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  • HIPPA Acknowledgement and User Agreement

    HIPPA AUTHORIZATION

    NOTICE OF PRIVACY PRACTICES

    THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

    If you have any questions about this notice, please contact the Facility Privacy Official by dialing the Austin, Texas corporate number at 512 372-1550.

    Authorization for Release of Medical Information I hereby authorize release of protected health information by affiliate laboratories (Quest Diagnostics) to Health and Bliss for Life, LLC for the purposes below.

    For Business Associates: There are some services provided in our organization through contracts with business associates. Examples include medical directors who are asked to review your laboratory data. When these services are contracted, we may disclose your health information to our business associates so that they can perform the job we’ve asked them to do. To protect your health information, however, business associates are required by federal law to appropriately safeguard your information.

    For Research: We may disclose information to researchers when an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information has approved their research and granted a waiver of the authorization requirement.

    For Future Communications: We may communicate to you via newsletters, mail outs, email, text messaging, telemedicine, and other means regarding, health related information, disease-management programs, wellness programs, or other community based initiatives or activities that may be available to you.

    I understand that I have the right to revoke this authorization at any time by providing written notice to [email protected] If this authorization is revoked, affiliate labs (Quest Diagnostic Laboratories) will no longer be able to disclose my health information to Health and Bliss for Life, LLC and associate Medical Director(s), and that Health and Bliss for Life, LLC services therefore will no longer be available to me.

    I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.

    A Paper Copy of This Notice: You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.

    CHANGES TO THIS NOTICE
    We reserve the right to change this notice and the revised or changed notice will be effective for information we already have about you as well as any information we receive in the future.

     

    USER AGREEMENT AND AUTHORIZATION FOR USE OF MY INFORMATION BY HEALTH AND BLISS FOR LIFE, LLC.

    IMPORTANT: PLEASE READ THIS AGREEMENT CAREFULLY BEFORE CHECKING THE BOX.

    By checking the box, you are indicating that you have read and understand this User Agreement.

    1. Contact Information and Age Representation. In case of laboratory data requiring urgent attention, I represent that I have provided or will provide to HEALTH AND BLISS FOR LIFE, LLC accurate personal information that may include my name, address, telephone number, fax number, email address so that I may be contacted. I also represent that I am an adult 18 years of age or older residing in the United States.

    2.Primary Care Physician. I represent that I have a primary care physician and am in good health. I understand and agree that Health Coaches are only providing limited general wellness information and are not a substitute for seeking the advice of my primary care physician or other qualified health care professionals. I agree that I will never delay seeking advice from my primary care physician or other health professionals due to information provided through HEALTH AND BLISS FOR LIFE, LLC. I will seek emergency help when needed, and continue to consult with my primary care physician.

    3. Use of Services. Our biomarker module testing will be performed by Quest Diagnostic Laboratories, which is independent of HEALTH AND BLISS FOR LIFE, LLC. I will submit samples to Quest Laboratories through a process established by HEALTH AND BLISS FOR LIFE, LLC from time to time, and I may be required to execute waivers and authorizations provided to me at the time my samples are collected. I will not submit my Laboratory Samples directly to HEALTH AND BLISS FOR LIFE, LLC. I understand that testing on my Laboratory Samples may be ordered by OUR MEDICAL DIRECTOR without any input or approval from me. Upon my execution of the proper HIPAA Authorization, the results from such testing will be sent to HEALTH AND BLISS FOR LIFE, LLC by Quest Laboratories. I may also purchase other goods and services from third parties made available to me by HEALTH AND BLISS FOR LIFE, LLC.

