new uses.
We store data only for as long as it is necessary to provide products and services to you and others, including those described above and for legal protections or as required by applicable laws and regulations.
We may enable access to public information that has been shared through our services.
We may allow service providers to access information so they can help us provide services.
IP addresses are used to identify the location of users, the number of visits from different countries and also to block disruptive use; and to analyze and improve the services offered on our website, e.g. to provide you with the most user-friendly navigation experience.
Certain information is needed to provide you with services, so we only delete this information after you delete your account.
Some forms of processing (sending promotional information, commercial profiling, behavioral advertising, geo-location, etc.) may require the express consent of the User. Specific information may be shown on the pages of the Site in connection with particular services or processing of Data provided by the Site User.
Upon request we provide site visitors with access to a description of information that we maintain about them. AdvantageCareH2H.com uses industry-standard encryption technologies when transferring and receiving consumer data exchanged with our site. If you feel that this site is not following its stated information policy, you may contact us at addresses or phone number below.
For content that is covered by intellectual property rights, like photos and videos you specifically grant AdvantageCareH2H.com a non-exclusive, transferable, sub-licensable, royalty-free, worldwide license to use any IP content that you post on or in connection with AdvantageCareH2H.com (IP License). This IP License ends when you delete your IP content or your account unless your content has been shared with others, and they have not deleted it.
When you delete IP content, it is deleted in a manner similar to emptying the recycle bin on a computer. However, you understand that removed content may persist in backup copies for a reasonable period of time (but will not be available to others).
Protecting the Privacy of your fellow AdvantageCare Tele-Health 2 Home Users
During your use of AdvantageCareH2H.com services, you will not send or otherwise post unauthorized commercial communications (such as spam) on AdvantageCareH2H.com .
You will not collect users’ content or information, or otherwise access AdvantageCareH2H.com , using automated means (such as harvesting bots, robots, spiders, or scrapers) without our permission:
You will not upload viruses or other malicious code.
You will not solicit login information or access an account belonging to someone else.
You will not bully, intimidate, or harass any other User.
You will not post content that: is hateful, threatening, or pornographic; incites violence; or contains nudity or graphic or gratuitous violence.
You will not provide any false personal information on AdvantageCareH2H.com , or create an account for anyone other than yourself without permission. You will not create more than one personal profile.
Portable Electronic Devices
The AdvantageCare Tele-Health 2 Home Platform is available on a multitude of portable electronic devices. We provide our connection to mobile services for free, but please be aware that your carrier’s normal rates and fees, such as text messaging fees, may still apply. You provide all rights necessary to enable users to sync (including through an application) their contact lists with any basic information and contact information that is visible to them on AdvantageCareH2H.com , as well as your name and profile.
Your Use of Your Personal Data
If a AdvantageCareH2H.com User utilizes the Site to publish or otherwise share Personal Data with third parties, he or she assumes full responsibility: the User states possession of the right to communicate or disclose personal data to third parties, and that they have received prior information thereto, thus relieving the Site of all responsibility for their improper use following disclosure or dissemination.
You will resolve any claim, cause of action or dispute (claim) you have with us arising out of or relating to this Statement or AdvantageCareH2H.com exclusively in a state or federal court located Callifornia. The laws of the State of California will govern this Statement, as well as any claim that might arise between you and us, without regard to conflict of law provisions.
If anyone brings a claim against us related to your actions, content or information on AdvantageCareH2H.com , you will indemnify and hold us harmless from and against all damages, losses, and expenses of any kind (including reasonable legal fees and costs) related to such claim.
Social Networks and AdvantageCare Tele-Health 2 Home
These services allow the web site to access the data on your profile in the social networks, and to interact through your post. These services are not activated automatically, but require express authorization by the User.
Cookies and Use Thereof on AdvantageCareH2H.com
A cookie is a small amount of data, which often includes a unique identifier that is sent to your computer, tablet, phablet, cell phone or other electronic devise (referred to here as a “device”) browser from a website’s computer and is stored on your device’s hard drive. Each website can send its own cookie to your browser if your browser’s preferences allow it, but (to protect your privacy) your browser only permits a website to access the cookies it has already sent to you, not the cookies sent to you by other sites. Many sites do this whenever a user visits their website in order to track traffic flows.
