Welcome to Health Loft, please take a few moments to read our practice policies. This agreement is between you and Health Loft.
Initial appointments and follow up appointments are usually 55 minutes in length. I understand that if I arrive more than 15 minutes late for my scheduled appointment, this may result in the cancellation of the appointment and I may be charged a late cancellation/no show fee described below.
Canceling and Rescheduling Appointments
I understand that Health Loft requires at least 24 hours notice when canceling or rescheduling an appointment. I understand that if I do not provide 24 hours notice it will result in a late cancellation/no show fee of $100. This charge will be made to the credit card on file and will not be covered by your insurance. By signing this form, I understand the Health Loft Policy and agree that Health Loft may charge my credit card on file for these fees usually on the day they occur.
Consent and Statement of Financial Responsibility
Consent for Treatment
I hereby consent to, and authorize the registered dietitians, health care providers, and the professional staff of Health Loft to perform any medical care which in their professional judgment is deemed necessary to treat the condition(s) that have brought about my seeking medical care for myself or a responsible party. I understand that response to medical intervention varies from person to person and that there are no guarantees made concerning the results or outcomes of the examination and treatment rendered by the dietitians and professional staff of Health Loft.
Workers Compensation Patients
I understand that Health Loft is required to inform my Worker’s Compensation Adjuster and/or Rehabilitation Manager of all missed or canceled appointments. I understand that any missed visits must be rescheduled.
Responsibility for Payment
I acknowledge that in consideration of the services provided to me by Health Loft, I am financially responsible for payment of my bill. I acknowledge that it is my responsibility to provide Health Loft with my current insurance information and to familiarize myself with my insurance plan and its policies. Any questions I have regarding my health insurance coverage or benefit levels should be directed to my health plan. My health insurance plan may provide that all or a portion of the charges and balance will remain my personal responsibility, such as my deductible, co-payment, co-insurance or charges not covered or denied by my health insurance, Medicare, or other programs for which I am eligible. I understand and agree to pay any such amounts that are my responsibility and that all co-payments, co-insurance, and self-pay amounts are due at the time of service and will be billed to my credit card on file. If formal collection procedures become necessary, such as the use of a collections agency, I am responsible for any “additional costs” incurred as a result of such collection procedures including attorney fees (These additional costs can be as high as 30% of the original balance).
Assignment of Benefits:
I hereby assign to Health Loft all my rights and claims for reimbursement under my health insurance policy. I agree to cooperate with Health Loft and to provide such information as is needed to establish my eligibility for such benefits. In the event that I do not have insurance coverage, I understand that I remain personally responsible for payment of services rendered including all costs of collection, including attorney’s fees and costs. I hereby request that my insurance carrier make payment directly to Health Loft for all services rendered by Health Loft. If my current policy prohibits direct payment to Health Loft, I direct my insurance carrier to make the check out in my name but send the check to Health Loft. If my insurance carrier makes payments to me I agree to immediately pay over these funds to Health Loft. I also authorize Health Loft to deposit checks received on my account when made out to me.
Access to and Release of Health Information
I understand that Health Loft may document medical and other information related to my treatment in electronic and other forms and that such information will be used in the course of my treatment, for payment purposes and to support those who are caring for me. I authorize my clinician(s) and Health Loft administrative staff to contact other healthcare professionals that may have information related to my prior and current health conditions and treatment.
Consent to Electronic Communication
I consent to receiving text, email and/or telephone communications for client care communication and occasional marketing purposes. Health Loft cannot ensure 100 percent confidentiality of communication through electronic media, including text/email messages and emails. I understand that texting, calling, and emailing are not a secure or confidential form of communication. I recognize that I may opt out of these communications at any time by contacting appointments@Healthloftco.com. I also consent to the aforementioned individuals receiving verbal communication regarding billing and payment information for treatment services provided on my behalf. I understand that this DOES NOT authorize the disclosure of my written health information.
Via your electronic signature (by clicking the checkbox as applicable), you voluntarily consent to sign electronically (“E-Sign”) documents presented to you (including those for signature) relating to Health Loft PLLC. You agree that Health Loft may accept an electronic signature from you and will have the same effect as a physical “wet” signature. At any time, you may withdraw your consent by emailing firstname.lastname@example.org
Consent to Telehealth
1. Purpose: The purpose of this form is to obtain your consent to participate in a telehealth consultation in connection with online nutrition and/or dietician consultation services.
