Weight Loss ~ Aesthetics~
Signed in as:
filler@godaddy.com
Weight Loss ~ Aesthetics~
Signed in as:
filler@godaddy.com
Proudly serving South Carolina Residents.
We are committed to protecting your privacy and developing technology that gives you the most powerful and safe online experience. This Statement of Privacy applies to our Practice's Web site and governs data collection and usage. By using this website, you consent to the data practices described in this statement.
This Practice collects personally identifiable information, such as your e-mail address, name, home or work address or telephone number. This Practice also collects anonymous demographic information, which is not unique to you, such as your ZIP code, age, gender, preferences, interests and favorites.
There is also information about your computer hardware and software that is automatically collected by this website. This information can include: your IP address, browser type, domain names, access times and referring Web site addresses. This information is used for the operation of the service, to maintain quality of the service, and to provide general statistics regarding use of this Web site.
Please keep in mind that if you directly disclose personally identifiable information or personally sensitive data through public message boards, this information may be collected and used by others.
This Practice encourages you to review the privacy statements of Web sites you choose to link to from the website so that you can understand how those Web sites collect, use and share your information. This Practice is not responsible for the privacy statements or other content on any other Web sites.
This Practice collects and uses your personal information to operate the Web site and deliver the services you have requested. This Practice also uses your personally identifiable information to inform you of other products or services available from this Practice and its affiliates. This Practice may also contact you via surveys to conduct research about your opinion of current services or of potential new services that may be offered.
This Practice does not sell, rent or lease its customer lists to third parties. This Practice may share data with trusted partners to help us perform statistical analysis, send you email or postal mail, provide customer support, or arrange for deliveries. All such third parties are prohibited from using your personal information except to provide these services and they are required to maintain the confidentiality of your information.
This Practice does not use or disclose sensitive personal information, such as race, religion, or political affiliations, without your explicit consent.
This Practice will disclose your personal information, without notice, only if required to do so by law.
The Web site uses "cookies" to help this Practice personalize your online experience. A cookie is a text file that is placed on your hard disk by a Web page server. Cookies cannot be used to run programs or deliver viruses to your computer. Cookies are uniquely assigned to you, and can only be read by a web server in the domain that issued the cookie to you.
This Practice secures your personal information from unauthorized access, use or disclosure. This Practice secures the personally identifiable information you provide on computer servers in a controlled, secure environment, protected from unauthorized access, use or disclosure. When personal information (such as a credit card number) is transmitted to other Web sites, it is protected through the use of encryption, such as the Secure Socket Layer (SSL) protocol.
This Practice will occasionally update this Statement of Privacy to reflect company and customer feedback. We encourage you to periodically review this Statement to be informed of how this Practice is protecting your information.
If you have questions or concerns regarding this policy, please contact New You Weight Loss & Wellness (843) 761-8905 or email newyouweight@gmail.com. Our office is located at 206 Rembert C Dennis Blvd Moncks Corner, SC 29461.
CONSENT AND POLICIES
INFORMED CONSENT TO TREAT
I hereby give my consent for New You Weight Loss & Wellness Inc.
I understand and I am informed that, as with all healthcare treatments, results are not guaranteed and there is no promise to cure.
I have had the opportunity to discuss with my provider the nature and purpose of treatments and procedures. I am aware that all existing methods of diagnosis and treatment, pose some level of risk.
I do not expect the provider to be able to anticipate and explain all risks and complications, and I wish to rely on the provider to exercise judgment during the course of the treatment which the provider feels at the time, based upon the facts then known, is in my best interests.
I will immediately inform the provider if I experience any gastrointestinal upset (nausea, gas, stomachache, vomiting or similar condition), allergic reactions (hives, rashes, tingling of the tongue, headache or similar condition), or any unanticipated or unpleasant effects associated with treatment or supplements prescribed/recommended.
I understand that if an emergency medical condition arises, I am expected to call 9-1-1.