Information supplied by cookies can help us to analyze the profile of our visitors so we can provide you with a better user experience.
Psychological Assessments: Questions from clinical scales that measure mental health and well-being. Psychological Assessments vary by condition.
Data/results: The quantitative scores that are based on responses to questions in the assessments.
General Location: The location of the state and city, but NOT address/place of residency.
Personal identifying information: Name, address, credit card number
We try to keep AdvantageCareH2H.com safe, but you use it at your own risk. We are providing AdvantageCareH2H.com as is without any express or implied warranties. We do not guarantee that AdvantageCareH2H.com will be safe or secure. AdvantageCareH2H.com is not responsible for the actions, content, information, or data of third parties, and you release us, our directors, officers, employees, and agents from any claims and damages, known and unknown, arising out of or in any way connected with any claim you have against any such third parties.
We strive to create a community with consistent standards for everyone, but we also strive to respect local laws. You consent to having your personal data transferred to and processed in the United States. If you are located in a country embargoed by the United States, or are on the U.S. Treasury Department’s list of Specially Designated Nationals you will not engage in commercial activities on AdvantageCareH2H.com (such as advertising or payments). By content we mean anything you post on AdvantageCareH2H.com that would not be included in the definition of information. By data we mean content and information that third parties can retrieve from AdvantageCareH2H.com or provide to AdvantageCareH2H.com through this Platform. By post we mean post on AdvantageCareH2H.com or otherwise make available to us (such as by using an application). By use we mean use, copy, publicly perform or display, distribute, modify, translate, and create derivative works of.
Understand, that we treat your use of our platform with the utmost respect to your privacy. We keep all information not disclosed above private between the Licensed healthcare provider and the User, keeping only non-decimated “file” copies for reference in case of legal dispute of by court order as we are required to under Federal Laws for period up to seven years. File retention protects both the User and the Licensed healthcare providers safety. The data will be protected at high levels of security and privacy.
AdvantageCare Tele-Health 2 Home is not responsible for data lost/exposed/used due to the nature of the Internet and digital environments, illegal actions of hackers and criminals, technical malfunctions of servers and database etc. These are the accepted risks of our Users and users of the Internet in general. You are agreeing to this standard in using our site.
AdvantageCare Tele-Health 2 Home reserves the right to amend this Privacy Statement at any time without notice, and only the current Privacy Statement may be deemed effective. Regardless of later updates or changes to our privacy notice, we will never use the information you submit under our current privacy notice in a new way without first providing you an opportunity to opt-out or otherwise prevent that use.
This Privacy notice was last updated on November 2, 2015 and is deemed effective as of this date.
Client-Provider Service Agreement
This document contains important information about our professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patient rights about the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations. Although these documents are long and sometimes complex, it is very important that you understand them. Please be aware that when using our website and submitting any correspondence like submitting forms or sending emails, you are digitally agreeing to our Terms and Service and/or any providers associated with the practice. It also represents an agreement between us.
Our providers will make every effort to keep your personal information private. There are some limitations to confidentiality to which you need to be aware. Our providers are required by law to release information when the client poses a risk to themselves or others and in cases of abuse to children or the elderly. If your provider receives a court order or subpoena, they may be required to release some information. In such a case, your provider will consult with other professionals and limit the release to only what is necessary by law.
Confidentiality and Technology
Some clients may choose to use technology in the course of their treatment. This includes but is not limited to online services via Skype, video conferencing, telephone, email, text or chat. Due to the nature of online healthcare, there is always the possibility that unauthorized persons may attempt to discover your personal information. Your provider will take every precaution to safeguard your information but cannot guarantee that unauthorized access to electronic communications could not occur. Please be advised to take precautions with regard to authorized and unauthorized access to any technology used. Be aware of any friends, family members, significant others or co-workers who may have access to your computer, phone, voice mail or other technology used. Should a client have concerns about the safety of their email, your provider can arrange to encrypt email communication with you.