2. Nature of Telehealth Consult: The following may occur during your telehealth consultation:
- Details of your medical history, examinations, lab results, and tests may be shared with health professionals through the use of interactive video, audio or telecommunication technology.
- A physical examination may take place.
- A non-medical technician may be present in the telehealth studio to aid in the video transmission.
- Video, audio and/or photo recordings may be used to facilitate the procedure(s) and/or service(s). If you decline the telehealth consultation, you may have to travel to see a licensed health care practitioner in-person.
3. Medical Information & Records: This telehealth consultation is subject to all existing laws regarding your access to medical information and copies of your medical records.
4. Confidentiality: All existing confidentiality protections under federal and Illinois state law apply to information disclosed during this telehealth consultation.
5. Rights: You may withhold or withdraw consent to the telehealth consultation at any time without affecting your right to future care or treatment, or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled.
6. Disputes You agree that any dispute arising from the telehealth consult will be resolved in the State of Illinois, and that Illinois law shall apply to all disputes.
7. Risks, Consequences, & Benefits: You have been advised of the potential risks, consequences and benefits of the telehealth services. Your health care practitioner has discussed with you the information provided above. You have had the opportunity to ask questions about the information presented on this form and the telehealth consultation. All of your questions have been answered, and you understand the written information provided above.
Protected Health Information (Health Insurance Portability and Accountability ACT – HIPAA)
This notice describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.
We may change the terms of our notice, at any time. The new notice will be effective for all protected health information that we maintain at that time. Upon your request, we will provide you with any revision of this policy. You may request a revised version by emailing us at email@example.com, or by calling the office and requesting that a revised copy be sent to you in the mail.
1. Uses and Disclosures of Protected Health Information
Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office who are involved in your care and treatment for the purpose of providing health care services to you. Your protected health information may also be used and disclosed to pay your health care bills and to support the operation of your physician’s practice.
Following are examples of the types of uses and disclosures of your protected health information that your physician’s office is permitted to make. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by our office.
- Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with another provider. For example, we would disclose your protected health information, as necessary, to a primary care physician that provides care to you. We will also disclose protected health information to other physicians who may be treating you. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you. In addition, we may disclose your protected health information from time-to-time to another physician or health care provider (e.g., a specialist or laboratory) who, at the request of your physician, becomes involved in your care by providing assistance with your health care diagnosis or treatment to your physician.
- Payment: Your protected health information will be used and disclosed, as needed, to obtain payment for your health care services provided by us or by another provider. This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services we recommend for you such as: making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.
- Health Care Operations: We may use or disclose, as needed, your protected health information in order to support the business activities of your physician’s practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, fundraising activities, and conducting or arranging for other business activities. We will share your protected health information with third party “business associates” that perform various activities (for example, billing or transcription services) for our practice. Whenever an arrangement between our office and a business associate involves the use or disclosure of your protected health information, we will have a written contract that contains terms that will protect the privacy of your protected health information.
We may use or disclose your protected health information, as necessary, to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you. You may contact our Privacy Officer to request that these materials not be sent to you. Other Permitted and Required Uses and Disclosures That May Be Made Without Your Authorization or Opportunity to Agree or Object.
We may use or disclose your protected health information in the following situations without your authorization or providing you the opportunity to agree or object. These situations include:
- Required By Law: We may use or disclose your protected health information to the extent that the use or disclosure is required by law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, if required by law, of any such uses or disclosures.
- Public Health: We may disclose your protected health information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. For example, a disclosure may be made for the purpose of preventing or controlling disease, injury or disability.
- Communicable Diseases: We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.
- Health Oversight: We may disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws.
- Abuse or Neglect: We may disclose your protected health information to a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, we may disclose your protected health information if we believe that you have been a victim of abuse, neglect or domestic violence to the governmental entity or agency authorized to receive such information. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.
- Food and Drug Administration: We may disclose your protected health information to a person or company required by the Food and Drug Administration for the purpose of quality, safety, or effectiveness of FDA-regulated products or activities including, to report adverse events, product defects or problems, biologic product deviations, to track products; to enable product recalls; to make repairs or replacements, or to conduct post marketing surveillance, as required.
- Legal Proceedings: We may disclose protected health information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), or in certain conditions in response to a subpoena, discovery request or other lawful process.
