B12 Miami Telehealth HIPAA Notice of Privacy Practice
This describes how your information may be disclosed and how you get access to this information. This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment, and healthcare 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, or PHI, 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 healthcare services.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 that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operations of the physician’s practice, and any other use required by law.Treatment We will only use and disclose your protected health information to provide, coordinate, or manage your health care and related services. This includes the coordination or management of your health care with a third party. For example, we would disclose your protected health information, as necessary, to a home health agency that provides you care to you, or provide it to a physician whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.PaymentYour protected health information will be used as needed to obtain payment for your health care services.Healthcare OperationsWe 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, employee review, training of medical students, and licensing. For example, we may call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointments.We may use or disclose your protected health information in the following situations without your authorization: as required by law, public health issues, communicable diseases, health oversight, abuse or neglect, food and drug administration requirements, legal proceedings, law enforcement, coroners, funeral directors, organ donation, research, criminal activity, military activity, and national security. Under the law, we must also make disclosures to you, and when required by the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500.Other Permitted & Required Uses and Disclosures will be made only with your authorization or opportunity to object unless required by law. You may revoke this authorization at any time, in writing, except to the extent that your physician or the physician’s practice has taken an action in reliance on the use or disclosure indicated in the authorization.Your Individual Rights:1.You have the right to inspect and receive a copy of your protected health information. Our practice will accept such requests in writing. Under federal law, however, you may not inspect or receive a copy of the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding; and protected health information that is subject to law that prohibits access to protected health information.2.You have the right to request a restriction on the disclosure 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 healthcare 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 a physician believes it is in your best interest to permit use and disclosure of our protected health information, your health information will not be restricted. You then have the right to use another healthcare professional.3.You have the right to request to receive confidential communications from us by an alternative means or at an alternative location.4.You have the right to obtain a paper copy of this notice from us.5. You have the right to receive an accounting of certain disclosure we have made, if any, of your protected health information. We reserve the right to change the terms of this notice and will post any changes in our waiting areas. You then have the right to object as provided in this notice.ComplaintsYou may file any complaints with our Office Manager Javier Cuenca at 954-512-8572 or with the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. We will not retaliate against you for filing a complaint.
B12 Miami, LLC Receipt of Notice of Privacy Practices
B12 Miami,LLC reserves the right to modify the privacy practices outlined in this notice.
By signing below, I am indicating that I have read and understand the Notice of Privacy practices.
Patient Authorization Agreement
TERMS AND CONDITION
Your health is a very important personal issue and we understand that confidentiality of your information is of the highest priority and of utmost importance. To protect your privacy, we have implemented and will follow specific security protocols and processes on every matter that is related to your files and information. We use the highest level of individual customer, electronic transfer and internet security features provided by Gravity Forms. They are specifically designed to guarantee your privacy and security to the very best of our ability. Our company policy is to not allow any unauthorized party access to any part of your personal financial or medical information without your written instruction. If you have a question on our security processes or protocols please contact us immediately.
ONLINE ORDERS
Nothing contained in this Web Site or in printed materials shall constitute an offer by B12 Miami,LLC, its officers, employees or affiliates to buy or sell products or services to you. No agreement to sell products or services shall be formed until an order is placed by you and then approved by B12 Miami,LLC, its affiliates in the manner set forth in B12 Miami,LLC’S specific ordering instructions. The terms of such agreement shall be those of B12 Miami,LLC’S established procedures or any such of our affiliate’s standard terms and conditions. All product requests or orders are subject to all applicable law of the State of Florida.
PATIENT AUTHORIZATION AND CONSENT
In consideration of instructions from B12 Miami, LLC, hereinafter referred to as («Coordinator) providing the undersigned patient, hereinafter referred to as («Patient») with medical management, administrative or referral services, Patient acknowledges and agrees to the following terms and conditions contained in this Patient Authorization Agreement («Agreement») and supersedes all other instructions written or oral received from B12 Miami, LLC. With this agreement, Patient also submits an accurately completed Medical History Form hereinafter referred to as («MHF»). Patient agrees to respond truthfully, accurately and completely in completing the MHF or with any agent provided by Coordinator to assist in completing the form and acknowledges that failure to provide truthful, accurate and complete information on the MHF or to Coordinator, the physicians, nurses or staff referred by B12 Miami, LLC could result in inappropriate treatment.