I understand that if I have suicidal ideation or self harm I will seek emergency services and or call 9-1-1
LABORATORY TESTS
I understand that New You Weight Loss & Wellness Inc may recommend blood, saliva, stool, urine or skin testing within their scope of practice. In addition to conventional testing, specific tests may be ordered through specialized laboratories to assess structural and/or functional deficiencies, and may not always be diagnostic, but can provide critical information to help improve my health outcomes. I agree to the use of such tests and will always have the opportunity to discuss their applicability and limitations with my provider, prior to sample collection. I agree to pay the laboratory any fees due for sample collection and processing.
TELEHEALTH CONSENT
I consent to voluntarily engaging in a telemedicine consultation with New You Weight Loss & Wellness Inc
I understand that the video conferencing technology will not be the same as a direct patient/health care provider visit:
Telehealth consultation has potential benefits including easier access to care, decreasing costs, and allowing visits to be performed from the comfort of my home.
It also has potential risks including interruptions, unauthorized access, and technical difficulties.
I understand that my health care provider or I can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.
If there is another individual present during the telehealth consultation, I will be informed of their presence and I will also disclose if there is another individual with myself. It is agreed that these individuals will maintain confidentiality of the information obtained.
I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history/physical examination that are personally sensitive to me; (2) ask non-medical personnel to leave the telemedicine examination room: and or (3) terminate the consultation at any time.
I understand that telemedicine has limitations in regard to the physical examination. I understand that the physical exam portion of the care provided through New You Weight Loss & Wellness Incwill be limited to inspection via video conferencing and some parts of the exam such as physical tests, examination of certain body parts, and vital signs may be conducted by individuals at my location at the direction of the consulting health care provider or not done at all.
Telemedicine services offered through New You Weight Loss & Wellness Inc are not an Emergency Service and in the event of an emergency or urgent medical issue, I will use a phone to call 911, go to the emergency department, or go to an urgent care.
To maintain my privacy, I will not share telemedicine login information or video conferencing links with anyone unauthorized to attend the appointment.
TELEPHONE CONSULTATION CONSENT
I understand that New You Weight Loss & Wellness Incmay, on rare occasion, allow telephone consultations - verbal conversation only / no video. I understand that these consultations have considerable limitations, including but not limited to no physical exam or visual assessment. I understand that my provider, during the telephone consultation, may determine that adequate care and treatment is not be possible with the limited assessment via telephone consult. I agree to follow through with them on any required in-person office visits or video telehealth visits. I consent to receive instructions via phone/telemedicine platform and take full responsibility to follow through with specific instructions as required for my treatment. I have had the opportunity to discuss the limitations with my provider.
EMAIL USE CONSENT
The preferred method of communication is via HIPPA-compliant Patient Portal
However, New You Weight Loss & Wellness Inc provides patients with the opportunity to communicate by e-mail.
Transmitting confidential health information by e-mail however, has a number of risks: E-mail can be immediately broadcast worldwide and be received by many intended and unintended recipients; recipients can forward e-mail messages to other recipients without the original sender(s) permission or knowledge; users can easily copy information.
It is the policy of New You Weight Loss & Wellness Incthat all e-mail messages sent or received which concern the diagnosis or treatment of a patient will be a part of the patient’s protected personal health information and cannot guarantee the security and confidentiality of e-mail or internet communication.
Patients may consent to the use of e-mail for confidential medical information after having been informed of the above risks with the following conditions: All e-mails to or from patients concerning diagnosis and/or treatment will be made part of the protected personal health information. As a part of the protected personal health information, other individuals, insurance coordinators and upon written authorization other healthcare providers and insurers will have access to e-mail messages contained in protected personal health information.
Provider and staff will endeavor to read e-mail promptly. However, can provide no assurance that the e-mail will read immediately. Therefore, e-mail must never be used in a medical emergency.
Because some medical information is so sensitive that unauthorized disclosure can be damaging, e-mail should not be used for communications concerning diagnosis or treatment of any sexually transmittable or communicable diseases such as syphilis, gonorrhea, and the like; behavioral health, mental health; or alcohol and drug abuse.
