Payment is expected at the time of service. Dominate Your Game does not offer refunds on any services provided.
Dominate Your Game does not bill insurance companies for professional services. The patient is responsible for the entire bill when the services are rendered. This includes any diagnostic testing that is recommended, and agreed upon to provide you with adequate care. If you fail to make payments for which you are responsible in a timely manner, you will be responsible for all costs of collecting monies owed, including court costs, collection agency fees, and attorney fees when necessary. If you are concerned about the cost of your treatments Dominate Your Game does offer financial assistance programs.
Dominate Your Game medical providers are NOT credentialed or contracted with any insurance companies or networks and do NOT accept Medicare or Medicaid programs.
Dominate Your Game requires a 24-hour cancellation notice. If you cancel an appointment with less than 24 hours notice or if you do not show up at your scheduled appointment, you will be charged no show fee.
CONSENT FOR TREATMENT
I, the undersigned, do hereby agree and give my consent for Dominate Your Game and other Dominate Your Game providers, to provide requested services. I understand it is my responsibility to list all health history and medications currently being taken.
I have read and understand all the above statements:
NOTICE OF PRIVACY PRACTICES
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
This Notice explains the ways in which we may use and disclose medical information about you. It describes your rights and certain obligations we have regarding the use and disclosure of your medical information. The law requires us to (1) Ensure your medical information is protected; (2) Provide you with this Notice describing our legal duties and privacy practices with respect to medical information about you; (3) Follow the current terms of the Notice in effect.
WAYS WE MAY USE AND DISCLOSEYOUR MEDICAL INFORMATION
The following sections describe different ways that we may use and disclose your medical information. For each category of uses or disclosures, we will explain what we mean and try to give some examples. Not every use or disclosure will be listed. All of the ways we are permitted to use and disclose information, however, will fall within one of the following categories.
Some information such as certain drug and alcohol information, HIV information and mental health information is entitled to special restrictions related to its use and disclosure. Our office shall abide by all applicable state and federal laws related to the protection of this information.
Treatment. We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, or other personnel who are involved in your care. For example, a doctor treating you may need to know if you have diabetes because diabetes may slow the healing process. We may also share medical information about you with our office personnel or other providers, agencies or facilities in order to provide or coordinate such things as prescriptions, lab work and x-rays. We also may disclose medical information about you to people outside our office who may be involved in your continuing medical care after you leave our office such as other health care providers, transport companies, community agencies and family members.Payment. We may use and disclose medical information about the treatment and services you receive at our office so that payment may be collected from you, an insurance company or a third party. For example, we may need to give information to your health plan about treatment you received at our office so your health plan will pay us or reimburse you. We may also tell your health plan about a proposed treatment in order to obtain prior approval or to determine whether your plan will cover the treatment.Health Care Operations. We may use and disclose medical information about you to support our office operations. These uses and disclosures are made to improve our quality of care. Your medical information may also be used or disclosed to comply with laws and regulations, for contractual obligations, patients claims, grievances or lawsuits, health care contracting, legal services, business planning and development, business management and administration, the sale of all or part of our office to another entity, underwriting and other insurance activities. For example, we may review medical information to find ways to improve treatment and services to our patients. We may also disclose information to doctors, nurses, technicians, and other personnel for performance improvement and educational purposes.Appointment Reminders. We may contact you to remind you that you have an appointment at our office.Treatment Alternatives. We may tell you about or recommend possible treatment options or alternatives that may be of interest to you.Health-Related Benefits and Services. We may contact you to tell you about benefits or services that we provide.Others Involved in Your Care. We may release medical information to anyone involved in your medical care, For example, a friend, family member, personal representative, or an individual you identify. We may give
information to someone who helps pay for your care or we may tell your family or friends about your general condition.
