Dr. Katina Health and Wellness, Inc a Nurse Practitioner Independently Owned and Run Primary Care Office

Welcome Letter & Guide for Our Patients

Welcome to Dr. Katina Health and Wellness and thank you for choosing us as your provider of primary medical care. Our primary goal is to provide quality medical care which is easily accessible and responsive to you in your time of need. Our staff includes a small and friendly team of professionals who will consistently strive to exceed your expectations to ensure that your experience with us is as comfortable and stress-free as possible.

We are patient-centered with a specialization in Primary Care/Gynecology/Mental Health

 As patient-centered, our approach is to provide our patients with comprehensive personalized health care, which is focused on all aspects of your health and overall well-being, including emotional, family, and social concerns. Along with your healthcare provider, you are the most important person in managing your health by strengthening your relationship with your primary care provider and the team responsible for your care. With our medical team, your quality of care will be significantly improved, and it will take less time for you to get the care when you need it.

Benefits of Dr. Katina Health and Wellness

• Your medical team will have an ongoing relationship with you and your family to manage your health care needs.
• You will see the same team each visit and they will assist you in coordinating care with  other providers, specialists, and community resources, if needed.
• Your team will have access to your health information through electronic records to effectively manage your care.
• You will have easy access to care through open scheduling and other methods of communication with your team.
• You will have access to your health information through a patient healthcare portal.

How You Can Help You

• Talk with your primary care provider and team about any questions you have.
• Keep in touch with your team if further questions arise about your health.
• Take care of your health by following the plan recommended by your team.
• Schedule an annual physical exam once a year.
• Always let us know how we are doing and how we can improve.

Sincerely,

Dr. Katina Kennedy, DNP, EdD, FNP-c, PMHNP-BC

OFFICE POLICIES & PROCEDURES FOR OUR PATIENTS

OFFICE HOURS

Our office is available Monday, Thursday, Friday 8:00 am-5:00 pm, Tuesday 7:00 am-5:00 pm, Wednesday 12:00 pm-6:00 pm, and one Saturday a month. We may be reached at 954-231-8700. Office hours will be posted on our website. If you need an appointment, prescription refill, or test results, please call during regular business hours. In the case of a life-threatening emergency, call 911 or go to the nearest Emergency Room.

Effective patient scheduling and access management are critical to ensure patient satisfaction and access to quality clinical care. It is also essential to maintain optimal staff productivity, protect client rights, and stay true to our vision. Therefore, the following applies:

APPOINTMENTS 

Dr. Katina Health and Wellness is committed to providing quality care for our patients. To ensure timely continued care, we encourage patients to schedule appointments in advance of follow-up due dates. When calling for an appointment, please provide your name, telephone number, chief complaint/reason for visit, as well as updated contact or insurance information. A patient’s appointment will be maintained or adjusted based on clinical need, preference, clinical staff availability, and appointment type time requirements.

While we strive to schedule appointments appropriately, emergencies can, and do, occur in Primary Care. We strive to give all our patients the time that they require. For this reason, we kindly request your patience and understanding should a delay or rescheduling become necessary on your appointment date. Follow-up may be required to be scheduled after testing has been completed, so that abnormal results may be reviewed together, and an effective and appropriate plan for your healthcare can be determined.

To ensure quality care, Dr. Katina Health and Wellness does not treat patients we have not seen (i.e., we will not call-in prescriptions or offer medical advice for patients prior to their initial visit).

CANCELLATION OF AN APPOINTMENT

Patients will be notified of their appointments verbally by staff, by phone, voicemail, text, and/or email. To be respectful of the medical needs of our patients, and the providers and staff at our office, we request that you please be courteous and call Dr. Katina Health and Wellness promptly if you are unable to attend an appointment. If it is necessary to cancel your scheduled appointment, we require that you call 24 hours in advance. Appointments are in high demand, and your early cancellation will give another patient the ability to have access to timely medical care.

LATE ARRIVALS

Established Patients arriving 15 minutes after an appointment, with or without notification, will be asked to reschedule. In some cases, we may not be able to accommodate you, even if you are less than 15 minutes late, but we will do our best, while not inconveniencing other patients that have arrived on time.