New You Weight Loss & Wellness Inc cannot guarantee that electronic communications will be private and is not liable for improper disclosure of confidential information not caused by its employee’s gross negligence or wanton misconduct and is not liable for breaches of confidentiality caused by the patient.
I understand that my consent to the use of e-mail may be withdrawn at any time be e-mail or written communication to New You Weight Loss & Wellness Inc I have read this form carefully and understand the risks and responsibility associated with the use of e-mail. I agree to assume all risks associated with the use of e-mail
APPOINTMENT REMINDERS CONSENT
New You Weight Loss & Wellness Inc may need to use my name, address, phone number, and my clinical records to contact me with appointment reminders/text message, information about treatment alternatives or other health related information that may be of interest to me. If this contact is made by phone and I am not available, a message will be left on my answering machine or with the person answering the phone.
By signing this form, I am giving New You Weight Loss & Wellness Center Inc the authorization to contact you with these reminders and information and to leave a message on my answering machine or with individuals at my home or place of employment.
RELEASE OF INFORMATION
I may restrict the individuals or organizations to which your health care information is released or I may revoke your authorization at any time: however, this revocation must be in writing and mailed to the office address. New You Weight Loss & Wellness Inc will not be able to honor my revocation request if they have already released my health information before the request to revoke authorization. In addition, if I was required to give my authorization as a condition of obtaining insurance, the insurance may have a right to your health information if they decide to contest any of your claims.
Information that New You Weight Loss & Wellness Inc may use or disclose based on the authorization I am giving may be subject to re-disclosure by anyone who has access to the reminder or other information and may no longer be protected by the federal privacy rules.
I have the right to refuse to give us this authorization. If I do not give authorization, it will not affect the treatment I receive or the methods used to obtain reimbursement for my care.
I may inspect or copy the information that is used contact me to provide appointment reminders, information about treatment alternatives, or other health information at any time.
This notice is effective on the date of signature. This authorization will expire seven years after the data on which I last receive services from New You Weight Loss & Wellness Inc
I authorize you to use or disclose my health information in manner described above. I acknowledge that I have received a copy of this authorization.
I understand photographs may be taken of me during my treatment to document progress that may be used for marketing purposes only if I give direct consent when asked and I have final editing rights to my images if they are selected for use.
FINANCIAL POLICIES
FEES AND PAYMENTS
New You Weight Loss & Wellness Inc does not file for insurance reimbursement. All services are paid by the patient at the time of service. You may pay cash, credit card, HSA card, or Flexible Spending Card. We will provide you with a superbill with all the necessary codes, so that you may file for reimbursement by your insurance company.
As the patient, it is in your best interest to know and understand your insurance plan benefits. It is important that you know your benefits prior to visit. Regardless of your individual insurance coverage or type, as the person seeking medical treatment you are ultimately responsible for all charges.
All outstanding balances must be paid in full prior to next office visit or receiving supplements.
MISSED APPOINTMENT FEE - This office requires 48-hour notice if you are unable to keep your new patient or initial visit and 48-hour notice if you cannot keep your follow up or routine visit. If you miss an appointment or fail to give sufficient notice, you will be charged $50.00 for that missed appointment. This payment is expected before any further treatment will be rendered, or supplements can be purchased.
RETURNED CHECK - There is a $30.00 fee for any check returned by the bank.
PAST DUE ACCOUNTS - If your account becomes past due, we will take necessary steps to collect this debt. At the time of your initial office visit a copy of your credit card will be taken. If your account becomes past due over 90 days, that credit card will be charged. If the credit card declines or there are any other problems, your account will be referred to our collection agency. You will be charged for this service in addition to your current account balance. If payment is not received your credit report will be blemished. If we have to refer collection of balance to a lawyer, you agree to pay all of the lawyer's fees, which we incur, plus all court costs.
SPECIAL LETTERS, FORMS, and DOCUMENTS - Completing special insurance forms, workplace documentation, writing letters of medical necessity, ESA etc. require significant provider time and will be charged an administrative fee of $50 per document/letter. Fees must be paid in advance. Some documentation may require extensive time / complexity and may justify a higher fee. If so, this fee will be disclosed to you prior to preparing the documents.
