For immediate assistance, please call or text us at (706) 296-7114. Our team is standing by 24/7.

   +1 706 296 7114

CONSENT FOR SERVICES & RELEASE OF LIABILITY WAIVER

CONSENT FOR SERVICES & RELEASE OF LIABILITY WAIVER

IV hydration therapy is designed to counteract symptoms of various illnesses and ailments including dehydration, fatigue, migraine headaches, morning sickness, chemo side effects, and the residual effects of alcohol ingestion, vitamin, mineral and other nutritional deficiencies, metal toxicity, and exposure to environmental toxins.

The procedure involves a qualified provider administering IV fluids, electrolytes, minerals, and/and or vitamins via an intramuscular injection (delivered via shot into muscle tissue of arm or leg) and/or intravenous infusion (delivered directly into the vein after obtaining intravenous access via venipuncture). 

I have informed the staff of any known allergies to drugs or other substances, or of any past allergic reactions. I have informed the staff of all current medications and substances that I am taking. I understand that I have the right to be informed of the procedure, any feasible alternative options, and the risks and benefits.

Alternatives to IV therapy include oral supplementation, and/or dietary and lifestyle modifications.

Risks of intravenous therapy may include the following:

  1. Discomfort, bruising or pain at the injection site
  2. Inflammation of the vein used for injection, phlebitis
  3. Metabolic disturbances
  4. Severe allergic reaction, anaphylaxis, cardiac arrest and death

Benefits of IV therapy:

  1. IV ingredients are not affected by stomach or intestinal disease
  2. 100% absorption of nutrients with total amount being available to tissue
  3. Nutrients are forced into cells by means of high concentration gradient
  4. Higher doses of nutrients can be given than possible with oral doses, without intestinal irritation

Your signature below means that:

I understand the information provided on this form. I have received all of the information and explanation I desire concerning the procedure(s) I am consenting IVme, LLC to perform. I am informed and agree to receive medical services from IVme LLC, a medically qualified owner, employee, affiliate, subsidiary, or contract employee. I understand that I am financially responsible for the services provided to me by IVme, LLC, and any affiliates or subsidiaries. I agree to immediately remit to IVme, LLC, and any affiliates or subsidiaries full payment at time of service. Furthermore, I understand the risks associated with treatment and agree to hold IVme, LLC, it’s owners, affiliates, subsidiary, or contract employees blameless in the event of an adverse effect/reaction or any negative outcome. A copy of this form is valid as an original.

                                                    WIRELESS COMMUNICATION POLICY AND CONSENT


By providing IVme with a phone number and/or email address you, or anyone authorized to act on your behalf, are providing expressed consent authorizing IVme, as well as its agents, subsidiaries, affiliates, officers, employees, partner, successors in interest, and any companies, acting its behalf, to contact you at any phone number or email address you provide or have provided to IVme at any time with information related to your account. By providing IVme with any phone number or email address, you are confirming you are the owner of or are authorized to use the provided phone number or email address. You also confirm that you will notify IVme immediately if you no longer own or are no longer authorized to use any phone number or email address you provide to IVme. You permit IVme to contact you via live operator, automatic telephone dialing systems, prerecorded and artificial voice messages, text messages (SMS or MMS), or email. Phone numbers and email addresses you authorized IVme to use to contact you include any that you provide to IVme, and that you contact IVme from, any that are provided to IVme by someone acting on your behalf, and any that IVme locates from other lawful sources. You understand that you are solely responsible for payment of any messages rates and data charges associated with communications you receive from or send to IVme. By providing IVme with any phone number or email address. By signing below, you acknowledge that you have read fully understand, and will comply with this Wireless Communication Policy and Consent. 

