Consent


PHI Consent, Responsibility & Acknowldgement

CONSENT FOR PURPOSES OF TREATMENT, PAYMENT & HEALTH CARE OPERATIONS

I consent to the use or disclosure of my protected health information (“PHI”) by New Age Health and Wellness, LLC (“New Age”) for the purpose of diagnosing or providing treatment to me, obtaining payment for my health care bills or to conduct health care operations of New Age.  I understand that diagnosis or treatment of me by New Age may be conditioned upon my consent as evidenced by my signature on this document.

My PHI means health information, including my demographic information, collected from me and created or received by my physician, another health care provider, a health plan, or my employer or a health care clearinghouse.  This PHI relates to my past, present or future physical or mental health or condition and identifies me, or there is reasonable basis to believe the information may identify me.

I understand and have a right to review the New Age Notice of Privacy Practices prior to signing this document.  The New Age Notice of Privacy Practices has been provided to me.  The Notice of Privacy Practices describes the types of uses and disclosures of my PHI that will occur in my treatment, payment of my bills or in the performance of health care operations of New Age.  The Notice of Privacy Practices for New Age is also provided at 8401 Lake Worth Road, Suite 242, Lake Worth, FL 33467. This Notice of Privacy Practices also describes my rights and the duties of P&R with respect to my PHI.  New Age reserves the right to change the privacy practices that are described in the Notice of Privacy Practices.

I may obtain a revised Notice of Privacy Practices by requesting it in writing from New Age or asking for one at the time of my next appointment. 

FINANCIAL RESPONSIBILITY / INSURANCE NOT ACCEPTED

I understand that medical billing is a service provided as a courtesy and that I am at all times financially responsible to New Age and or its affiliated entities for all charges.  I understand that all services provided by New Age are elective, non-covered medical benefits and therefore, the Medicare, Medicaid Assistance or any other medical insurance plan (collectively “Medical Insurance”) will not be billed.  I understand and acknowledge that New Age does not accept any form of Medical Insurance; New Age will not and shall not bill any Medical Insurance for any services or supplies rendered. I expressly agree not to seek reimbursement for services rendered by New Age, including lab fees, from any Medical Insurance or other third-party payment program. I understand that by signing this form that I am accepting financial responsibility as explained above for full payment for all medical services and/or supplies received.

ACKNOWLEDGMENT OF RECEIPT NOTICE OF PRIVACY PRACTICES

I acknowledge that I have received a copy of New Age’s Notice of Privacy Practices, which describes how New Age will use and protect my health information.  This Notice describes my rights under the Health Insurance Portability and Accountability Act (“HIPAA”) and New Age’s use and disclosure of my PHI.

Initial Here

April 22, 2019

NEW PATIENT General Consent for Care and Treatment

GENERAL CONSENT FOR CARE AND TREATMENT

TO THE PATIENT: You have the right, as a patient, to be informed about your condition and the recommended surgical, medical or diagnostic procedure to be used so that you may make the decision whether or not to undergo any suggested treatment or procedure after knowing the risks and hazards involved. At this point in your care, no specific treatment plan has been recommended. This consent form is simply an effort to obtain your permission to perform the evaluation necessary to identify the appropriate treatment and/or procedure for any identified condition(s).

THIS CONSENT provides New Age Health and Wellness, LLC with your permission to perform reasonable and necessary medical examinations, testing and treatment. By signing below, you are indicating that (1) you intend that this consent is continuing in nature even after a specific diagnosis has been made and treatment recommended; and (2) you consent to treatment by New Age Health and Wellness, LLC. The consent will remain fully effective until it is revoked in writing. You have the right at any time to discontinue services.

YOU HAVE THE RIGHT to discuss the treatment plan with your health care provider about the purpose, potential risks and benefits of any test ordered for you. If you have any concerns regarding any test or treatment recommend by your health care provider, we encourage you to ask questions.

I VOLUNTARILY REQUEST a Physician, Nurse Practitioner, Physician Assistant, Clinical Nurse Specialist, and/or other health care providers or the designees as deemed necessary, to perform reasonable and necessary medical examination, testing and treatment for the condition which has brought me to seek care at New Age Health and Wellness, LLC. I understand that if additional testing, invasive or interventional procedures are recommended, I will be asked to read and sign additional consent forms prior to the test(s) or procedure(s).

I CERTIFY that I have read and fully understand the above statements and consent fully and voluntarily to its contents.

Initial Here

April 22, 2019

Consent for BHRT

I,  request that New Age Health and Wellness, LLC prescribe for me Bioidentical Hormone Replacement Therapy (“BHRT”), if deemed necessary.

  • I understand that BHRT is not specifically approved by the FDA for preventative medicine and my request for BHRT is off-label.
  • I understand that the medical literature indicates that there may be health benefits to the use of BHRT and its long-term effects are undetermined.
  • I understand that New Age Health and Wellness, LLC cannot guarantee any results or that there will be no harm. The potential health risks and benefits of using BHRT have been explained to me to my satisfaction.
  • I understand that BHRT is purely elective and that it may not be deemed medically necessary by insurance companies.
  • I understand that New Age Health and Wellness, LLC provides quality services on a “Cash for Service” basis. All procedures must be paid for at the time of service. Quoted rates are subject to change without notice, however, we will attempt to notify you of any changes.
  • I understand that New Age Health and Wellness, LLC and its providers do not participate with any insurance plans, including Medicare. We will not file claims for any services to any insurer.
  • I understand that New Age Health and Wellness, LLC asks that I give at least 2 business days notification of cancellation from your scheduled date to be seen and we reserve the right to charge a fee for not showing for an appointment or for cancelling an appointment that is less than 2 business days. The charge will be 50% of the usual appointment charge. Upon scheduling of your first appointment, we will request a credit card to be kept on file to assist with any charges. By doing so, you are giving us permission to charge this card for cancellation fees as previously stated.
  • I certify that I have read the above consent and fully understand it. I believe that I have adequate knowledge upon which to base this BHRT informed consent.
  • I fully understand what I am signing and hereby request and consent to BHRT treatment.

