I Live Well IV

Medical Consent

Last updated: January 22nd, 2024 (v 1.0.0)

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NOT A SUBSTITUTE FOR EMERGENCY MEDICAL SERVICES. IN CASE OF MEDICAL EMERGENCY, SEEK IMMEDIATE IN-PERSON MEDICAL CARE OR DIAL 911 OR YOUR LOCAL EMERGENCY NUMBER.

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These terms may be modified at any time, as required by law, for reasons including legal, business, or competitive changes.

HIPAA Consent

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The Health Insurance Portability and Accountability Act (HIPAA) safeguards your privacy, starting April 14, 2003. This document provides a condensed version; a comprehensive text is available online and in the office.

Key points: HIPAA regulates who can access your Protected Health Information (PHI). While ensuring your rights and protections, we balance this with providing quality service. More details are available at www.hhs.gov.

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We adhere to the following policies:

• Patient information is kept confidential, shared only as necessary for services or administrative matters related to your care.

• Patient files may be temporarily in administrative areas, accessible only to office staff and third-party providers.

• Appointments may be reminded via telephone, email, U.S mail, or other convenient means.

• Vendors must comply with HIPAA confidentiality rules.

• Your information won't be used for marketing, advertising, or disclosed without consent.

• Access to records is provided in accordance with state and federal laws.

• The right to request restrictions on the use of your PHI is acknowledged.

• The right to change, add, delete, or modify provisions to serve both practice and patient needs is retained.

 

Your continued service use implies understanding and acceptance of these terms and any subsequent changes.

Financial Consent

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To receive services, any outstanding balances for services must be paid in full. Authorization is granted for I Live Well IV, LLC. to submit on your behalf and release necessary medical records. Fee schedules and receipts are available on request.

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Authorization is given to make invoice changes, debit accounts, and charge credit cards for unpaid balances. Auto-renewal of programs is accepted unless explicitly canceled before processing. No refunds or exchanges are allowed.

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Certification as an authorized credit card user and a commitment not to dispute payments with the credit card company are acknowledged.

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Shipping Authorization

Prescription medications dispensed comply with state and federal laws. The customer agrees to hold I Live Well IV, LLC. harmless for shipping delays or errors. Medication is considered dispensed upon shipping sign-out, not upon delivery.

Continued service use implies understanding and acceptance of these terms, granting permission for I Live Well IV, LLC. to ship medication to the provided address, and agreement with the listed conditions.