IVme, LLC AUTHORIZATION FOR RELEASE OF INFORMATION

IVme, LLC understands that your health information is highly personal and we are committed to safeguarding your privacy. Please read this Notice of Privacy Practices thoroughly. It describes how IVme, LLC will use and disclose your Protected Health Information (PHI). The Notice refers to IVme, LLC by using the terms “us”, “we,” or “our.” I. IVme, LLC (“Provider”) Privacy Notice This notice describes how we secure the Protected Health Information (PHI) that we have about you that relates to your medical information or personal health information. Protected Health Information refers to medical information and may include other 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 health care services. This Notice of Privacy Practices describes how we may use and disclose to others your Personal Health Information to carry out payment or healthcare operations and for other purposes that are permitted or required by law. It also describes your rights to access and control of your Personal Health Information. We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice at any time. The new notice will be effective for all Personal Health Information that we maintain at that time. This notice may also be revised if there is a material change to the uses or disclosures of Personal Health Information, your rights, our legal duties, or other privacy practices stated in this notice. Within 60 days of a material revision to this notice we will provide you with a copy of the revised notice. Additionally, upon your request, we will provide you with any revised Notice of Privacy Practices by calling us at 1-800-692-7199 and requesting that a revised copy be sent to you in the mail. Federal and state laws provide special protections for certain kinds of personal health information (mental health records, alcohol and drug treatment records, communicable disease records or genetic test records) and, therefore: calls for specific authorizations from you to disclose information to third parties. When your personal health information falls under these special protections, we will secure the required written authorization, pursuant to a valid court order or as otherwise required by law. II. How We Will Use And Disclose Your PHI To Provide Treatment. IVme, LLC may use and disclose your PHI to coordinate care within the IVme, LLC program and with others involved in your care, such as your attending physician, members of IVme, LLC interdisciplinary team and other health care professionals who have agreed to assist IVme, LLC in coordinating your care. IVme, LLC also may disclose your health care information to individuals outside of the hospice program which are involved in your care, including, family members, clergy whom you have designated, pharmacists, suppliers of medical equipment and/or other health care professionals. For example, we may disclose your PHI to a pharmacy to fill a prescription or to a laboratory to order a blood test. We may also disclose your PHI to another physician who may be treating you or consulting with us regarding your care. To Obtain Payment. IVme, LLC may also use and disclose your PHI, as needed, to obtain payment for services that we provide to you. This may include certain communications to your health insurer or health plan to confirm (1) your eligibility for health benefits, (2) the medical necessity of a particular service or procedure, or (3) any prior authorization or utilization review requirements. We may also disclose your PHI to another Provider involved in your IVme, LLC 09/2013 care for the other Provider’s payment activities. For example, this may include disclosure of demographic information to another physician practice that is involved in your care, or to a hospital where you were recently hospitalized, for payment purposes. To Perform Health Care Operations. IVme, LLC may also use or disclose your PHI, as necessary, to carry on our day-to-day health care operations and to provide quality care to all of our Patients. The PHI disclosed will be imparted on a “need to know” basis. These health care operations may include such activities as: quality assessment and performance improvement activities; professional review and performance evaluation; Activities designed to improve health or reduce health care costs; health professional training programs, including those in which students, trainees, or practitioners in health care learn under supervision; accreditation; certification; licensing or credentialing activities; compliance reviews and audits; defending a legal or administrative claim; business management development; and other administrative activities. In certain situations, IVme, LLC may also disclose your PHI to another health care Provider or health plan to conduct their own particular health care operation requirements. To Contact You. To support our treatment, payment and health care operations, IVme, LLC may also, from time to time, contact you at home, either by telephone or mail, (1) to remind you of an upcoming activity date, (2) for bereavement activities or (3) to ask you to return a call to IVme, LLC unless you ask us, in writing, to use alternative means to communicate with you regarding these matters. We may also contact you by telephone to coordinate interdisciplinary visits, inform you of specific test results or treatment plans. Your signature on this HIPAA Notice of Privacy Practices implies your permission. Business Associates. IVme, LLC provides some services through contracts with business associates, included, but not limited to: accountants, consultants, and attorneys, so that they can perform the tasks that we have assigned to them. To protect your health information, we require the business associate to appropriately safeguard health information about you. To Be In Contact With Your Family or Friends. Additionally, IVme, LLC may also disclose certain of your PHI to your designated family member/primary caregiver or another relative, a close personal friend, or any other person