Patient authorizes Coordinator to obtain on my behalf medical laboratories or diagnostic testing when required, Physicians, and dispensing pharmacies. In addition, Patient authorizes and instructs Coordinator and Physicians hereinafter referred to as («Physicians»), referred by Coordinator and any dispensing pharmacies obtained on my behalf to provide medical care and prescribed pharmaceuticals if necessary are based on the MHF, laboratory diagnostic tests, and other information submitted to Coordinator and Physician under this agreement. Patient agrees to present photo identification upon any blood testing pursuant to a Physician’s test requisition.
Patient acknowledges that therapies, laboratory and diagnostic testing services supplied or obtained by Coordinator as well as medical services provided to me by Physicians or pharmacies, are not covered or reimbursed by insurance.
Patient acknowledges that Coordinators, employees and agents are not licensed physicians and that licensed Physicians obtained for me by Coordinator are independent contractors, which will be compensated by Patient with funds provided to Coordinator. Patient acknowledges that B12 Miami, LLC does not practice medicine and that they are a medical management, administrative, consultant and referral service that does not direct, control, or influence the treatment decisions made by Physician. I further understand and agree that Coordinator is rendering services and that Coordinator is instructed by Patient and is authorized by Patient to arrange for the prescribed pharmaceuticals if required to be dispensed and sent to my address by any pharmacy in my country of residence. All medical care and treatments are agreed upon by the Patient, the Physician and the Patients personal Physician.
Patient acknowledges and assigns B12 Miami, LLC as a designee of the patient, to engage in discussion with the physician or the physician assistant regarding treatment options and the risks and benefits of treatment.
Patient covenants and agrees to comply with the method of instructions, treatment and dosage schedules prescribed by the Physician, Patient further agrees to immediately cease any medical treatment prescribed by the Physician in the event of any adverse reaction or side effect arising from or believed to arise from the prescribed treatment, and to immediately provide Physician and Patients Personal Care Physician with written notice via e-mail to Physician at [email protected] or by telephone to 954-512-8572 of any such adverse reaction or side effect.
I further acknowledge and agree that B12 Miami, LLC is not liable for any negligent act or omission of the Physician. Patient acknowledges that diagnosis and treatment may involve risk of injury, and that B12 Miami,LLC and Physician have made no guarantees or warranties with respect to the above-described diagnostic testing, analysis of test results, examination of medical history.
Nonetheless, Patient freely consents to such care and treatment, and executes this Agreement with a complete, informed understanding of the HCG Assisted Diet protocols for the purpose of authorizing Physician to administer such treatment to attempt to enhance Patient’s physical condition and health based on Patients MHF. Patient further acknowledges that the methods of medical treatment offered by Physician are not accompanied by any claims, guarantees, promises or warranties.
It is fully agreed and understood by the patient that personal prescription products purchased through or obtained on my behalf require a medical prescription and as such are NOT returnable or refundable under any circumstances under both Federal and/or State laws. It is unlawful for a pharmacy to accept the return of prescription medications once they have left the control of the pharmacy.
Patient is freely seeking medical consultation via the Internet, phone, or direct contact and acknowledges, request and consents to Physician reviewing their medical history without having the opportunity to conduct an in-person physical examination. Patient solicits Coordinator to order any specific prescription medication to take part in the HCG Assisted Diet. Further, Patient agrees that Physician’s consultations, diagnoses, and treatments will be deemed to have occurred in Florida, and with the legal rules for Telemedicine in Florida.
Patient represents that he or she is under the care of a Primary Care Physician (PCP) and that the Physician will not rely or substitute the advice of any physician should that advice conflict with the advice given by Patient’s Primary Care Physician. Before taking any medication patient agrees to have or to have had a physical examination by their (PCP). Patient agrees to notify his or her (PCP) and advise such (PCP) that they intend to begin the HCG Assisted Diet Program.
Patient acknowledges that under Florida law, physicians are generally required to carry medical malpractice insurance or otherwise demonstrate financial responsibility to cover potential claims for medical malpractice. Physician, Coordinator, and B12 Miami, LLC have DECIDED NOT TO CARRY MEDICAL MALPRACTICE INSURANCE. This is permitted under Florida law subject to certain conditions. Florida law imposes penalties against non-insured physicians who fail to satisfy adverse judgments arising from claims of medical malpractice. This notice is provided pursuant to Florida law.