- Law Enforcement: We may also disclose protected health information, so long as applicable legal requirements are met, for law enforcement purposes. These law enforcement purposes include (1) legal processes and otherwise required by law, (2) limited information requests for identification and location purposes, (3) pertaining to victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) in the event that a crime occurs on the premises of our practice, and (6) medical emergency (not on our practice’s premises) and it is likely that a crime has occurred.
- Coroners, Funeral Directors, and Organ Donation: We may disclose protected health information to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose protected health information to a funeral director, as authorized by law, in order to permit the funeral director to carry out their duties. We may disclose such information in reasonable anticipation of death. Protected health information may be used and disclosed for cadaveric organ, eye or tissue donation purposes.
- Research: We may disclose your protected health information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information.
- Criminal Activity: Consistent with applicable federal and state laws, we may disclose your protected health information, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. We may also disclose protected health information if it is necessary for law enforcement authorities to identify or apprehend an individual.
- Military Activity and National Security: When the appropriate conditions apply, we may use or disclose protected health information of individuals who are Armed Forces personnel (1) for activities deemed necessary by appropriate military command authorities; (2) for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits, or (3) to foreign military authority if you are a member of that foreign military services. We may also disclose your protected health information to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally authorized.
- Workers’ Compensation: We may disclose your protected health information as authorized to comply with workers’ compensation laws and other similar legally-established programs.
- Inmates: We may use or disclose your protected health information if you are an inmate of a correctional facility and your physician created or received your protected health information in the course of providing care to you.
Uses and Disclosures of Protected Health Information Based upon Your Written Authorization
Other uses and disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law as described below. You may revoke this authorization in writing at any time. If you revoke your authorization, we will no longer use or disclose your protected health information for the reasons covered by your written authorization. Please understand that we are unable to take back any disclosures already made with your authorization.
Other Permitted and Required Uses and Disclosures That Require Providing You the Opportunity to Agree or Object
We may use and disclose your protected health information in the following instances. You have the opportunity to agree or object to the use or disclosure of all or part of your protected health information. If you are not present or able to agree or object to the use or disclosure of the protected health information, then your physician may, using professional judgment, determine whether the disclosure is in your best interest.
- Facility Directories: Unless you object, we will use and disclose in our facility directory your name, the location at which you are receiving care, your general condition (such as fair or stable), and your religious affiliation. All of this information, except religious affiliation, will be disclosed to people that ask for you by name. Your religious affiliation will be only given to a member of the clergy, such as a priest or rabbi.
- Others Involved in Your Health Care or Payment for your Care: Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your protected health information that directly relates to that person’s involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose protected health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition or death. Finally, we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care.
2. Your Rights
Following is a statement of your rights with respect to your protected health information and a brief description of how you may exercise these rights.
- You have the right to inspect and copy your protected health information. This means you may inspect and obtain a copy of protected health information about you for so long as we maintain the protected health information.
- You may obtain your medical record that contains medical and billing records and any other records that your physician and the practice uses for making decisions about you. As permitted by federal or state law, we may charge you a reasonable copy fee for a copy of your records. Under federal law, however, you may not inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding; and laboratory results that are subject to law that prohibits access to protected health information. Depending on the circumstances, a decision to deny access may be reviewable. In some circumstances, you may have a right to have this decision reviewed.
- Please contact our Privacy Officer if you have questions about access to your medical record. You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or health care operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.
- Your physician is not required to agree to a restriction that you may request. If your physician does agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment. With this in mind, please discuss any restriction you wish to request with your physician.
- You have the right to request to receive confidential communications from us by alternative means or at an alternative location. We will accommodate reasonable requests. We may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not request an explanation from you as to the basis for the request. Please make this request in writing to our Privacy Officer.
- You may have the right to have your physician amend your protected health information. This means you may request an amendment of protected health information about you in a designated record set for so long as we maintain this information. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Please contact our Privacy Officer if you have questions about amending your medical record.
- You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. This right applies to disclosures for purposes other than treatment, payment or health care operations as described in this Notice of Privacy Practices. It excludes disclosures we may have made to you if you authorized us to make the disclosure, for a facility directory, to family members or friends involved in your care, or for notification purposes, for national security or intelligence, to law enforcement (as provided in the privacy rule) or correctional facilities, as part of a limited data set disclosure. You have the right to receive specific information regarding these disclosures that occur after April 14, 2003. The right to receive this information is subject to certain exceptions, restrictions and limitations. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice electronically.
You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our Privacy Officer of your complaint. We will not retaliate against you for filing a complaint. You may contact your doctor if you have any other questions about privacy practices.