specified by you, but only if the PHI is directly related (1) to the person’s involvement in your treatment or related payments, or (2) to notify the person of your physical location or a sudden change in your condition. Although you have a right to request reasonable restrictions on these disclosures, IVme, LLC will only be able to grant those restrictions that are reasonable and not too difficult to administer, none of which would apply in the case of an emergency. According to Laws That Require or Permit Disclosure. IVme, LLC may disclose your PHI when we are required or permitted to do so by any federal, state or local law, as follows: 1. When There Are Risks to Public Health. IVme, LLC may disclose your PHI to (1) report disease, injury or disability; (2) report vital events such as births and deaths; (3) conduct public health activities; (4) collect and track FDA-related events and defects; (5) notify appropriate persons regarding communicable disease concerns; or (6) inform employers about particular workforce issues. 2. To Report Suspected Abuse, Neglect Or Domestic Violence. IVme, LLC may notify government authorities if we believe that a Patient is the victim of abuse, neglect or domestic violence, but only when specifically required or authorized by law or when the Patient agrees to the disclosure. IVme, LLC 09/2013 3. To Conduct Health Oversight Activities. IVme, LLC may disclose your PHI to a health oversight agency for activities including audits; civil, administrative, or criminal investigations, proceedings, or actions; inspections; licensure or disciplinary actions; or other activities necessary for appropriate oversight, but we will not disclose your PHI if you are the subject of an investigation and your PHI is not directly related to your receipt of health care or public benefits. 4. In Connection With Judicial and Administrative Proceedings. IVme, LLC may disclose your PHI in the course of any judicial or administrative proceeding in response to an order of a court or administrative tribunal. In certain circumstances, we may disclose your PHI in response to a subpoena if we receive satisfactory assurances that you have been notified of the request or that an effort was made to secure a protective order. 5. For Law Enforcement Purposes. IVme, LLC may disclose your PHI to a law enforcement official to, among other things, (1) report certain types of wounds or physical injuries, (2) identify or locate certain individuals, (3) report limited information if you are the victim of a crime or if your health care was the result of criminal activity, but only to the extent required or permitted by law. 6. To Coroners, Funeral Directors, and for Organ Donation. IVme, LLC may disclose your PHI to a coroner or medical examiner for identification purposes, to determine cause of death or for the coroner or medical examiner to perform other duties. We may also disclose PHI to a funeral director in order to permit the funeral director to carry out their duties. PHI may also be disclosed for organ, eye or tissue donation purposes. 7. In the Event of a Serious Threat to Health or Safety, or For Specific Government Functions. IVme, LLC may, consistent with applicable law and ethical standards of conduct, use or disclose your PHI if we believe, in good faith, that such use or disclosure is necessary to prevent or lessen a serious and imminent threat to your health or safety or to the health and safety of the public, or for certain other specified government functions permitted by law. 8. Marketing. IVme, LLC must obtain your written authorization to use and disclose health information about you for most marketing purposes. 9. For Worker’s Compensation. IVme, LLC may disclose your PHI to comply with worker‘s compensation laws or similar programs. 10. Correctional Institutions. If you are an inmate of a correctional institution or under the custody of a law enforcement official, IVme, LLC may use or disclosure health information about you. Such health information will be disclosed to the correctional institution or law enforcement official when necessary for the institution to provide you with health care and to protect the health and safety of others. 11. Information Not Personally Identifiable. IVme, LLC may use or disclose health information about you in ways that do not personally identify you or reveal who you are. 12. With Your Prior Express Written Authorization. Other than as stated above, IVme, LLC will not disclose your PHI, or more importantly, your Special PHI, without first obtaining your express written authorization. Please note that you may revoke your IVme, LLC 09/2013 authorization in writing at any time except to the extent that we have taken action in reliance upon the authorization. III. Your Individual Rights Concerning Your PHI A. The Right to Inspect and Copy Your PHI. You may inspect and obtain a copy of your PHI that IVme, LLC has created or received as we provide your treatment or obtain payment for your treatment. A copy may be made available to you either in paper or electronic format if we use an electronic health format. Under federal law, however, you may not inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or for use in, a civil, criminal, or administrative action or proceeding; and PHI that is subject to a law prohibiting access. Depending on the circumstances, you may have the right to request a second review if our Privacy Officer denies your request to access your PHI. Please note that you may not inspect or copy your PHI if your physician believes that the access requested is likely to endanger your life or safety or that of another person, or if it is likely to cause substantial harm to another person referenced within the information. As before, you have the right to request a second review of this decision. To inspect and copy your PHI, you must submit a written request to the Privacy Officer. IVme, LLC may charge you a fee for the reasonable costs that we incur in processing your request. B. The Right to Request Restrictions on How We Use and