Our goal is to provide a safe environment for patients and staff, and to advance the safety of our local community. This document provides information we ask you to acknowledge and understand regarding the coronavirus (SARS-CoV-2) or COVID-19. SARS-CoV-2 or coronavirus (COVID-19) is a serious and highly contagious infection that arrived in the United States early 2020. The World Health Organization has classified this deadly virus as a global pandemic. Our practice wants to ensure you are aware of the additional risks of contracting COVID-19 associated with receiving alternative treatments. Due to the long incubation period, you or your healthcare provider(s) may have the virus and not show any symptoms and yet still be highly contagious. Determining who is infected with COVID-19 is challenging and complicated as many are asymptomatic carriers. Due to the frequency and timing of office visits with our practice for treatment, the characteristics of the virus, and the nature of the alternative treatments via intravenous infusions or injections, there is an increased risk of you contracting the virus by simply being in the office. Our goal is to minimize the risk of infection to our patients and staff. Our client treatment rooms are cleaned before and after use. We ask that each client wear a mask during treatment to protect yourself, healthcare provider and staff. If you have a fever, cough, or shortness of breath, we ask that you kindly reschedule your appointment after you have completed a 14-day self-quarantine.

I confirm that I have read the notice above and understand and accept that there is an increased risk of contracting COVID-19 virus while in a health care clinic receiving treatment. I further confirm I am seeking alternative treatment for health and wellness. I understand and accept the additional risk of contracting COVID-19 from contact within this office. I also acknowledge that I could contact the COVID-19 virus from outside this office and unrelated to my visit here.

I have read and understand the information stated above:

PATIENT'S BILL OF RIGHTS AND RESPONSIBILITIES

Section 381.026 Florida Statutes

A PATIENT HAS THE RIGHT TO:

1. Be treated with courtesy and respect, with appreciation of his/her dignity, and with protection of privacy.

2. Receive a prompt and reasonable response to questions and requests.

3. Know who is providing medical services and is responsible for his/her care.

4. Know what patient support services are available, including if an interpreter is available if the patient does not speak English.

5. Know what rules and regulations apply to his/her conduct.

6. Be given by the health care provider information such as diagnosis, planned course of treatment, alternatives, risks, and prognosis.

7. Refuse any treatment, except as otherwise provided by law.

8. Be given full information and necessary counseling on the availability of known financial resources for care.

9. Know whether the health care provider or facility accepts the Medicare assignment rate, if the patient is covered by Medicare.

10. Receive prior to treatment, a reasonable estimate of charges for medical care.

11. Receive a copy of an understandable itemized bill and, if requested, to have the charges explained.

12. Receive medical treatment or accommodations, regardless of race, national origin, religion, handicap, or source of payment.

13. Receive treatment for any emergency medical condition that will deteriorate from failure to provide treatment.

14. Know if medical treatment is for purposes of experimental research and to give his/her consent or refusal to participate in such research.

15. Express complaints regarding any violation of his/her rights.

A PATIENT IS RESPONSIBLE FOR:

1.Giving the health care provider accurate information about present complaints, past illnesses, hospitalizations, medications, and any other information about his/her health.

2. Reporting unexpected changes in his/her condition to the health care provider.

3. Reporting to the health care provider whether he/she understands a planned course of action and what is expected of him/her.

4. Following the treatment plan recommended by the health care provider.

5. Keeping appointments and, when unable to do so, notifying the health care provider or facility.

6. His/her actions if treatment is refused or if the patient does not follow the health care provider's instructions.

7. Making sure financial responsibilities are carried out.

8. Following health care facility conduct rules and regulation.

HIPAA-PATIENT CONSENT FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION (PHI) ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICIES

I have been provided with Dr. Katina Health and Wellness, LLC, "Notice of Privacy Practices", and I am giving my consent for the use and disclosure of Protect Health Information as required and / or permitted by law.

Purpose: This form is used to obtain your consent to communicate with you by email/mobile text messaging regarding your Protected Health Information. Dr. Katina Health and Wellness, LLC offers patients the opportunity to communicate by email/mobile text messaging. Transmitting patient information by email/mobile text messaging has a number of risks that patients should consider before granting consent to use email/mobile text messaging for these purposes. Dr. Katina Health and Wellness, LLC will use reasonable means to protect the security and confidentiality of email/mobile text messaging information sent and received. However, Dr. Katina Health and Wellness, LLC cannot guarantee the security and confidentiality of email/mobile text messaging communication and will not be liable for inadvertent disclosure of confidential information.