SUPPLEMENT DISCLAIMER
Many supplements, vitamins, medical grade foods, nutritional powders, botanicals, and homeopathic remedies have not been evaluated by the US Food & Drug Administration (FDA) and these products are not intended to diagnose, treat, cure, or prevent any disease.
NO REFUNDS, CREDITS, OR EXCHANGES are allowed on any supplement(s), herbs, homeopathic remedy/remedies, vitamins, and nutritional supplements. Once these items have been purchased or left the office, they cannot be brought back under any circumstance.
All services and supplementation must be PAID IN FULL at the time of service. A remaining balance is not allowed.
Supplements may be bought directly from our trusted online dispensary or you can choose to purchase them at a dispensary of your choice. The cost of supplements is not included in the visit fee.
Please inform the practitioner if you are vegetarian and require vegetarian supplementation. Remember, there are NO refunds, exchanges or credits given. All sales are FINAL.
CREDIT CARD AUTHORIZATION
I authorize to maintain my credit card number in the electronic health record and to use it to process payment for services rendered or supplements or other items purchased by me.
I authorize New You Weight Loss & Wellness Inc to process the credit card on file for any balance due on my account past 90 days and for any payments authorized by me.
I understand that a receipt superbill and receipt showing what was paid for will be sent to me within 30 days of each visit. I know that I am responsible for letting the clinic know if anything has changed concerning my credit card information.
PRIVACY POLICY / HIPPA COMPLIANCE
OUR LEGAL RESPONSIBILITIES
We are required by law to give you this notice. It provides you on how we may use and disclose protected health information about you and describes your rights and our obligations regarding the use and disclosure of that information. We shall maintain the privacy of protected health information and provide you with notice of our legal duties and privacy practices with respect to your protected health information.
We have the right to change these policies at any time. If we change our privacy policies, we will notify you of these changes immediately. This current policy is in effect unless stated otherwise. If the policy is changed, it will apply to all your current and past health information.
You may request a copy of our notice any time. You may contact New You Weight Loss & Wellness Inc at 206 Rembert C Dennis Blvd Moncks Corner, SC 29461 or newyouweight@gmail.com at any time to request a copy of this privacy policy.
HOW WE MAY USE OR DISCLOSE YOUR PROTECTED HEALTH INFORMATION
The following examples describe ways that we may use your protected health information for your treatment, payments, healthcare operations etc. but please be advised that not every use or disclosure in a particular category will be listed.
Treatment: We may use and disclose your protected health information to provide you treatment. This includes disclosing your protected health information to other medical providers, trainees, therapists, medical staff, and office staff that are involved in your health care.
For example, your medical provider might need to consult with another provider to coordinate your care. Also, the office staff may need to use and disclose your protected health information to other individuals outside of our office such as the pharmacy when a prescription is called in.
Payment: Your protected health information may also be used to facilitate payment or reimbursement to you from an insurance company or another third part. This may include providing an insurance company your protected health information for a pre-authorization for a medication we prescribed.
Health Care Operations: We may use or disclose your protected health information in order to operate this medical practice. These activities include training students, reviewing cases with employees, utilizing your information to improve the quality of care, and contacting you be telephone, email, or text to remind you of your appointments.
If we have to share your protected health information to third party “business associates” such as a billing service, if so, we will have a written contract that contains terms that will protect the privacy of your protected health information.
We may also use and disclose your protected health information for marketing activities. For example, we might send you a thank you card in the mail with a coupon for specialized services or products. We may also send you information about products or services that might be of interest to you. You can contact us at any point to stop receiving this information.
We will not use or disclose your protected health information for any purpose other than those identified in this policy without your specific, written Authorization. You may give us written authorization to use your protected health information or to disclose it to anyone for any purpose. You can revoke this authorization at any time but will not affect the protected health information that was shared while the authorization was in effect.
