IN8 HEALING

Credit Card Authorization

I authorize In8 Healing to charge my card for services rendered.

I understand that though this information is secured in an online protected client file, and is unlikely to be tampered with, I agree to assume the risk if the file and credit card information is compromised. 

I agree that if I have any concerns or questions regarding charges to my account, or if the charge fails to post to my account, I will contact In8 Healing for assistance and/or disclosure. I agree that I will not dispute any charges with my credit card company unless I have already attempted to rectify the situation directly with In8 Healing and those attempts have failed. 

I understand and agree to these terms. I understand the conditions of this payment policy and agree to the conditions stated above:  

_________________

Consent Form

I understand that the Healing Touch/Iridology I receive is provided for the basic purpose of assessment and services. If I experience any pain or discomfort during the session, I will immediately inform the practitioner.

I further understand that Healing Touch/Iridology should not be construed as a substitute for medical examination, diagnosis, or treatment. I understand that nurses, healing touch practitioners, and Iridologists do not diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. I affirm that I have stated all my known medical conditions, and answered all questions honestly.

I agree to keep the practitioner updated as to any changes in my medical profile during the session and understand that there shall be no liability on the practitioner’s part should I fail to do so. I understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session. I also understand that the practitioner reserves the right to refuse to treat anyone whom they deem to have a condition which is contraindicated.

__________________

Notice of Privacy Practices

For Healing Touch Clients

This notice describes how health information about you may be used and disclosed and how you can get access to this information. Please carefully review this notice. As a provider of Healing Touch, I am committed to protecting health information about you. I create a record of our interactions and the services that you receive from me for use in your health care and Healing Touch service. Typically, this record contains information regarding your health history, symptoms you may be experiencing, physical health and energy assessment, nursing diagnosis, intervention, and proposed plan of care. This health information will only be utilized to the extent necessary to provide you with quality health care.

My Responsibility. 

I am required by law to:

• Ensure that health information that identifies you is kept private and confidential.

• Give you this Notice of my legal duties and privacy practices with respect to your health information.

• Follow the terms of this Notice as long as it is in effect. If I revise this notice, I will follow the terms of the revised Notice as long as the revised Notice is in effect.

I. How I may use or disclose your health information

• Treatment/intervention: The type and amounts of your health information provided to other health care providers within our practice will be limited to relevant and appropriate information needed to provide you care and treatment.

• Payment: I may disclose your health information to third party payers, such as your insurance company, Medicare or Medicaid or worker’s compensation in order to receive payment or support your reimbursement for services rendered.

• Regular Health Care Operations: I may be required to disclose your health information in order to review my services for purposes of quality assurance, inspection or audit. I may disclose health information to other health care providers to the extent necessary for them to provide you the appropriate level of care and treatment. To the extent allowed by law, we may release Health Information about you to a family member, other relative, or close personal friend who is involved in your health care if the health information released is directly relevant to such person’s involvement with your care.

• To avert a serious threat to health and safety: I may use and disclose health information about you when necessary to prevent a serious threat to your health and safety or to the health and safety of another person or the general public. Any disclosure, however, would only be to someone who is able to help prevent the threat.

• Research: I may disclose your health information to researchers conducting research that has been approved by an institutional review board and for which you have given informed consent.

• Judicial, administrative proceedings or law enforcement activities' may disclose your health

information in the course of any administrative or judicial proceeding, during lawsuits and disputes and for certain law enforcement activities.

• Public Health: I may disclose your health information to public health authorities for purposes related to: preventing or controlling disease, injury or disability; reporting child or adult abuse or neglect; reporting domestic violence; reporting disease or infection exposure.

• Appointment Reminders: I may use and disclose health information in order to contact you as a reminder that you have an appointment with me.

• Special Privacy Protections for Alcohol and Drug Abuse Information: Alcohol and drug abuse health information has special privacy protections. I will not disclose any information identifying a client as being a patient, or provide any health information, relating to a client’s substance abuse treatment unless: (a) the client consents in writing; (b) a court order requires disclosure of the information; (c) health personnel need to the information to meet a health emergency; (d) it is necessary to report a crime or a threat to commit a crime, or to report abuse or neglect as required by law.

II. When I may not use or disclose your health information

Except as described in this Notice of Privacy Practices, we will not use or disclose your health information without your written authorization. If you do authorize me to use or disclose your health information for another purpose, you may revoke your authorization in writing at any time. A revocation of authorization will be effective on the date it is received and will not affect previous disclosures.

III. Your Health Information Rights

• Right to request restriction. You may request restrictions on certain uses and disclosure of your health information. I am not required to agree to that restriction that you requested.

• Right to confidential communications. You may request that I communicate confidential information in a certain way or at a certain location, but you must specify how or where you wish to be contacted.

• Right to inspect and copy. You have the right to inspect and copy your health information, however, I may decline to release certain therapy records if in my opinion the release may be harmful to your health. You may be charged a nominal fee for requested copies of your health information record.

• Right to request amendment. You have a right to request that I amend your health information that is incorrect or incomplete. I am not required to change your health information and will provide you with information if your request is denied and how you can disagree with the denial.

• Right to accounting of disclosures. You have a right to request a list of the disclosures of your health information that have been made to persons or institutions other than for health care treatment, payment or operations in the past six years but not prior to April 14, 2003.

• Right to a copy of this notice. You may request a paper copy of this Notice of Privacy Practices.

IV. Changes to Notice of Privacy Practices

I reserve the right to amend this Notice of Privacy Practices at any time in the future, and to make the new provisions effective for all information that it maintains, including information that was created or received prior to the date of such change. Until such an amendment is made, I am required by law to comply with this notice. In the event that changes are made to this Notice, you will be provided with a written copy at your next treatment session with me. You may also request a copy of the Privacy Policy at any time.

Healing Touch International August 2003

I have read and understand the above notice.

Client Signature: 

Date: