Please read the below statements outlining our Terms and Conditions Agreement. Please check the box at the end of this agreement and type in your name and then press submit.
1. Valhalla Vitality's hormone therapy treatment program is $149.95 per month.
2. Valhalla Vitality does not accept insurance. Health Savings Accounts (HSA) and Flex Spending Accounts (FSA) can be used for the monthly cost of treatment if it is backed by a major credit card (VISA, Mastercard, Discover, etc.).
3. A credit or debit card will be securely kept on file and a payment of $149.95 will be debited automatically on a monthly basis. (Your billing cycle will begin one month from the date that this agreement is acknowledged and accepted).
4. Two (2) months of medication will be shipped every other month.
5. $299.90 is the cost of two months of medication/treatment.
6. Due to federal laws, any medication that is misplaced, broken, stolen, etc., cannot be replaced. (This is with the exception that it has been determined that the incident was caused by the carrier (FedEx, UPS, USPS).
7. To ensure a patient's healthcare, additional labs and physicals may be required at the physician's discretion. Failure to adhere to the additional labs and physicals may result in a patient's removal of the program. (Altering of labs in any way is considered a criminal offense).
8. The patient will not be responsible for lab costs, if the patient has made six (6) consecutive monthly payments. Otherwise, the patient will be obligated to pay LabCorp directly for all the labs performed and pay Valhalla Vitality $149.95 for administrative fees.
9. Patients with repeated failed payments, may be required to pay for the medication up front which is a payment of $299.90.
10. It is a patient's responsibility to notify Valhalla Vitality of any address change prior to the prescription being faxed to the pharmacy. Failure to do so will result in a $30 re-routing/re-shipping fee.
11. To cancel therapy, Valhalla Vitality must be notified via email or send a registered letter and call a minimum of 72 hours prior to the next prescription refill date to avoid being billed $299.90.
12. If a patient decides to cancel hormone therapy in the middle of a billing cycle, the patient is still responsible for the second installment payment of $149.95.
13. If the package is refused/not accepted, the patient will still be held accountable for the entire payment, as federal law requires that any medication be destroyed once returned to the sender and prohibits the resale, relabel or re-shelf of the medication.
14. Please be advised, that you have the option to request to use a pharmacy of your choice.
15. The patient has 48 hours from the time they receive their package to notify Valhalla Vitality if there is anything claimed to be missing from the package. The time limit is based on that each prescription is video recorded being packaged and we must be able to access the video to prove the missing item was not packaged. Proof is needed to comply with federal law.
16. This Terms and Conditions Agreement is governed by the laws of the State of New York. Venue of any dispute of this Agreement shall lie in Queens County Court, New York.
Notice of Privacy Practices
How We Collect Information About You: Valhalla Vitality and its employees collect data through a variety of means, including but not limited to letters, phone calls, emails, voice mails, and from the submission of applications, that is either required by law, or necessary to process applications or other requests for assistance through our organization. What We Do Not Do With Your Information: Information about your financial situation and medical conditions and care that you provide to us in writing, via email, on the phone (including information left on voicemails), contained in or attached to applications, or directly or indirectly given to us, is held in the strictest confidence. We do not give out, exchange, barter, rent, sell, lend or disseminate any information about applicants or clients who apply for or actually receive our services. That information is considered patient confidential, is restricted by law, or has been specifically restricted by a patient/client in a signed HIPAA consent form. How We Do Use Your Information: Information is only used as necessary to process your application or to provide you with health or counseling services which may require communication between Valhalla Vitality and health care providers, medical product or service providers, pharmacies and other providers necessary to: verify that your medical information is accurate; determine the type of medical supplies or any health care services you need or to obtain or purchase any type of medical supplies, devices and medications. If you apply or attempt to apply to receive assistance through us and provide information with the intent or purpose of fraud or that results in either an actual crime of fraud for any reason including willful or un-willful acts of negligence or in any way demonstrates or indicates attempted fraud, your non-medical information can be given to legal authorities including police, investigators, courts, and/or attorneys or other legal professionals, as well as any other information as permitted by law.
Patient acknowledges and agrees that Physician and Group, along with their assigns, will be entitled to use any data, discoveries, results, improvements or other information resulting from the Services for any lawful purpose whatsoever, including, but not limited to, internal research, academic or other publications or commercial purposes. All data will be kept on a Cloud Based system that is password protected, and accessible to Valhalla Vitality staff.
give my express permission to Valhalla Vitality, to obtain and access to all of my medical records. I understand that my personal and medical information may be stored on a password protected secure cloud service.