Patient acknowledges and agrees that B12 Miami, LLC is not responsible for the negligent or intentional acts or omissions of any health care provider, Physician or supplier that Patient is referred or for any action or inaction taken by Patient, and that the total liability of B12 Miami, LLC, its officers, directors, employees, agents, and stockholders is limited to the purchase price of any products through B12 Miami, LLC, Physicians or Pharmacies, and that B12 Miami, LLC and Physicians will not be liable for any direct, indirect, special, accidental, consequential, or punitive damages.
During Patients relationship with Coordinator and Physician, Patient will receive a range of proprietary business information including, confidential disclosures, and trade secrets, business practices and B12 Miami, LLC’s associates and suppliers («Confidential Information»). No matter how received by the Patient during the parties’ relationship, Patient agrees that Confidential Information is confidential, proprietary and uniquely valuable to B12 Miami, LLC and could gravely affects the conduct of business of B12 Miami, LLC and B12 Miami, LLC’s goodwill. Patient agrees not to disclose, divulge or communicate, in any fashion, form, or manner, either directly or indirectly, any Confidential Information or take any action that may result in disclosure of Confidential Information to any third party person, firm, or business.
Patient agrees that the amount of B12 Miami, LLC’s actual damages in such circumstances would be difficult, if not impossible, to determine with accuracy, but would be substantial in any event, and Patient agrees that such damages are a penalty.
Based on the above-understanding and my signature below, Patient agrees to release B12 Miami, LLC, its officers, directors, employees, agents and shareholders, and Physician from any and all liability associated with or arising from the Physician’s consultation or from the medical, physical, behavioral or other effects of any medication or treatment that may be ordered, prescribed or purchased as a result of the Physician’s consultation.
This Agreement shall be governed, construed and enforced in accordance with the laws of the State of Florida, applicable to agreements made and to be made and to be performed entirely within such State, without regard to principles of conflict of laws. Any disputes arising out of, in connection with or with respect to this Agreement, shall be adjudicated in a court of competent jurisdiction sitting in Broward County, Florida and nowhere else. Patient hereby irrevocably submits to the jurisdiction of such court for the purposes of any suit, civil action or other proceeding arising out of, in connection with or with respect to this Agreement. In the event of any litigation arising out of this Agreement, the prevailing party shall be entitled to recover all expenses and costs incurred, including reasonable attorneys’ fees and legal assistants’ fees.
This Agreement contains the entire understanding of the parties and supersedes all prior and contemporaneous agreements and discussions between the parties. Any and all representations or agreements by any agent or representative of either party not contained in this Agreement shall be null, void, and of no effect.
If any provision of this Agreement or the application thereof to any person or circumstances is invalid or unenforceable in any jurisdiction, the remainder hereof, and all application of such provision to such person or circumstances in any other jurisdiction, shall not be effected thereby, and to this end the provisions of this Agreement shall be severable.
Patient covenants and agrees to indemnify, defend, protect, and hold harmless, and Physician and their respective officers, directors, employees, stockholders, assigns, successors, and affiliates hereinafter referred to as («Indemnified Parties») from, against and in respect of all liabilities, losses, claims, damages, punitive damages, causes of action, lawsuits, administrative proceedings, investigation, demands, judgments, settlement payments, deficiencies, penalties, fines, interest and costs and expenses suffered, sustained, incurred or paired by the Indemnified Parties in connection with, resulting from, or arising out of, any acts, directly or indirectly, by B12 Miami, LLC, their staff and/or Physician’s rendering medical care services, advice and/or treatment resulting from Patient’s acts or omissions or failure to disclose all relevant information regarding Patient’s medical and physical condition. B12 Miami, LLC and Physician are released from any responsibility to patient that results from acts, omissions or failures of disclosure by Patient as mentioned above.
Patient is aware of potential side effects associated with the above-described diet treatment, accepts all risks involved in taking medication and the very low calorie diet protocols and will not seek damages from the Indemnified Parties of this Agreement.
I the undersigned Patient have read and clearly understand and agree to all of the above Terms and Conditions of this Agreement from B12 Miami, LLC.