Appointment reminders: We may contact you as a reminder that you have an appointment for your initial visit, follow up visit, or lab work via text, phone or email.
Others Involved in Your Health Care: We may disclose protected health information about you to your family members or friends if we obtain your verbal agreement to do so, or if we give you an opportunity to object to such a disclosure and you do not raise an objection. For example, we may assume that if your spouse or friend is present during your evaluation, that we can disclose protected professional information to this person. 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 if there is an urgent or emergent need.
Research; We will not use or disclose your health information for research purposes unless you give us authorization to do so.
Organ Donation: If you are an organ donor, we may release protected health information to organizations that handle organ procurement or organ, eye or tissue transplantation if it is necessary to facilitate this process.
Public Health Risks: We may disclose your protected health information, if necessary, in order to prevent or control disease, report adverse events from medications or products, prevent injury, disability or death. This information may be disclosed to healthcare systems, government agencies, or public health authorities. We may have to disclose your protected health information to the Food and Drug Administration to report adverse events, defects, problems, enable recalls etc. if required by FDA regulation.
Health Oversight Activities: We may disclose protected health information to health oversight agencies for audits, investigations, inspections or licensing purposes. These disclosures might be necessary for state and federal agencies to monitor healthcare systems and compliance with civil law.
Required by Law: We will disclose protected health information about you when required to do so by federal, state and/or local law.
Workman’s compensation: We may disclose your protected health information to workman’s comp or similar programs.
Lawsuits: We may disclose your protected health information in response to a court action, administrative action or a subpoena.
Law Enforcement: We may release protected health information to a law enforcement official in response to a court order, subpoena, warrant, subject to all applicable legal requirements.
YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION
Access to medical records: You have the right to access and receive copies of your protected health information that we use to make decisions about your care. You must submit a written request to obtain your protected health information to the individual listed at the end of this privacy policy. We reserve the right to charge you a fee for the time it takes to obtain and copy the protected health information and provide it to you.
Amendment: If you believe the protected health information, we have about you is incorrect or incomplete, you may ask us to amend the information You will need to submit a written request on why you feel the health information should be amended. We may deny your request to amend if you did not send a written request or give a reason on why it should be amended. If we deny your request, we will provide you a written explanation. We may deny your request if we believe the protected health information is accurate and complete.
Accounting of Disclosures: You have the right to receive a list of instances in which we disclosed your personal health information unless the disclosure was used for treatment, payment, healthcare operations, was pursuant to a valid authorization and as otherwise provided in applicable federal and state laws and regulations. You must submit a written request to obtain this “accounting of disclosures” to the individual listed at the bottom of this policy. After your request has been approved, we will provide you the dates of the disclosure, the name of the individual or entity we disclosed the information to, a description of the information that was disclosed, the reason why it was disclosed, and any additional pertinent information. This information may not be longer than 3 years ago prior to the date the accounting is requested. We reserve the right to charge a reasonable fee for this process.
Restriction Requests: You have the right to request a restriction or limitation on the protected health information we use or disclose about you for treatment, payment, or healthcare operations. We shall accommodate your request except where the disclosure is required by law. We require this be a written request submitted to the individual at the end of this policy.
Confidential Communication: You have the right to request that we communicate with you about healthcare matters in a certain way and at a certain location. We must accommodate your request if it is reasonable and allows us to continue to collect payments and bill you.
Paper copy of this notice: You may request a hard copy of this practice policy if you reviewed and signed it via electronic means. To obtain this copy, contact the individual at the end of this privacy policy.
Complaints: If you believe your privacy rights have been violated, you may file a complaint with our office. You also file a complaint with the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request.
Name of Contact Person:
Richard Brinson, FNP-C
843-761-8905
206 Rembert C Dennis Blvd Moncks Corner SC 29461
PATIENT RIGHTS AND RESPONSIBILITIES
We are committed to serving you with compassion, care, and respect. As one of our valued clients you are entitled to the following:
You have the right:
You have the responsibility:
By signing this form, I certify: