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.
February 21, 2019
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.
I, request that New Age Health and Wellness, LLC prescribe for me Bioidentical Hormone Replacement Therapy (“BHRT”), if deemed necessary.
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).
Name of Individual:
Date of Birth:
Last 4 Digits of SSN:
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.
Instructions for Completing the Authorization for the Use and Disclosure of Protected Health Information Form
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.
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:
If you have questions about the contents of this document, you can email the document owner.
Document Name: Consent
Agree & Sign