Research. Your medical information may be important to further research efforts. We may use and disclose your medical information for research purposes, subject to the confidentiality provisions of state and federal law.As Required By Law. We will disclose medical information about you when required to do so by federal or state law; If asked to do so by law enforcement in response to a court or administrative order, subpoena, discovery request, warrant, summons or other lawful process; or for intelligence, counterintelligence, and other national security activities authorized or required by law.To Avert a Serious Threat to Health or Safety. We may use and disclose medical information about you for public health purposes or when necessary to prevent or lessen a serious and imminent threat to your health and safety or the health and safety of the public or another person. Any disclosure would be to someone able to help stop or reduce the threatWorkers' Compensation. We may use or disclose medical information about you for Workers' Compensation or similar programs as authorized or required by law. These programs provide benefits for work-related injuries or illness.Inmates. If you are an inmate of a correctional institution or under the custody of law enforcement officials, we may release medical information about you to the correctional institution as authorized or required by law.YOUR RIGHTS REGARDING MEDICAL INFORMATIONABOUT YOU
Although the medical information we obtain about you is the property of our office, you do have the following rights:
Inspect and Copy. With certain exceptions, you have the right to inspect and/or receive a copy of your medical and billing information. To inspect and/or to receive a copy of your information, you must submit your request in writing to our Office 3111 S. Valley View Blvd N-104 Las Vegas, NV 89102. If you request a copy of the information, we may charge a fee for these services. We may deny your request to inspect and/or to receive a copy in certain limited circumstances. If you are denied access to medical information, in most cases, you may have the denial reviewed. Another licensed health care professional chosen by the Our office will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.Request an Amendment or Addendum. If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information or add an addendum (addition to the record). You have the right to request an amendment or addendum for as long as the information is kept by or our office. To request an amendment, your request must be made in writing and submitted to our Office Manager. In addition, you must provide a reason that supports your request. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that: Was not created by our office; Is not part of the medical information kept by or for Our office; Is not part of the information which you would be permitted to inspect and copy; or Is accurate and complete in the record. An addendum must not be longer than 250 words per alleged incomplete or incorrect item in your record.Accounting of Disclosures. You have the right to receive a list of the disclosures we have made of medical information about you that were for purposes other than treatment, payment, health care operations and certain other purposes. To request this accounting of disclosures, you must submit your request in writing to our Office Manager. Your request must state a time period that may not be longer than the six previous years. You are entitled to one accounting within any 12-month period at no cost. If you request a second accounting within that 12-month period, we may charge you for the cost of compiling the accounting. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.Right to Request Restrictions. You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, such as a family member or
use or disclose information to a family member about a surgery you had. We are not required to agree to your request. If we do agree, our agreement must be in writing, and we will comply with your request unless the information is needed to provide emergency treatment. To request a restriction, you must make your request in writing to our Office Manager. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse.
Right to Request Confidential Communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. To request confidential communications, you must make your request in writing to our Office Manager. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.Right to 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 OUR PRIVACY PRACTICES AND THIS NOTICEWe reserve the right to change our office’s privacy practices and this Notice. We reserve the right to make the revised or changed Notice effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of the current Notice at our office. The Notice will contain the effective date on the first page in the top right-hand corner. In addition, at any time you may request a copy of the current Notice in effect.
COMPLAINTSIf you believe your privacy rights have been violated, you may file a complaint with our Office Manager [3111 S Valley View Blvd N-104 Las Vegas, NV 89102]. All complaints must be submitted in writing. You will not be penalized for filing a complaint.
OTHER USES OF MEDICAL INFORMATIONOther uses and disclosures of medical information not covered by this Notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we will retain our records of the care provided to you as required by law.
I authorize healthcare provider to use and disclose the protected health information described below to DYG staff member seeking information .
This authorization for release covers the period of healthcare from blanks to blank . Or all past, present and future periods
*This medical information may be used by the person I authorize to receive this information for medical treatment or consultation, billing or claims payment, or other purposes I direct
*This authorization will be in force and effect for 1 year from signed date, at which time this authorization expires.
*I understand that I have the right to revoke this authorization, in writing, at any time. I understand taht a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim
*I understand that my treatment, payment, enrollmentm or eligibility for benefits will not be conditioned on whether I sign this authorization
*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 laws.