    4. Costs and Payments. I acknowledge and agree that I will be responsible for all applicable fees for HEALTH AND BLISS FOR LIFE, LLC and the Goods and Services I purchase (the fees for HEALTH AND BLISS FOR LIFE, LLC Services are the "Services Fees") and for any applicable cancelation fees for cancelation of appointments without the required advance notice. Fees are established and subject to modification by HEALTH AND BLISS FOR LIFE, LLC from time to time as determined by HEALTH AND BLISS FOR LIFE, LLC. I understand that HEALTH AND BLISS FOR LIFE, LLC will bill me for all Services Fees and for all Goods and Services, and I will pay such invoices when they are due. HEALTH AND BLISS FOR LIFE, LLC may bill me in advance and may provide HEALTH AND BLISS FOR LIFE, LLC Services and Goods and Services only after I pay my outstanding bills. Fees for Goods and Services may include fees for Testing Laboratories, and even if HEALTH AND BLISS FOR LIFE, LLC provides a single charge for a "package" of services to me, I understand that such fees are separate and collected by HEALTH AND BLISS FOR LIFE, LLC as an agent for such Testing Laboratories. By providing my credit card account information for payment of Services Fees and other charges, I represent and warrant that the credit card for which I provide account information is my credit card and I authorize HEALTH AND BLISS FOR LIFE, LLC to charge to such credit card all applicable charges for the HEALTH AND BLISS FOR LIFE, LLC Services and Goods and Services I have ordered.

    5. No Medical or Health Services. I understand that HEALTH AND BLISS FOR LIFE, LLC is not a Testing Laboratory, and HEALTH AND BLISS FOR LIFE, LLC does not provide direct patient care, nor does HEALTH AND BLISS FOR LIFE, LLC itself perform any testing on my samples to provide Testing Results. HEALTH AND BLISS FOR LIFE, LLC does not practice medicine or any other licensed profession, and does not interfere with the practice of medicine.

    6.HIPAA Acknowledgment. I also understand that HEALTH AND BLISS FOR LIFE, LLC is not a "covered entity" as defined in the Health Insurance Portability and Accountability Act and the regulations promulgated under that Act ("HIPAA"). However, I understand that my Quest Diagnostic Laboratories are "covered entities" that are subject to the provisions of HIPAA. Therefore, I understand and agree that my Health Information provided to HEALTH AND BLISS FOR LIFE, LLC by Testing Laboratories is subject to or protected by HIPAA. I agree to provide a separate HIPAA AUTHORIZATION before accessing HEALTH AND BLISS FOR LIFE, LLC Services, which HEALTH AND BLISS FOR LIFE, LLC is authorized to provide to Quest Diagnostic Laboratories but I understand that my Quest Diagnostic Laboratories may require my execution of additional documents authorizing their disclosure of My Information.

    7. Limitations. NEITHER PARTY WILL BE LIABLE FOR ANY CONSEQUENTIAL, INDIRECT, INCIDENTAL, SPECIAL, PUNITIVE OR EXEMPLARY DAMAGES, OR FOR DIRECT DAMAGES IN AN AMOUNT GREATER THAN $10,000, EXCEPT FOR A VIOLATION OF SECTION 15. NEITHER HEALTH AND BLISS FOR LIFE, LLC NOR ITS OFFICERS, DIRECTORS, EMPLOYEES AND AGENTS ARE NOT LIABLE FOR THE ACTIONS OR OMISSIONS OF QUEST DIAGNOSTIC LABORATORIES AND I HEREBY AGREE THAT I WAIVE ANY AND ALL CLAIMS AGAINST ANY OF THEM ARISING FROM OR RELATING TO THE SERVICES PROVIDED TO ME BY QUEST DIAGNOSTIC LABORATORIES.

    8. Termination. Unless earlier terminated pursuant to this Agreement, the term of this Agreement ("Term") will commence upon my checking the "Accept" box and will continue for the period of time I am a subscriber to HEALTH AND BLISS FOR LIFE, LLC. Either party may terminate this Agreement at any time on written notice with or without any reason. Upon termination: a. HEALTH AND BLISS FOR LIFE, LLC will not thereafter share Registration Information with any other party. b. HEALTH AND BLISS FOR LIFE, LLC may continue to use My Information as permitted in the HEALTH AND BLISS FOR LIFE, LLC Privacy Policy. c. My access rights to HEALTH AND BLISS FOR LIFE, LLC Services shall terminate. d. All outstanding fees will become due and payable.

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