1. OFFICE POLICIES & FINANCIAL AGREEMENT

The policy of NeuDrip is to collect all payments at the time services are rendered. For your convenience we accept cash, check, most major credit cards. At this time, we are not contracted with insurance.

Health insurance is a contract between the patient and their insurance provider. Your policy may or may not cover claims made by this office, and some services provided by our physicians may be covered at different plan benefit levels. Claims may not be submitted with different codes if they have been denied due to lack of coverage.

It is your responsibility to verify NeuDrip services under coverage and benefits with your insurance company prior to your first visit, and to know the limits and exclusions of your insurance coverage. We do not submit insurance claims for our patients; all charges and outstanding balances are ultimately patient responsibility.

Referral Policy: It is necessary to be seen by a doctor for a health assessment and diagnosis before a referral can be given.

You will be charged a Missed Appointment fee of $50.00 for any missed appointments or late cancellations (less than 2 hours notice) for IV appointments.

Payment is due at time of service.

All dispensary products must be paid for at pick-up. There are no refunds on dispensary products. If products are to be mailed, we require prepayment with a credit card. Shipping and handling charges will apply.  We do not accept personal checks as payment *

2. HIPPA NOTICE OF PRIVACY PRACTICES

USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION

We follow HIPAA guidelines for your protection and you have the right to your medical information, read more about it here: http://www.hhs.gov/sites/default/files/ocr/privacy/hipaa/understanding/consumers/consumer_rights.pdf

We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information. If you have any objections to this form, please ask to speak with our staff members in person or by phone at our main phone number.

TELEPHONE ACCESSIBILITY If you need to contact, please email at info@Neudrip.com  or call 480-675-7926 (Phoenix) or email info@SDNeuDrip.com or call 619-393-9311 (San Diego). If a true emergency situation arises, please call 911 or any local emergency room.

ELECTRONIC COMMUNICATION
We cannot ensure the confidentiality of any form of communication through non-encrypted electronic media, including text messages. If you prefer to communicate via email or text messaging for issues regarding scheduling or cancellations, we will do so, but only to book and reschedule appointments. We cannot guarantee the safety and security of Protected Health Information via email nor texting services and you do so at your own risk.  While we may try to return messages in a timely manner, we cannot guarantee immediate response and request that you do not use these methods of communication to discuss therapeutic content and/or request assistance for emergencies.

3. INFORMED CONSENT FOR MEDICAL TREATMENT AND REQUEST FOR TeleHealth MEDICAL CARE

I have the right to be informed about my health condition(s) and recommended treatment. This disclosure is to help me become better informed by discussing the potential benefits, risks and hazards involved.

The undersigned (or “Patient”) agrees to the IV vitamin therapy administration by NeuDrip for the limited purpose of boosting athletic performance or reducing fatigue and shorten physical fitness recovery time from participating in the event described below. Patient understands IV vitamin therapy affects patients in various ways and may not meet Patient’s desired results. IV vitamin therapy is provided for pre or post-Event health optimization purposes only, do not in any way constitute a medical diagnosis, and that additional screening or procedures not provided by NeuDrip might be required in the event a medical diagnosis is desired. Patient acknowledges and agrees it is their sole responsibility to consult with the Patient’s personal physician with regard to his or her health concerns and to obtain any follow-up care determined by that physician to be appropriate. Further, Patient understands that this screening is not a complete physical exam and is not a substitute therefor. Patient further understands that the administration of IV vitamin therapy requires a prick to patient’s skin and patient may experience some pain. The undersigned agrees that he or she has truthfully disclosed all of Patient’s health related history and information requested. Patient understands that NeuDrip will not provide Patient’s medical health information to any physician for any further review of any health condition that may be disclosed by Patient The undersigned, on behalf of him or herself and his or her legal representatives, heirs, successors and assigns, does hereby release and forever discharge

NeuDrip and its agents, employees, successors and assigns, from any and all claims, losses, costs, expenses, and damages of any kind involving or related to errors, omissions, or negligence in the performance, procedures and administration of the IV vitamin therapy. Without limiting the foregoing, the undersigned agrees that if any condition exists that is not detected by the pre-IV vitamin therapy screening, NeuDrip, and its agents, employees, successors and assigns, shall not be held liable.

CONSENT FOR TELEHEALTH CONSULTATION

1. I understand that my health care provider wishes me to engage in a telehealth consultation. 2. My health care provider explained to me how the video conferencing technology that will be used to affect such a consultation will not be the same as a direct client/health care provider visit due to the fact that I will not be in the same room as my provider. 3. I understand that a telehealth consultation has potential benefits including easier access to care and the convenience of meeting from a location of my choosing. 4. I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my health care provider or I can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation. 5. I have had a direct conversation with my provider, during which I had the opportunity to ask questions in regard to this procedure. My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language in which I understand. CONSENT TO USE THE TELEHEALTH BY DrChrono EHR SERVICE Telehealth by DrChrono EHR is the technology service we will use to conduct telehealth videoconferencing appointments. It is simple to use and there are no passwords required to log in. By signing this document, I acknowledge: 1) Telehealth is NOT an Emergency Service and in the event of an emergency, I will use a phone to call 9-1-1.   2) Though my provider and I may be in direct, virtual contact through the Telehealth Service, neither DrChrono nor the Telehealth Service provides any medical or healthcare services or advice including, but not limited to, emergency or urgent medical services.   3) The Telehealth facilitates videoconferencing and is not responsible for the delivery of any healthcare, medical advice or care. 4) I do not assume that my provider has access to any or all of the technical information in the Telehealth Service – or that such information is current, accurate or up-to-date. I will not rely on my health care provider to have any of this information in the Telehealth. 5) To maintain confidentiality, I will not share my telehealth appointment link with anyone unauthorized to attend the appointment. Healthcare providers will only prescribe medications if they believe that they are in the best interest of myself, the patient.