 

I acknowledge that I have read and fully understand this consent form. I understand the risks associated with communication of email/mobile text messaging between Dr. Katina Health and Wellness, LLC and I, and consent to the conditions outlined herein. Any questions I may have had were answered.

 

Patient Acknowledgment & Agreement

IN CASE OF EMERGENCY: Please call 911 or proceed to the nearest emergency room. Do not use this way of communication for that purpose.

 

PATIENT REGISTRATION FORM

Patient's Legal Name: (Last) Preferred Full Name (if different from above): Address:

RESPONSIBLE PARTY INFORMATION (If not self) (Information used for patient balance statements)

INSURANCE INFORMATION: Provide your insurance card(s) (primary, secondary, etc to the front desk at check-in.

EMERGENCY CONTACT INFORMATION

Dr. Katina Health and Wellness

GENERAL CONSENT FOR CARE AND TREATMENT CONSENT

TO THE PATIENT: You have the right, as a patient, to be informed about your condition and the recommended surgical, medical or diagnostic procedure to be used so that you may make the decision whether or not to undergo any suggested treatment or procedure after knowing the risks and hazards involved. At this point in your care, no specific treatment plan has been recommended. This consent form is simply an effort to obtain your permission to perform the evaluation necessary to identify the appropriate treatment and/or procedure for any identified condition(s

This consent provides us with your permission to perform reasonable and necessary medical examinations, testing and treatment. By signing below, you are indicating that (1) you intend that this consent is continuing in nature even after a specific diagnosis has been made and treatment recommended; and (2) you consent to treatment at this office or any other satellite office under common ownership. The consent will remain fully effective until it is revoked in writing. You have the right at any time to discontinue services.

You have the right to discuss the treatment plan with your healthcare provider about the purpose, potential risks and benefits of any test ordered for you. If you have any concerns regarding any test or treatment recommend by your health care provider, we encourage you to ask questions. I voluntarily request a nurse practitioner, physician, physician assistant, or clinical nurse specialist, and other health care providers or the designees as deemed necessary, to perform reasonable and necessary medical examination, testing and treatment for the condition which has brought me to seek care at this practice. I understand that if additional testing, invasive or interventional procedures are recommended, I will be asked to read and sign additional consent forms prior to the test(s) or procedure(s I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents.

Patient Consent for Financial Communications

Financial Agreement

• I acknowledge, that as a courtesy, Dr. Katina Health and Wellness may bill my insurance company for services provided to me.
• I agree to pay for services that are not covered, or covered charges not paid in full including, but not limited to any co-payment, co-insurance and/or deductible, or charges not covered by insurance.

   INSURANCE

  Dr. Katina Health and Wellness accepts most insurance plans. If you have specific questions regarding your insurance, please contact our billing department.
  It is the patient's responsibility to inform our office of any changes in insurance coverage. Failure to do so could cause delay or denial of insurance payment.
   All patients will be asked to present their current insurance card at each appointment. Failure to have your card could delay your appointment, and it will be the responsibility of the patient to provide proof of coverage.
  Copay, Deductible & Coinsurance:  A copay is a set dollar amount you owe for each office visit.  Some insurance plans are subject to deductible and coinsurance.  You will be expected to make payment before services are rendered.
  Estimation of Fees:  Whenever possible, our staff will verify your benefits with your insurance company and will provide you with the approximate cost of the service.  The final cost may change based on what is actually done the day of your visit.  Additionally, the estimate of our charges will not include any outside lab or pathology services.
  Lab/Pathology Fees:  If any laboratory testing is collected  (blood work, cultures, biopsy, PAP smear, etc) in our office to confirm a diagnosis or a course of treatment, the laboratory will perform the actual testing on the sample.  THIS MEANS YOU MAY RECEIVE A SEPARATE BILL FROM THE LAB/PATHOLOGIST- we do not verify your lab benefits.

 COMPLETION OF FORMS/LETTERS

We understand that at times, various forms or letters may be required to assist you with your healthcare needs. The staff at Dr. Katina Health and Wellness will be happy to complete forms and write medical letters as necessary upon your request. Please note, there is a fee for completion of this paperwork and prices start at $25. However, because this can be time consuming, please allow 7-10 days for completion of requested forms/letters. Depending on the type of form, an office visit may be required due to the extent of the form.