Disclose Your PHI. You may ask IVme, LLC not to use or disclose certain parts of your PHI but only if the request is reasonable. For example, if you pay for a particular service in full, out-of-pocket, on the date of service, you may ask us not to disclose any related PHI to your health plan. You may also ask us not to disclose your PHI to certain family members or friends who may be involved in your care or for other notification purposes described in this Privacy Notice, or how you would wish us to communicate with you regarding upcoming appointments, treatment alternatives and the like by contacting you at a telephone number or address other than at home. Please note that we are only required to agree to those restrictions that are reasonable and which are not too difficult for us to administer. We will notify you if we deny any part of your request, but if we are able to agree to a particular restriction, we will communicate and comply with your request, except in the case of an emergency. Under certain circumstances, IVme, LLC may choose to terminate our agreement to a restriction if it becomes too burdensome to carry out. Finally, please note that it is your obligation to notify us if you wish to change or update these restrictions by contacting the Privacy Officer directly. C. Right to Request Alternative Method of Communication. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. Your request must be in writing. We will accommodate all reasonable requests. D. The Right to Request Amendments to Your PHI. You may request that your PHI be amended so long as it is a part of our official Patient Record. All such requests must be in writing and directed to our Privacy Officer. In certain cases, we may deny your request for an amendment. If IVme, LLC denies your request for amendment, you have the right to file a statement of disagreement with us and we may respond to your statement in writing and provide you with a copy. E. Right to Revoke Authorization. You have the right to revoke your authorization to use or disclose health information, except to the extent that action has been taken in reliance upon your authorization. Your request must be in writing F. The Right to Receive an Accounting. You have the right to request an accounting of those disclosures of your PHI that we have made for reasons other than those for treatment, payment and health care operations, which are specified in Section II (A-C) above. The accounting is not required to report PHI disclosures (1) to those family, friends and other persons involved in your treatment or payment, (2) that you otherwise requested in writing, (3) that you agreed to by signing an authorization form, or (4) that we are otherwise required or permitted to make by law. As before, your request must be made in IVme, LLC 09/2013 writing to our Privacy Officer. The request should specify the time period, but please note that we are not required to provide an accounting for disclosures that take place prior to September 01, 2007. Accounting requests may not be made for periods of time in excess of six years. We will provide the first accounting you request during any 12-month period without charge. Subsequent accounting requests may be subject to a reasonable cost-based fee. G. The Right to Receive Notice of a Breach. You have the right to receive written notice in the event IVme, LLC learns of any unauthorized acquisition, use or disclosure of your PHI that was not otherwise properly secured as required by HIPAA. We will notify you of the breach as soon as possible but no later than sixty (60) days after the breach has been discovered. H. Right to Opt Out of Fundraising Communications. IVme, LLC may contact you for fundraising purposes. You have the right to opt out of receiving any of these communications. I. Right to Copy of Notice of Privacy Practices. You have the right to a paper copy of our Notice at any time. Please contact IVme, LLC’s Privacy Officer at the address or phone listed below to obtain a copy. J. The Right to File a Complaint. You have the right to contact the IVme, LLC Privacy Officer at any time if you have questions, comments or complaints about our privacy practices or if you believe we have violated your privacy rights. You also have the right to contact our Privacy Officer or the Department of Health and Human Services’ Office for Civil Rights in Atlanta, GA regarding these privacy matters, particularly if you do not believe that we have been responsive to your concerns. We urge you to contact our Privacy Officer if you have any questions, comments or complaints, either in writing or by telephone as follows:

I understand that my treatment or continued  treatment by IVme, LLC is in no way conditioned on whether or not I sign this authorization and that I may refuse to sign it. I understand that under applicable law the information disclosed under this authorization may be subject to further disclosure by the recipient and thus, may no longer be protected by federal  privacy regulations. I understand that I may inspect or request a copy of the information to be used or disclosed by the recipient.

This authorization will be valid for a period of one year from the signature date below. Medical records will only be released for dates of service which occur prior to  the authorization date unless disclosure of a future service date is specifically authorized. I understand that I may cancel this authorization at any time by notifying IVme, LLC in writing, but if I do it will not have any effect on actions that the releasee took before it received the cancellation.

I acknowledge that I have received or was offered IVme’s Notice of Privacy Practices (NPP). I understand that if I would like to receive a copy of the NPP in the future, I may request one by emailing info@ivmemobile.net

I HAVE READ AND FULLY UNDERSTAND THE MEDICAL CONSENT AND RELEASE OF LIABILITY WAIVER, WIRELESS COMMUNICATION POLICY AND CONSENT, AND NOTICE OF PRIVACY PRACTICES.

Alright. Are you ready?

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