New patients not arriving at least 10 minutes before the appointment time will be rescheduled. We will not see any New Patient arriving late. Also, the new patient packet must be completed 24 hours before the appointment time. Any new patient that does not complete their required initial paperwork prior to the date of the appointment will automatically be cancelled and may call to reschedule said appointment once they complete the required paperwork.

NO SHOW POLICY 

 A “no show” is the term we use when a patient misses an appointment without cancelling it at least 24 hours in advance. Unfortunately, “No-Shows” inconveniences those patients who need access to medical care in a timely manner. A failure to present at the time of a scheduled appointment will be recorded in your medical chart as a “no-show.”  A record of the no-show will be recorded in your chart. An administrative fee of $35.00 will be billed to your account.   ***Fee is subject to change without notice*** Designated staff will attempt to reschedule missed or cancelled appointments, as needed for continuity of care. The receptionist or designated staff will document rescheduling attempts in the patient's medical record.

Three (3) “no-shows” within one (1) calendar year will result in a suspension of services. To reinstate services, you will be required to meet with your Primary Care provider within 30 days of the third no-show to evaluate your situation.

OFFICE CLOSINGS DUE TO WEATHER OR OTHER CIRCUMSTANCES

If our office is closed due to weather conditions or other circumstances beyond our control, the following procedures are used to inform our patients:

You will be notified by phone, text, or email if any changes to our normal schedule occur. We will also attempt to update our website, should we be forced to close unexpectedly.

In the case of the provider or office rescheduling an appointment, the patient will not be penalized with a “no-show.”

All questions regarding this policy should be directed to the designated staff for clarification. The receptionist or designated staff will provide you with a copy of this policy. Please sign and date below your acknowledgment:

I have read and understood the Appointment Scheduling, Cancellations & No-Show Policy and acknowledge its terms. I also agree that the clinic may amend such terms from time to time.

INSURANCE

• Dr. Katina Health and Wellness accepts most insurance plans. If you have specific questions regarding the acceptance of 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. In such a case the patient is responsible for all charges.
• All patients will be asked to present their current insurance card at each appointment. Failure to have your current 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. A deductible is an amount set by your insurance company, which you must pay prior to any charges being paid by the insurance company. Coinsurance is the amount, usually a percentage, that the insurance deems you are responsible for once you have met your deductible. You will be expected to make these payments before the 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 done on the day of your visit. You are responsible for the difference in what is estimated, and what the insurance deems your final responsibility. Additionally, the estimate of our charges will not include any outside lab or pathology services. You are responsible for any balance not covered by your insurance.
• 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.  There will be a $20 convenience charge for the collection of labs by our office.

  PAYMENTS

• Patients are responsible for co-pays at the time of service. There will be an additional fee of $20 for all co-pays not paid on the day of the appointment.
•  If applicable, our billing department will bill you for services not covered by your insurance (as stated in your insurance contract)
•  Dr. Katina Health and Wellness accepts cash, debit cards, credit cards, and Care Credit.
•  It is the policy of Dr. Katina Health and Wellness to make all reasonable attempts to collect outstanding balances should they accrue, including convenient payment arrangements.
•  Following these attempts, accounts in poor standing will be outsourced to a third party for the purpose of collection.
•  Patients with outstanding balances must bring their account current prior to being seen, or  in absence of such, approved appropriate payment arrangements must be in place for payment prior to the appointment time. Any such arrangements are at the discretion of the office manager.

 PRESCRIPTION REFILLS & PHARMACY INFORMATION 

Please inform Dr. Katina Health and Wellness as to which Pharmacy you use and update us immediately if this should change. Please allow two to three business days for refill requests. We encourage our patients to review their medications prior to their office appointments and to request refills at that time, if needed. 

If the pharmacy is out of your medication, it is the responsibility of the patient to attempt to locate a pharmacy that has the medication in-stock, and request that the new pharmacy request a prescription transfer from the original pharmacy. 

To expedite prescription refill authorizations the patient should contact their pharmacy so that the pharmacy can request authorization from our office. This is the quickest method of gaining authorization for refills. 

• Please note that we do not prescribe Narcotic Medications, Controlled Substances, or antibiotics over the phone. Patients who need new prescriptions, antibiotics, or controlled drugs must make an appointment.

• Your healthcare provider will prescribe the appropriate number of prescription refills until your next appointment.

• Please request or submit any medication refill requests at the start of your visit.

• It is essential to keep your follow-up appointments to ensure you receive your refills promptly. Repeated no-shows or cancellations will result in a denial of refills. We cannot care for the health of our patients without required follow-up appointments.

• Refills will be permitted only for medications our clinic's healthcare providers prescribe.
  If you have any questions about your medications, please ask your healthcare provider during your appointment.

• Some medications, high-cost drugs, and weight loss medications, for example, may require prior approval for patients with health insurance. Therefore, please contact your pharmacy or insurance company for updates on such drugs and approvals. Your pharmacy benefit determines the eligibility for your drug coverage, not your provider’s office.

• Unless a brand name drug is medically necessary, we will always authorize generic prescriptions when available.

• In an emergency, prescription refill requests should be submitted electronically by the pharmacy to the healthcare provider's office. If your healthcare provider approves, they will offer an appropriate refill to the pharmacy. If your healthcare provider does not authorize the refill, we will notify you that an appointment is required.

• We will charge an administrative fee if you request multiple refills outside your appointment day(s).
   

CONFIDENTIALITY & MEDICAL RECORDS 

Per HIPAA guidelines, copies of medical records must be requested in writing. To ensure your privacy, a form for the release of medical information must be completed prior to receipt of these materials. All patients can request a copy of their medical records, one time, free of charge. Additional copies may be requested at a cost of $1.00 per page. The law allows Medical Offices 30 days to complete requests for records. However, our medical records department puts forth every effort to respond to these requests in a timely manner. 

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 the completion of this paperwork and prices start at $25. Because this can be time-consuming, please allow 7-10 days for completion of the requested forms/letters. Depending on the type of form, an office visit may be required due to the requirements or the extent of the form. 

OUR PATIENT PORTAL 

As a means of ensuring timely communication with our patients, we strongly encourage you to sign up for the Patient Portal, which can provide a quick and easy method for scheduling appointments, updating medications, allowing for patient/provider communication, etc. As a new patient, you will receive instructions on how to sign up for the Patient Portal. 

AFTER-HOURS TELEPHONE and EMAIL CORRESPONDENCE 

Please text 954-231-8700 on our HIPAA-compliant phone app for after-hours concerns or emergencies. You may also email info@drkatinahealth.com for after-hours concerns. If the concern is not an emergency or does not warrant after-hours communication, your text or email will be responded to on the next business day. Please keep in mind that we will attempt to address your concerns in a timely manner, but please note that after-hours there is no guarantee of a response, as we are, in fact, closed. AS ALWAYS, IN THE EVENT OF A LIFE-THREATENING EMERGENCY, CALL 911 OR PROCEED TO THE NEAREST EMERGENCY ROOM FOR ASSISTANCE.

ADDITIONAL INFORMATION 

If you have further questions or need additional information about our services, please feel free to call our office at 954-231-8700, email, and/or visit our website at www.drkatinahealthandwellness.com.

By signing below, I acknowledge that I have received/read, reviewed, understand, and will comply with the policies and procedures explained in the Dr. Katina Health and Wellness OFFICE POLICIES & PROCEDURES FOR PATIENTS form.

* Policy is subject to changes and updates.

 

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 an 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, 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 regulations.

Privacy Policy 

Notice of Privacy Practices Information and Acknowledgement/HIPAA Consent for Use and Disclosure of PHI

This notice describes how medical information about you may be used and disclosed, and how you can gain access to this information. Please review it carefully.

 Protected health information (PHI), about you, is maintained as a written and/or electronic record of your contacts or visits for healthcare services with our practice. Specifically, PHI is information about you, including demographic information (i.e., name, address, phone, etc.), that may identify you and relates to your past, present, or future physical or mental health condition and related healthcare services.

Our practice is required to follow specific rules on maintaining the confidentiality of your PHI, using your information, and disclosing or sharing this information with other healthcare professionals involved in your care and treatment. This notice describes your rights to access and control your PHI. It also describes how we follow applicable rules and use and disclose your PHI to provide your treatment, obtain payment for services you receive, manage our healthcare operations, and for other purposes that are permitted or required by law.

The following is a statement of your rights, under the Privacy Rule, in reference to your PHI. Please feel free to discuss any questions with our staff.

You have the right to receive, and we are required to provide you with, a copy of this Notice of Privacy Practices. We are required to follow the terms of this notice. We reserve the right to change the terms of our notice at any time. Upon your request, we will provide you with a revised Notice of Privacy Practices if you call our office and request that a revised copy be sent to you in the mail or ask for one at the time of your next appointment. The notice will also be posted in a conspicuous location within the practice, and if such is maintained by the practice, it is on the website.

You have the right to authorize other use and disclosure. This means you have the right to authorize any use or disclosure of PHI that is not specified within this notice. For example, we would need your written authorization to use or disclose your PHI for marketing purposes, for most uses or disclosures of psychotherapy notes, or if we intended to sell your PHI. You may revoke an authorization, at any time, in writing, except to the extent that your healthcare provider or our practice has taken an action in reliance on the use or disclosure indicated in the authorization.

You have the right to request an alternative means of confidential communication. This means you have the right to ask us to contact you about medical matters using an alternative method (i.e., email, telephone), and to a destination (i.e., cell phone number, alternative address, etc.) designated by you. You must inform us in writing, using a form provided by our practice, how you wish to be contacted if other than the address/phone number that we have on file. We will follow all reasonable requests.

You have the right to inspect and copy your PHI. This means you may inspect and obtain a copy of your complete health record. If your health record is maintained electronically, you will also have the right to request a copy in electronic format. We have the right to charge a reasonable fee for paper or electronic copies as established by professional, state, or federal guidelines.

You have the right to request a restriction of your PHI. This means you may ask us, in writing, not to use or disclose any part of your protected health information for the purposes of treatment, payment, or healthcare operations. If we agree to the requested restriction, we will abide by it, except in emergency circumstances when the information is needed for your treatment. In certain cases, we may deny your request for a restriction. You will have the right to request, in writing, that we restrict communication to your health plan regarding a specific treatment or service that you, or someone on your behalf, has paid for in full, out-of-pocket. We are not permitted to deny this specific type of requested restriction. 

You may have the right to request an amendment to your protected health information. This means you may request an amendment of your PHI for as long as we maintain this information. In certain cases, we may deny your request. 

You have the right to request disclosure accountability. This means that you may request a listing of disclosures that we have made, of your PHI, to entities or persons outside of our office. 

You have the right to receive a privacy breach notice. You have the right to receive written notification if the practice discovers a breach of your secured PHI and determines through a risk assessment that notification is required. If you have questions regarding your privacy rights, please feel free to contact our Privacy Manager. Contact information is provided on the following page under Privacy Complaints. 

How We May Use or Disclose Protected Health Information 

The following are examples of uses and disclosures of your protected health information that we are permitted to make. These examples are not meant to be exhaustive, but to describe possible types of uses and disclosures. 

Treatment 

We may use and disclose your PHI to provide, coordinate, or manage your healthcare and any related services. This includes the coordination or management of your healthcare with a third party that participates in your care and treatment. For example, we would disclose your PHI, as necessary, to a pharmacy that would fill your prescriptions. We will also disclose PHI to other Healthcare Providers who may be involved in your care and treatment.

 Special Notices 

We may use or disclose your PHI, as necessary, to contact you to remind you of your appointment. We may contact you by phone or other means to provide results from exams or tests and to provide information that describes or recommends treatment alternatives regarding your care. Also, we may contact you to provide information about health-related benefits and services offered by our office, for fund-raising activities, or with respect to a group health plan, to disclose information to the health plan sponsor. You will have the right to opt out of such special notices, and each such notice will include instructions for opting out. 

Payment 

Your PHI will be used, as needed, to obtain payment for your healthcare services. This may include certain activities that your health insurance plan may undertake before it approves or pays for the healthcare services we recommend for you, such as making a determination of eligibility or coverage for insurance benefits. 

Healthcare Operations

We may use or disclose, as needed, your PHI to support the business activities of our practice. This includes, but is not limited to business planning and development, quality assessment and improvement, medical review, legal services, auditing functions, and patient safety activities. 