Assignment of Benefits. I hereby assign to Dr. Katina Health and Wellness any insurance or other third- party benefits available for health care services provided to me. I understand Dr. Katina Health and Wellness has the right to refuse or accept assignment of such benefits. If these benefits are not assigned to Dr. Katina Health and Wellness, I agree to forward all health insurance or third-party payments that I receive for services rendered to me immediately upon receipt.

Medicare Patient Certification and Assignment of Benefit. I certify that any information I provide, if any, in applying for payment under Title XVIII ("Medicare") or Title XIX ("Medicaid") of the Social Security Act is correct. I request payment of authorized benefits to be made on my behalf to Dr. Katina Health and Wellness by the Medicare or Medicaid program.

Consent to Telephone Calls for Financial Communications. I agree that, in order for Dr. Katina Health and Wellness, or Extended Business Office (EBO) Servicers and collection agents, to service my account or to collect any amounts I may owe, I expressly agree and consent that Dr. Katina Health and Wellness or EBO Servicer and collection agents may contact me by telephone at any telephone number, without limitation of wireless, I have provided or Dr. Katina Health and Wellness or EBO Servicer and collection agents have obtained or, at any phone number forwarded or transferred from that number, regarding the services rendered. or my related financial obligations. Methods of contact may include using pre- recorded/artificial voice messages and/or use of an automatic dialing device, as applicable.

A photocopy of this consent shall be considered as valid as the original.

CONSENT FOR PELVIC EXAMINATION

A MALE and FEMALE Pelvic Examination is an examination of the vagina, cervix, uterus, fallopian tubes, ovaries, rectum, or external genitals, pelvic tissue or organs. This procedure is used to diagnose and/or treat conditions that involve the pelvis. It may be performed using any combination of modalities, which may include the health care provider’s gloved hand or instrumentation. For purposes of this consent, vaginal sonography is included. 

If I shall need a pelvic exam, I consent to receiving one from nurse practitioner Dr. Katina Kennedy or a nurse practitioner student (only if verbal consent granted, you may decline a student pelvic exam verbally).

 

authorize and direct Dr. Katina Health and Wellness, Dr. Katina Kennedy, Nurse Practitioner and Nurse practitioner students if permission is granted to perform a pelvic examination, including vaginal sonography, as described above.

By my signature below I acknowledge that I have read and understand the contents of this form

Privacy Policy

OUR LEGAL RESPONSIBILITIES

 

We are required by law to give you this notice. It provides you on how we may use and disclose protected health information about you and describes your rights and our obligations regarding the use and disclosure of that information. We shall maintain the privacy of protected health information and provide you with notice of our legal duties and privacy practices with respect to your protected health information.

We have the right to change these policies at any time. If we change our privacy policies, we will notify you of these changes immediately. This current policy is in effect unless stated otherwise. If the policy is changed, it will apply to all your current and past health information.

You may request a copy of our notice any time. You may contact Dr. Katina Health and Wellness, LLC at DrKatinaHealth@gmail.com or call 954-231-8700 at any time to request a copy of this privacy policy.

HOW WE MAY USE OR DISCLOSE YOUR PROTECTED HEALTH INFORMATION

The following examples describe ways that we may use your protected health information for your treatment, payments, healthcare operations etc. but please be advised that not every use or disclosure in a particular category will be listed.

Treatment: We may use and disclose your protected health information to provide you treatment. This includes disclosing your protected health information to other medical providers, trainees, therapists, medical staff, and office staff that are involved in your health care.

For example, your medical provider might need to consult with another provider to coordinate your care. Also, the office staff may need to use and disclose your protected health information to other individuals outside of our office such as the pharmacy when a prescription is called in.

Payment: Your protected health information may also be used to obtain payment from an insurance company or another third part. This may include providing an insurance company your protected health information for a pre-authorization for a medication we prescribed.

Health Care Operations: We may use or disclose your protected health information in order to operate this medical practice. These activities include training students, reviewing cases with employees, utilizing your information to improve the quality of care, and contacting you be telephone, email, or text to remind you of your appointments.

If we have to share your protected health information to third party "business associates" such as a billing service, if so, we will have a written contract that contains terms that will protect the privacy of your protected health information.

