The following document is a combined consent form requiring your signature stating that you agree and consent to Glacier Nurse Direct providing nursing care; GND Payment Policy, & HIPAA Notice.  Please read each section thoroughly before completing with signature and date at the bottom. Must be signed and completed at start of care.

HEALTH CARE CONSENT

I request and agree to receive all services provided by the professionals authorized to care for me with Glacier Nurse Direct. I understand these services may include:

-Services provided under the direction or instruction of attending physicians and other authorized health care professionals.
-GND provides nursing services only. GND does not provide diagnoses but will consult with your healthcare provider as necessary in determining a plan.
-Routine procedures used for treatment.
-Additional or related treatments and procedures GND determines are necessary & in my best interest including the use of photos, and video/audio monitoring and/or recording.
-Digital and telehealth services, including virtual visits, online evaluation, telephone visits, consultation and between providers to assist in care.

 

Injections | Informed Consent

Vitamin injections maintain good health and have been shown to be beneficial in helping to: Reduce stress, fatigue, improve memory and cardiovascular health, and maintain a good body weight. It can also assist the body in converting proteins, fats and carbohydrates into energy and is necessary for healthy skin and eyes. Vitamin injections are better absorbed by the body since they go directly into the blood stream.

Alternatives to vitamin injections are oral vitamins, B12 patch, lozenges, liquid drops, and nasal spray.

1. Risks: I understand there is a risk of mild diarrhea, upset stomach, nausea, a feeling of pain and a warm sensation at the site of the injection, a feeling, or a sense, of being swollen over the entire body, headache and joint pain.

2. If any of these side effects become severe or troublesome, I will contact my physician immediately.

3. I understand that although rare, vitamin injections can result in serious side effects. Although this is relatively rare occurrence, anyone taking vitamin injections should be aware of the possibility.

Uncommon side effects include:
-rapid heartbeat
-chest pain
-flushed face
-muscle cramps and weakness
-difficulty breathing and swallowing
-dizziness
-confusion
-tight feelings in the chest
-hives, skin rashes
-shortness of breath when there is no physical exertion and unusual wheezing, and     coughing.

4. Before starting Vitamin injections, I will make sure to talk to my physician prior if I am pregnant, lactating, or have any of the following conditions:

- Leber’s disease
- Kidney disease
- Liver disease
- An infection
- Iron deficiency
- Folic acid deficiency
- Receving any treatment that has an effect on bone marrow
- Taking any medication that has aneffect on bone marrow
- An allergy to cobalt or any other medication, vitamin, dye, food or preservative.

5. I understand that certain herbal products, vitamins, minerals, nutritional supplements, prescription and non-prescription medications may result in side effects when the interact with the vitamin injection.

6. I understand that I may be receiving a B12 vitamin injection or a Vitamin and Amino Acid injection consisting of Vitamin B12, methionine, inosital, and choline. This injection is commonly referred to as a lipotropic injection or a MIC-B12 “fat burner” injection.

By signing below, I acknowledge that I have read the foregoing informed consent and agree to the Vitamin treatment with its associated risks. I hereby give consent to perform this and all subsequent injections with the above understood. I hereby release the Glacier Nurse Direct & the nurse injecting the vitamins
liability associated with this procedure.

I ALSO UNDERSTAND:

-There may be risks and alternatives to a particular treatment or procedure GND recommends.
-My provider may need to explain and discuss certain treatments or procedures. It is important for me to ask questions or ask for more information about the care or treatment I may receive with GND.

I UNDERSTAND THAT I HAVE NOT RECEIVED ANY PROMISES OR GUARANTEES ABOUT THE OUTCOMES I MAY EXPECT FROM MY CARE WITH GLACIER NURSE DIRECT.

PAYMENT POLICY

GND requires a minimum of 24 hour notice of cancellation or rescheduling for a previously scheduled appointment. You will be charged a non-refundable fee of $50 for no-show/no-call appointments. We accept all major forms of credit/debit cards as well as cash & check.  See below for specific payment policies related to the service you are requesting.

IV Therapy & Injectables:

Payment due in full at time of service as noted above & can be purchased with FSA/HSA cards. Payment is non-refundable, non-negotiable. All IV & Injectable packages and gift certificates require payment in full at time of booking or in person at appointment. Inquire for details.

HIPAA-NOTICE OF PRIVACY PRACTICES

Glacier Nurse Direct, LLP

This notice describes how medical information about you may be used and disclosed by Glacier Nurse Direct and how you can get access to this information. Please review it carefully.