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April 22, 2019

Print Name:   

If you are a legal representative of the person whose information you are requesting, you must provide documentation proving your legal authority to request this information (for example, power of attorney, guardianship papers, health care surrogate form, Custody Order, Order Appointing Personal Representative, Letters of Administration).

 

AUTHORIZATION FOR THE USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

Name of Individual:  

Phone Number:  

Date of Birth: 

Last 4 Digits of SSN:   

Address:

 

 Date I wish this authorization to expire:  (expires in 2 year if no date provided).

  include specific authorization to include documents related to sensitive health conditions including: drug, alcohol or substance abuse, psychological or psychiatric treatment, sickle cell anemia, birth control or family planning, genetic diseases or tests, tuberculosis, HIV/AIDS or sexually transmitted diseases.  Re-disclosure of this information is not allowed except in compliance with law or with your written permission.

I understand the following:  I have the right to revoke this authorization at any time by writing to John D. Haslup, New Age Health and Wellness, LLC, 8401 Lake Worth Road, Suite 242, Lake Worth, FL 33467. The information described above (excluding information related to sensitive health information) may be re-disclosed by the person or group that I am giving New Age Health and Wellness, LLC permission to disclose to and therefore my information may no longer be protected by Federal privacy regulations. I may refuse to sign this authorization and my refusal to sign will not affect my ability to obtain treatment.

 

I DECLARE UNDER PENALTY OF LAW THAT THE INFORMATION ON THIS FORM IS TRUE AND CORRECT.

Initial Here

April 22, 2019

Print Name:   

If you are a legal representative of the person whose information you are requesting, you must provide documentation proving your legal authority to request this information (for example, power of attorney, guardianship papers, health care surrogate form, Custody Order, Order Appointing Personal Representative, Letters of Administration).

Instructions for Completing the Authorization for the Use and Disclosure of Protected Health Information Form

  1. Complete the first page of this form and return it to: John D. Haslup, New Age Health and Wellness, LLC, 8401 Lake Worth Road, Lake Worth, FL 33467.
  2. Special types of health information have specific laws and rules that must be followed before that information may be disclosed:

HIV/AIDS and Sexually Transmitted Diseases (STD): All information about HIV/AIDS and sexually transmitted diseases is protected under Federal and State laws and cannot be disclosed without your written authorization unless otherwise provided in the regulations. To release HIV/AIDS or STD information, this authorization must include a statement of the specific HIV/AIDS or STD information you are giving New Age Health and Wellness, LLC permission to disclose. Re-disclosure of HIV/AIDS information is not allowed except in compliance with law or with your written permission.

Alcohol or Drug Treatment: Alcohol and/or drug treatment records are protected under Federal and State laws and regulations and cannot be disclosed without your written authorization, unless otherwise provided for in Federal and State laws or regulations. To release alcohol and/or drug treatment information, this authorization must include a statement of the specific information that you are giving New Age Health and Wellness, LLC permission to disclose (for example, “For the purposes of my assessment, treatment plan, attendance, or discharge plan.”) Re-disclosure of your alcohol and/or drug treatment records is not allowed except in compliance with law or with your written permission (see 45 CFR Part 2).

Mental Health Treatment: Mental health treatment records are protected under Federal and State laws and regulations and cannot be disclosed without your written authorization unless otherwise allowed in Federal or State laws or regulations. To release mental health treatment information, this authorization must include a statement of the specific information that you are giving New Age Health and Wellness, LLC permission to disclose (for example, “For the purposes of my assessment, treatment plan, attendance, or discharge plan.”) Disclosure of your psychotherapist’s notes needs separate written permission. Re – disclosure of your mental health treatment records is not allowed except in compliance with law or with your written permission.

Credit Card Authorization

Please choose Option-A OR Option-B and sign below

In order to be considered complete, you must fill-out ONLY ONE of the options below.

I choose OPTION-A

I authorize New Age Health and Wellness, LLC to keep my signature on file and to charge my credit card account after verbal or electronic (text, email) communication. I understand that this authorization is valid for two years from the below date unless I cancel the authorization through written notice. I also agree to contact the merchant if there are any changes to my credit card account information.

I choose OPTION-B

I don’t want my signature on file and understand that I will have to provide my complete credit card information every time I make a purchase or reorder my prescriptions.

Choose:

Initial Here

April 22, 2019

Print Name:   

By signing below, I certify all information is true and correct to the best of my
knowledge. The signature below authenticates all initials as approved acknowledgments.  

 

 

Leave this empty:

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Signature Certificate
Document name: Consent
Unique Document ID: 2ae718372583623e64c2a0b4223ba7f19a79f5b7
Timestamp Audit
October 2, 2018 12:57 pm EDTConsent Uploaded by JD Haslup - admin@nahaw.com IP 73.0.200.103