We may also use and disclose your protected health information for marketing activities. For example, we might send you a thank you card in the mail with a coupon for specialized services or products. We may also send you information about products or services that might be of interest to you. You can contact us at any point to stop receiving this information.

We will not use or disclose your protected health information for any purpose other than those identified in this policy without your specific written authorization. You may give us written authorization to use your protected health information or to disclose it to anyone for any purpose. You can revoke this authorization at any time but will not affect the protected health information that was shared while the authorization was in effect.

Appointment reminders: We may contact you as a reminder that you have an appointment for your initial visit, follow up visit, or lab work via text. phone or email.

Others Involved in Your Health Care: We may disclose protected health information about you to your family members or friends if we obtain your verbal agreement to do so, or if we give you an opportunity to object to such a disclosure and you do not raise an objection. For example, we may assume that if your spouse or friend is present during your evaluation, that we can disclose protected professional information to this person. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment if there is an urgent or emergent need.

Research: We will not use or disclose your health information for research purposes unless you give us authorization to do so.

Organ Donation: If you are an organ donor, we may release protected health information to organizations that handle organ procurement or organ, eye or tissue transplantation if it is necessary to facilitate this process.

Public Health Risks: We may disclose your protected health information, if necessary, in order to prevent or control disease, report adverse events from medications or products, prevent injury, disability or death. This information may be disclosed to healthcare systems, government agencies, or public health authorities. We may have to disclose your protected health information to the Food and Drug Administration to report adverse events, defects, problems, enable recalls etc. if required by FDA regulation.

Health Oversight Activities: We may disclose protected health information to health oversight agencies for audits, investigations, inspections or licensing purposes. These disclosures might be necessary for state and federal agencies to monitor healthcare systems and compliance with civil law.

Required by Law: We will disclose protected health information about you when required to do so by federal, state and/or local law.

Workman's compensation: We may disclose your protected health information to workman's comp or similar programs.
Lawsuits: We may disclose your protected health information in response to a court action, administrative action or a subpoena.

Law Enforcement: We may release protected health information to a law enforcement official in response to a court order, subpoena, warrant, subject to all applicable legal requirements.

YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION

Access to medical records: You have the right to access and receive copies of your protected health information that we use to make decisions about your care. You must submit a written request to obtain your protected health information to the individual listed at the end of this privacy policy. We reserve the right to charge you a fee for the time it takes to obtain and copy the protected health information and provide it to you.

Amendment: If you believe the protected health information, we have about you is incorrect or incomplete, you may ask us to amend the information You will need to submit a written request on why you feel the health information should be amended. We may deny your request to amend if you did not send a written request or give a reason on why it should be amended. If we deny your request. we will provide you a written explanation. We may deny your request if we believe the protected health information is accurate and complete.

Accounting of Disclosures: You have the right to receive a list of instances in which we disclosed your personal health information unless the disclosure was used for treatment. payment. healthcare operations, was pursuant to a valid authorization and as otherwise provided in applicable federal and state laws and regulations. You must submit a written request to obtain this "accounting of disclosures" to the individual listed at the bottom of this policy. After your request has been approved, we will provide you the dates of the disclosure, the name of the individual or entity we disclosed the information to. a description of the information that was disclosed, the reason why it was disclosed. and any additional pertinent information. This information may not be longer than (STATUTE OF LIMITATIONS) years ago prior to the date the accounting is requested. We reserve the right to charge a reasonable fee for this process.

Restriction Requests: You have the right to request a restriction or limitation on the protected health information we use or disclose about you for treatment, payment, or healthcare operations. We shall accommodate your request except where the disclosure is required by law. We require this be a written request submitted to the individual at the end of this policy.

Confidential Communication: You have the right to request that we communicate with you about healthcare matters in a certain way and at a certain location. We must accommodate your request if it is reasonable and allows us to continue to collect payments and bill you.

Paper copy of this notice: You may request a hard copy of this practice policy if you reviewed and signed it via electronic means. To obtain this copy. contact the individual at the end of this privacy policy.
Complaints: If you believe your privacy rights have been violated, you may file a complaint with our office. You also file a complaint with the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request.

Name of Contact Person:

Dr. Katina Health and Wellness, LLC

Please sign and date indicating you have read and understand your Patient Rights.