Health Information Organization 

The practice may elect to use a health information organization, or other such organization to facilitate the electronic exchange of information for the purposes of treatment, payment, or healthcare operations. 

To Others Involved in Your Healthcare 

Unless you object, we may disclose to a member of your family, a relative, a close friend, or any other person, that you identify, your PHI that directly relates to that person's involvement in your healthcare. 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. We may use or disclose PHI to notify or assist in notifying a family member, personal representative, or any other person that is responsible for your care, of your general condition or death. If you are not present or able to agree or object to the use or disclosure of the PHI, then your healthcare provider may, using professional judgment, determine whether the disclosure is in your best interest. In this case, only the PHI that is necessary will be disclosed. 

 Other Permitted and Required Uses and Disclosures 

We are also permitted to use or disclose your PHI without your written authorization for the following purposes: as required by law; for public health activities; health oversight activities; in cases of abuse or neglect; to comply with Food and Drug Administration requirements; research purposes; legal proceedings; law enforcement purposes; coroners; funeral directors; organ donation; criminal activity; military activity; national security; worker's compensation; when an inmate in a correctional facility; and if requested by the Department of Health and Human Services in order to investigate or determine our compliance with the requirements of the Privacy Rule.

You may request a copy of our notice at any time. You may contact Dr. Katina Health and Wellness, Inc at DrKatinaHealth@gmail.com or call 954-231-8700 at any time to request a copy of this privacy policy. The privacy policy can also be found on our website at www.drkatinahealthandwellness.com 

Privacy Complaints 

You have the right to complain to us, or directly to the Secretary of the Department of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying the Privacy Manager at: 

Dr. Katina Health and Wellness, Inc.
2901 Coral Hills Drive
Ste 330
Coral Springs, FL  33065

We will not retaliate against you for filing a complaint.

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

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

EMAIL/TEXT MESSAGE TO MOBILE PHONE CONSENT FORM 

Purpose: This form is used to obtain your consent to communicate with you by voicemail/email/mobile text messaging regarding your Protected Health Information. Dr. Katina Health and Wellness, Inc offers patients the opportunity to communicate by email/mobile text messaging. Transmitting patient information by voicemail/email/mobile text messaging has several risks that patients should consider before granting consent to use voicemail/email/mobile text messaging for these purposes. Dr. Katina Health and Wellness, Inc will use reasonable means to protect the security and confidentiality of voicemail/email/mobile text messaging information sent and received. However, Dr. Katina Health and Wellness, Inc cannot guarantee the security and confidentiality of voicemail/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 the communication of voicemail/email/mobile text messaging between Dr. Katina Health and Wellness, Inc and I, and consent to the conditions outlined herein. Any questions I may have had were answered.

 

 

CONSENT FOR PELVIC EXAMINATION  

A MALE and FEMALE Pelvic Examination is an examination of the vagina, cervix, uterus, fallopian tubes, ovaries, rectum, 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 healthcare provider’s gloved hand or instrumentation. For purposes of this consent, vaginal sonography is included. If I need a pelvic exam, I consent to receive one from the healthcare provider or a nurse practitioner student (only if verbal consent is granted, you may decline a student pelvic exam verbally). 

By signing this consent, I authorize and direct the healthcare provider, 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.

 

Patient Consent for Financial Communications 

Financial Agreement 

• I acknowledge, that as a courtesy, Dr. Katina Health and Wellness may bill my
  insurance company for the 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.
• I understand there is a fee for returned checks.

Third-Party Collection
I acknowledge Dr. Katina Health and Wellness may use the services of a third-party business associate or affiliated entity as an Extended Business Office ("EBO Servicer") for medical account billing and servicing.

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 the 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 prerecorded/artificial voice messages and/or the use of an automatic dialing device, as applicable.

