CONSENT FOR IV THERAPY
This section is intended to serve as confirmation of informed consent for intravenous (IV) therapy as overseen by the medical director at Glacier Nurse Direct, LLP.
I have informed the medical practitioner of the following:
-Current medications and supplements I am taking as well as any pre-existing medical conditions.
-ALL known drug allergies or of any past reactions to anesthetics/IV therapy.
*I understand that I have the right to be informed of the procedure, any feasible alternative options, and the risks and benefits of IV therapy.
1) Benefits of intravenous therapy:
IV therapy is not affected by stomach or intestinal disease/malabsorption.
Full amount of IV infusion enters the bloodstream for availability to tissues.
Higher doses of nutrients can be given intravenously without intestinal irritation that can accompany doses given orally.
2) Risks and potential side effects of intravenous therapy:
-Discomfort, bruising, and pain at the site of injection.
-Inflammation of the vein used for injection, phlebitis, metabolic disturbances, and injury.
-Severe reaction, anaphylaxis, cardiac arrest, or death.
3) Alternatives to IV vitamin therapy:
-Dietary and lifestyle changes
I understand that I have the right to consent to or refuse any treatment at any time prior to its administration. My signature on this form affirms that I have given my consent to intravenous therapy and I am aware that other unforeseen complications can occur. Therefore, I give my consent to Glacier Nurse Direct using the Emergency Protocol should it be deemed necessary by the Medical practitioner. If the Emergency Protocol is not effective for the client, Glacier Nurse Direct’s medical practitioner’s reserve the right to call 911.
I understand that if I am currently, or was recently, under the influence of drugs and/or alcohol that Glacier Nurse Direct is not responsible for any adverse effects or interactions as a result of receiving IV hydration therapy.
I understand the risks and benefits of the procedure and have had the opportunity to have all my questions answered by Glacier Nurse Direct’s medical staff.
I understand that there is no implied or stated guarantee of success or effectiveness of any treatment offered thru Glacier Nurse Direct. I understand that Glacier Nurse Direct is not treating or diagnosing any condition. I understand that I am free to withdraw my consent and to discontinue participation in treatment at any time.
My signature below confirms that:
*I understand the information provided above and agree to the foregoing.
*The procedure set forth above has been adequately explained to me by Glacier Nurse Direct's staff.
*I authorize and consent to the performance of the procedure.
This billing consent is required to be completed and signed prior to Glacier Nurse Direct LLP providing any services.
WE DO NOT BILL INSURANCE, MEDICARE, OR MEDICAID
We do require credit card authorization upon booking any of our services. We also require a minimum of 24 hour notice of cancellation or rescheduling for a previously scheduled appointment. You will be charged a non-refundable fee of $50 for no-show/no-call appointments. We accept all major forms of credit/debit cards as well as cash & check. See below for specific payment policies related to services:
IV Therapy: Payment is due in full no later than at time of service. Payment is non-refundable, non-negotiable. All IV package deals or gift certificates require payment in full at time of booking. If you choose to pay at time of appointment for a regular IV therapy visit we will accept any of the above specified forms of payment.
Any payment that is not paid in full at time of service will be charged to the credit card we have on file from initial intake. You will be turned over to creditors for any unpaid charges 60 days after any service visit in which you did not pay.
HIPAA-NOTICE OF PRIVACY PRACTICES
Glacier Nurse Direct, LLP
This notice describes how medical information about you may be used and disclosed by Glacier Nurse Direct and how you can get access to this information. Please review it carefully.
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.
Get an electronic or paper copy of your medical record
You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.
We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
Ask us to correct your medical record
You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
We may say “no” to your request, but we’ll tell you why in writing within 60 days.
Request confidential communications
You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
We will say “yes” to all reasonable requests.
Ask us to limit what we use or share
You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.
If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.
Get a list of those with whom we’ve shared information
You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
Get a copy of this privacy notice
You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
Choose someone to act for you
If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act for you before we take any action.
File a complaint if you feel your rights are violated
You can complain if you feel we have violated your rights by contacting us directly at:
Glacier Nurse Direct:
You can file a complaint with the U.S. Department of Health and Human Services Office Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, or by calling , calling 1-877-696-6775.
We will not retaliate against you for filing a complaint.
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.
In these cases, you have both the right and choice to tell us to:
Share information with your family, close friends, or others involved in your care
Share information in a disaster relief situation
Include your information in a hospital directory
If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
In these cases we never share your information unless you give us written permission:
Sale of your information
Most sharing of psychotherapy notes
In the case of fundraising:
We may contact you for fundraising efforts, but you can tell us not to contact you again.
Our Uses and Disclosures
How do we typically use or share your health information?
We typically use or share your health information in the following ways.
We can use your health information and share it with other professionals who are treating you.
Example: A doctor treating you for an injury asks another doctor about your overall health condition.
Run our organization
We can use and share your health information to run our practice, improve your care, and contact you when necessary. We are a very discreet and private organization and never sell nor market any personal information.
To remind you of an appointment you have for medical care;
To assess your satisfaction with our services;
To tell you about health-related benefits or services;
For conducting training programs and reviewing competence of health care professionals.
Example: We use health information about you to manage your treatment and services.
Bill for your services
We can use and share your health information to bill and get payment from health plans or other entities. We currently do not bill insurance, but this may be valid in the future should we start billing insurance for any reason.
Example: We give information about you to your health insurance plan so it will pay for your services.
How else can we use or share your health information?
We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes.
Help with public health and safety issues
We can share health information about you for certain situations such as:
Helping with product recalls
Reporting adverse reactions to medications
Reporting suspected abuse, neglect, or domestic violence
Preventing or reducing a serious threat to anyone’s health or safety
We can use or share your information for health research.
Comply with the law
We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.
Respond to organ and tissue donation requests
We can share health information about you with organ procurement organizations.
Work with a medical examiner or funeral director
We can share health information with a coroner, medical examiner, or funeral director when an individual dies.
Address workers’ compensation, law enforcement, and other government requests
We can use or share health information about you:
For workers’ compensation claims
For law enforcement purposes or with a law enforcement official
With health oversight agencies for activities authorized by law
For special government functions such as military, national security, and presidential protective services
Respond to lawsuits and legal actions
We can share health information about you in response to a court or administrative order, or in response to a subpoena.
Business Associates: There are some services provided in our organization through contracts with business associates. We may disclose your health information to our business associate so they can perform the job we've asked them to do. To protect your health information, however, we require the business associate to appropriately safeguard your information.
Individuals Involved in Your Care or Payment for Your Care: We may release medical information about you to a friend or family member who is involved in your medical care or who helps pay for your care.
We are required by law to maintain the privacy and security of your protected health information.
We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
We must follow the duties and privacy practices described in this notice and give you a copy of it.
We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
Changes to the Terms of this Notice
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.
This Notice is effective as of the date that this document is signed.