Your provider may keep records of your treatment and a treatment plan. These records are kept to ensure your continuity in service. They will not be shared except with respect to the limits to confidentiality discussed in the Confidentiality section. Should the client wish to have their records released, they are required to sign a release of information which specifies what information is to be released and to whom. Records will be kept for at least 7 years but may be kept for longer. Records will be kept either electronically on a USB flash drive or in a paper file and stored in a locked cabinet in the practice office.
You are responsible for paying at the time of your session unless prior arrangements have been made. Payment must be made by credit card, check or cash. If you refuse to pay your debt, we reserve the right to use an attorney or collection agency to secure payment.
If you anticipate becoming involved in a court case, we recommend that we discuss this fully before you waive your right to confidentiality. If your case requires provider participation, you will be expected to pay for the professional time required.
Payment plan options may be available to receive sliding scale fees. Fees are subject to change at your provider’s discretion.
Your provider can accept all insurance carriers as in or out of network for most insurance carriers. We cannot guarantee that your provider will be in network with your health insurance carrier. If you have a health insurance policy, it may or not provide coverage for your treatment. You are responsible for knowing your coverage and payment of any deductibles or fees.
You should also be aware that most insurance companies require you to authorize us to provide them with medical necessity. Sometimes we have to provide additional information which will become part of the insurance company files. By agreeing to the Terms and Service you are essentially agreeing digitally and agree that your provider can provide requested information to your carrier.
In addition, if you plan to use your insurance, authorization from the insurance company may be required before they will cover any fees. Many policies leave a percentage of the fee to be covered by the patient. Either amount is to be paid at the time of the visit by debit card, check or cash. In addition, some insurance companies also have a deductible, which is an out-of-pocket amount that must be paid by the patient before the insurance companies are willing to begin paying any amount for services.
A receipt will be furnished for any fees you pay. If your provider is not a participating provider for your insurance plan, we will supply you with a receipt of payment for services, which you can submit to your insurance company for reimbursement. Please note that not all insurance companies reimburse for out-of-network providers. If you prefer to use a participating provider, we can assist with referring you to a colleague or other provider.
I hereby instruct and direct my insurance company to pay by check made payable to: any providers associated with the clinic to be reimbursed for medical expense benefits allowable and otherwise payable to me under my current insurance policy as payment toward the total charges for the professional services rendered.
THIS IS A DIRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS FROM THIS POLICY. This payment will not exceed my indebtedness to the above mentioned assigned, and I agree to pay any balance of said professional services charges over and above this insurance payment at the time service is rendered.
I also authorize the release of any information pertinent to my case to any insurance company. A photocopy or facsimile of this Assignment shall be considered as effective and valid as the original.
Email Opt In
Your providers may request your email address. Client has the right to refuse to divulge email address. Your provider may use email addresses to periodically check in with clients or coordinate sessions. If you would like to opt out of email correspondence, please contact us so we can mark it in your chart.
Text Messaging Opt In
Normally providers do not text message patients. By agreeing to these Terms and Service you understand that providers may utilize text messaging to send appointment reminders. By texting your provider, you are automatically opting in and authorizing us to respond back with a text message.
NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT
I understand that under the Health Insurance Portability & Accountability Act of 1996 (“HIPAA”), I have certain rights to privacy regarding my protected health information. I understand this information can and will be used to:
- Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and/or indirectly;
- Obtain payment from third-party payers; and
- Conduct normal healthcare operations such as quality assessments and physician certifications.
I acknowledge and understand this Notice of Privacy Practices uses and disclosures of my health information. I understand this organization has the right to change its Notice of Privacy Practices from time to time, and I may contact this organization at any time at the address below to obtain a current copy of the Notice of Privacy Practices.
I understand I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree, you are bound to abide by such restrictions.
NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT
By using our services, website, or using any correspondence between you and our practice/clinic/providers associated with our clinic, you fully AGREE and indicate that you have READ AND FULLY UNDERSTAND the entire Terms and Service and AGREE to its terms.