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

CONSENT FOR TELEHEALTH CONSULTATION 

1. I understand that I am voluntarily engaging in a telemedicine consultation with Dr. Katina Health and Wellness.
2. I understand that the video conferencing technology and/or phone consultations will not be the same as a direct patient/health care provider visit because I will not be in the same room as my health care provider.
3. I understand that a telehealth consultation has potential benefits including easier access to care, decreasing costs, and allowing visits to be performed from the comfort of my home.
4. I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my healthcare 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 understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. I understand that if there is another individual present during the telehealth consultation I will be informed of their presence and I will also disclose if there is another individual with myself. It is agreed that these individuals will maintain the confidentiality of the information obtained. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history/physical examination that are personally sensitive to me; (2) ask non‐medical personnel to leave the telemedicine examination room: and or (3) terminate the consultation at any time.
6. I understand that the alternative to a telemedicine consultation is to forgo evaluation and treatment with Dr. Katina Health and Wellness and to seek out an in-person evaluation elsewhere. Thus, I am freely choosing to participate in a telemedicine consultation.
7. I understand that telemedicine has limitations regardingthe physical examination. I understand that the physical exam portion of the care provided through Dr. Katina Health and Wellness will be limited to inspection via video conferencing and some parts of the exam such as physical tests, examination of certain body parts, and vital signs may be conducted by individuals at my location at the direction of the consulting health care provider or not done at all.
8. Telemedicine services offered through Dr. Katina Health and Wellness are not an Emergency Service and in the event of an emergency or urgent medical issue, I will use a phone to call 911, go to the emergency department, or go to urgent care.
9. To maintain my privacy, I will not share telemedicine login information or video conferencing links with anyone unauthorized to attend the appointment.

         By signing this form, I certify:  

• That I have read or had this form explained/read to me and I understand its contents including the risks and benefits of telemedicine.
• That I have had the opportunity to ask questions and have had them answered to my satisfaction.
• I AM AGREEING THAT I HAVE READ, UNDERSTOOD, AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT

Photo and Video Consent Form

Photographs and video recordings are essential parts of medical records. They also play critical roles in educating healthcare providers, benefiting future patients, and informing the public during public health campaigns.

By signing this consent form, I permit the healthcare provider or a representative to take photographs or video images of me. Although my photographs or video recordings will not include my details, someone may recognize me. 

I also acknowledge that my participation is voluntary and that using photographs or videos confers no ownership, compensation, or royalties. Furthermore, family members, heirs, descendants, administrators of my estate, executors of my will, and anyone else who has or may have a legal claim or rights are bound by the terms to which I have consented. 

In addition, I understand that I can only revoke my consent by writing to the clinic or healthcare provider. Also, I recognize that the decision to withdraw my consent affects future disclosure but does not affect earlier released information. 

Furthermore, by signing this document, I agree that the medical information relayed to other non-medical institutions or individuals by my healthcare provider or clinic is no longer protected by state and federal privacy laws and may be re-disclosed by that source. However, the clinic or healthcare provider will try to avoid such re-disclosure. 

Furthermore, I acknowledge that my healthcare provider or the clinic has the right to edit, modify, and change my photo, resemblance, statements, audio, and video for use however they see fit. These changes, edits, or alterations will not be forwarded to me for review or approval. 

I am aware that my participation is entirely voluntary. My healthcare, any payments, enrollment in a health plan, or eligibility for any medical benefits or services will not be affected if I do not sign this form.

 

 

Consent type A: Medical records
I understand and consent to use photographs or video recordings as part of my medical records and for medical teaching or training purposes.

Consent type B: Marketing and advertising purposes
I understand and consent to the clinic or healthcare provider using photographs or video recordings of me for marketing and advertising purposes (website, print, digital or social media).

Refusal of Treatment and Non-compliance Policy

To ensure that the patient has been given all relevant information, understands the procedures ordered by the provider, and is making an informed decision to refuse treatment, and… 

To ensure that the patient is fully informed about why they are being discharged or why the healthcare provider-patient relationship has been terminated at the discretion of the provider or medical facility and that the process does not endanger their health, and….