Your Rights

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

Get an electronic or paper copy of your medical record

You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.
We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

Ask us to correct your medical record

You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
We may say “no” to your request, but we’ll tell you why in writing within 60 days.

Request confidential communications

You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
We will say “yes” to all reasonable requests.

Ask us to limit what we use or share

You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.
If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.

Get a list of those with whom we’ve shared information

You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of this privacy notice

You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

 Choose someone to act for you

If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated

You can complain if you feel we have violated your rights by contacting us directly at:

Glacier Nurse Direct: 

Ph:(406) 480-6061

Email: questions@glaciernursedirect.com

You can file a complaint with the U.S. Department of Health and Human Services Office Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, or by calling , calling 1-877-696-6775.
We will not retaliate against you for filing a complaint.

Your Choices

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us to:

Share information with your family, close friends, or others involved in your care
Share information in a disaster relief situation
Include your information in a hospital directory
If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases we never share your information unless you give us written permission:

Marketing purposes
Sale of your information
Most sharing of psychotherapy notes
In the case of fundraising:

We may contact you for fundraising efforts, but you can tell us not to contact you again.

Our Uses and Disclosures

How do we typically use or share your health information?

We typically use or share your health information in the following ways.

Treat you

We can use your health information and share it with other professionals who are treating you.

Example: A doctor treating you for an injury asks another doctor about your overall health condition.

Run our organization

We can use and share your health information to run our practice, improve your care, and contact you when necessary. We are a very discreet and private organization and never sell nor market any personal information.

To remind you of an appointment you have for medical care;
To assess your satisfaction with our services;
To tell you about health-related benefits or services;
For conducting training programs and reviewing competence of health care professionals.
Example: We use health information about you to manage your treatment and services.

Bill for your services

We can use and share your health information to bill and get payment from health plans or other entities. We currently do not bill insurance, but this may be valid in the future should we start billing insurance for any reason.

Example: We give information about you to your health insurance plan so it will pay for your services.

How else can we use or share your health information?
We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes.

Help with public health and safety issues

We can share health information about you for certain situations such as:

Preventing disease
Helping with product recalls
Reporting adverse reactions to medications
Reporting suspected abuse, neglect, or domestic violence
Preventing or reducing a serious threat to anyone’s health or safety
Do research

We can use or share your information for health research.

Comply with the law

We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.

Respond to organ and tissue donation requests

We can share health information about you with organ procurement organizations.

Work with a medical examiner or funeral director

We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

Address workers’ compensation, law enforcement, and other government requests

We can use or share health information about you:
For workers’ compensation claims
For law enforcement purposes or with a law enforcement official
With health oversight agencies for activities authorized by law
For special government functions such as military, national security, and presidential protective services

Respond to lawsuits and legal actions

We can share health information about you in response to a court or administrative order, or in response to a subpoena.

Business Associates: There are some services provided in our organization through contracts with business associates. We may disclose your health information to our business associate so they can perform the job we've asked them to do. To protect your health information, however, we require the business associate to appropriately safeguard your information.

Individuals Involved in Your Care or Payment for Your Care: We may release medical information about you to a friend or family member who is involved in your medical care or who helps pay for your care.

Our Responsibilities
We are required by law to maintain the privacy and security of your protected health information.
We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
We must follow the duties and privacy practices described in this notice and give you a copy of it.
We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

Changes to the Terms of this Notice
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.

This Notice is effective as of the date that this document is signed. 

Photo & Video Release

I hereby grant and authorize Glacier Nurse Direct the right to take, edit, alter, copy, exhibit, publish, distribute and make use of any and all pictures, video, and/or audio taken of me to be used in and/or for any lawful promotional materials including, but not limited to, newsletters, flyers, posters, brochures, advertisements, press kits, websites, social media sites and other print or digital communications without payment or any other consideration.

 This authorization extends to all languages, media, formats, and markets now known and later discovered.

 I will be consulted about the use of the photograph and/or video recording for any purpose other than those listed below:

• promotional materials-printed and/or digital
• educational presentations or courses
• informational presentations
• online educational courses
• educational videos
• social media posts
   

There is no time limit on the validity of this release nor is there any geographical limitation on where these materials may be distributed.

 By signing this form I acknowledge that I have completely read and fully understand the above release and agree to be bound thereby. I hereby release any and all claims against any person or organization utilizing this material for educational purposes.