To ensure that any termination of a healthcare provider-patient relationship or discharge is carried out under applicable state and federal laws, rules, regulations, and professional guidelines, as well as this policy, we have in place the following procedures:

 Procedure

 A. When a patient refuses treatment 

1. Contact the healthcare provider immediately whenever a patient refuses drugs, tests, treatment, or other procedures ordered by them (the provider).
2. The healthcare provider will explain or reexplain to the patient the reasons for requiring or ordering the drugs, tests, treatment, or other procedures and the possible adverse effects.
3. The healthcare provider will provide the patient with all the relevant information to understand the consequences of refusing to follow the recommended course of action regarding their care.
4. The healthcare provider will record the initial refusal and the outcome in the patient's medical record, either consent given or continued refusal. The provider's record will specify that they informed the patient of relevant information, including potential consequences of continued refusal. The patient's decision to follow the recommended procedure or continued refusal is valid only when they are free from duress or coercion.
5. In the scenario where the patient refuses the recommended treatment procedure, the healthcare provider or staff member must document the refusal of treatment in the patient’s medical records.

B. Discharge from practice and medical services at the discretion of the medical facility and healthcare provider. 

1. The healthcare provider or representative may terminate the provider-patient relationship when they identify a patient whose relationship with the provider or representative has been negatively impacted or is no longer therapeutic.
2. The healthcare provider must fully document the cause of discharging the patient. These causes include but are not limited to:
• Abusive, threatening, offensive, violent, or rude or offensive behavior directed at a physician, other staff, or other patients or visitors.
• Efforts by the patient to use the relationship to obtain controlled illegally or improperly, e.g., narcotics, for non-therapeutic purposes.
• The patient tries to abuse, or abuses controlled drugs, or refuses to seek treatment for controlled drug abuse, addiction, or is diverting controlled drugs.
• The patient obtains multiple prescriptions from different physicians.
• Failure to meet financial obligations to this medical facility for services rendered or medical products given or to cooperate with payment processes by this medical facility's payment policies.
• Repeated failure to keep appointments without reasonable cause and or without prior notice of intention to cancel appointments.
• Repeated non-compliance with treatments, procedures, or tests deemed essential by the physician or other attending healthcare provider.
• Consistent unreasonable refusal to comply with the physician's recommended treatment plan, counsel, or procedures.
• Serious personality conflicts affecting the quality of care.
• The patient's condition is such that medical care is no longer reasonably required, or the physician can no longer provide the necessary or needed care.
• The patient chooses to end the relationship or expresses a desire to do so
• The healthcare provider agreed only to provide medical care for a specific condition or decided to treat the patient at a particular time or place. 
3. Before discharge, the healthcare provider or representative must give written notice of withdrawal of care or discharge respectively and allow sufficient time for the patient to employ another healthcare provider or another medical facility, typically 30 days. Acceptable forms of communication regarding termination include either email or postal mail. Email sent to a patient provided email address will serve as sufficient notification.
4. The healthcare provider or representative using their discretion, must inform the patient of the reason for withdrawing care in the termination or discharge letter. Advising patientswith chronic or emergency conditions is appropriate if they need ongoing medical care. Stress any medical urgency and medication requirements and reinforce earlier health care recommendations.
5. The healthcare provider or representative will notify the medical facility of discharge or withdrawal of care and submit all relevant documents, including medical records, recommended medical procedures or treatment plans, and any counseling conducted by them.
6. Where appropriate, the healthcare provider or representative will suggest to the patient any local medical society for names of healthcare providers or medical facilities that accept new patients.
7. The patient must acknowledge the "Withdrawal from Care" letter from the healthcare provider or discharge letter from the medical facility. If the patient refuses to acknowledge  the receipt of a "Withdrawal from Care" or discharge letter, the healthcare provider or representative will document such in the patient’s medical records.
8. In the case of patients referred by managed care organizations, the medical facility should refer patients assigned by a managed care organization back to the managed care organization for reassignment to another provider.
9. The appointment schedulers must be informed when a patient has been sent a withdrawal from care or discharge letter. This is to ensure that appointment(s) are not offered to the patient during the transition period to avoid scenarios where this is seen as a re-establishment of the provider-patient relationship.
10. Only on the patient's written authorization should their medical records be sent to another provider or the patient. Under no circumstance should a provider or representative withdrawing from care or discharging the patient refuse to provide a subsequent treating healthcare provider or medical facility with a copy of the patient's medical record(s) because the patient has not paid for medical services.

Dr. Katina Health and Wellness, Inc COVID-19 Pandemic Alternative Treatment
Notice and Acknowledgement of Risk Form

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:

 

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 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.