It is important that you follow these pre-examination instructions correctly so that the findings of your infrared thermal image will be accurate.  Please sign below to acknowledge that you have performed that you have followed these guidelines and complied with these instructions. 

Our technician will ask you when you arrive for your thermal image if you followed these instructions.  IF IT IS DETERMINED THAT YOU DID NOT FOLLOW THESE INSTRUCTIONS, YOUR SCAN WILL BE INACCURATE, YOUR APPOINTMENT WILL NEED TO BE CANCELLED AND YOU WILL FORFEIT YOUR PAYMENT.   

IF YOU RESCHEDULE AND PREPAY FOR YOUR APPOINTMENT WITHIN A WEEK AND UNDERGO THERMAL IMAGING WITHIN 4-6 WEEKS AND AND IT IS ABLE TO BE PERFORMED DUE TO CORRECT PREPERATION, YOU WILL RECEIVED A CREDIT OF $100 FOR THE FIRST CANCELLED APPOINTMENT. 

The charge for Breast Infrared Thermal Imaging is $260 ($140 for current Carolina Center patients seen within one year).  Payment is due in advance to reserve your appointment and is refundable up to 14 days prior to the scheduled appointment less a $50 processing fee (refund amount $210).  No refund will be provided for cancellations made with less than 14 days prior notification. 

If cancellation is made with less than 14 days prior notification, a 50% cancellation fee credit will be given to reschedule that appointment within the next 7 days to be seen within the next 14 days or the next available appointment, whichever is first ($105 credit).

The following are important instructions for pre-examination preparation.  Please read these instructions carefully and if you have any questions or concerns about any aspect of the examination, contact our office so we can address these prior to your appointment. 

 Please follow these instructions before your scan:

• Avoid sun exposure, tanning bed use, or sunburn the day before and the day of the exam. 
• Avoid physical stimulation or treatment of the body parts being imaged 24 hours prior to the exam
• Avoid exercise, massage, acupuncture, chiropractic, physical therapy, ice or heat use, ultrasound, dry needling, moxibustion, occupational therapy, saunas, the use of TENS or electric muscle stimulation units, laser therapy or ozone therapy 24 hours prior to imaging. 
• No lotions, creams, powders, or make-up on the area to be examined the day of the scan.
• No smoking, hot showers, hot beverages or caffeine for 4 hours prior to the exam.
• No alcoholic beverages 48 hours prior to the exam
• No x-rays (including mammograms) at least one week prior to your scan.
• You may continue taking medications and supplements as directed by your physician.  Specifically notify the technician if beta blockers, niacin or female hormones are being taken. 
• Thermal imaging should not be performed until 6-8 weeks after undergoing any vaccination or surgery.
• For infrared breast imaging: 
  • Do not use external breast prosthesis for at least 12 hours prior to the examination.
  • Avoid the application of underarm deodorants or antiperspirants the day of the exam.
  • Avoid underarm shaving on the day of the exam.
  • Do not wear a bra the day of the scan. 
  • For women, you should schedule your scan about halfway through your monthly cycle, no earlier than 7 days after your period. 
  • Please pull your hair up off your neck and do not wear a necklace. 
     

You will be required to disrobe the body parts to be examined and acclimate to a cool room for 15 minutes, then the first set of images will be taken. You will then place your hands in cold water for 1 minute, after which another set of images will be taken. The entire procedure will take approximately 30 minutes. If you do not follow these preparation instructions, the findings of the thermal image will not be accurate and you will need to be rescheduled. 

Test Results:   Once your infrared thermal image has been interpreted by our thermologist, you and any physician or health care provider you request will receive a copy of your images and a written report in the mail within 2-3 weeks.  You are solely responsible for acting on any recommendations made in this report.   Should you have any questions regarding your report, please call the office at 919-781-6999.  

NOTICE:    It is important to be aware infrared thermal imaging is a health risk assessment tool but does not provide diagnostic information.  Skin temperature mapping can give insights into the function of structures and tissues underneath but can also provide information about general health. Serial studies are very important, having a baseline then following changes over time. Infrared thermal imaging does not replace any other diagnostic procedures.  Female clients are advised to maintain their regularly scheduled breast examinations and routine radiographic mammography with their primary care physician.  Infrared imaging increases the chance of early detection of breast disease but is not a standalone procedure and there is no guarantee of detection of cancer. A complete program of breast health includes monthly self-exam, annual physical exam, annual thermal imaging and mammography as indicated.                                                                                                                                     

I acknowledge that I have followed these pre-examination preparation instructions.  I understand that I will forfeit my payment for the procedure if I arrive for the appointment and it is determined I have not performed the preperation correctly.  

I request and consent to undergo a non-invasive, non-contact procedure called Infrared Thermal Imaging.   I understand that thermal imaging is an examination of physiology that is complimentary to anatomical imaging techniques. Though proven to be highly accurate, thermal imaging is an adjunctive procedure; and as such, it is not intended to replace anatomic studies such as mammography, ultrasound, MRI, CT, X-ray, or others,

I understand that I have been advised to continue to undergo whatever diagnostic procedures my primary care provider or other physician specialists have recommended.  I understand that the information provided by this thermal scan is used along with my medical history and mammogram to enable my health care provider to plan an approach to my care. I also understand that a licensed medical practitioner is the only qualified person to read this scan. 

I understand that some applications of thermal imaging such as breast thermography is a widely used and accepted procedure among Integrative Health Practitioners but is not considered a mainstream procedure among most conventional physicians.  I understand that Carolina Thermascan, LLC is only a provider of this risk-assessment screening service and is not responsible for any medical treatment or care as a result of the findings from the scan, other than informing me of the findings and making recommendations for follow-up care.   I have read the above information and I understand that I am not receiving a diagnosis of any condition based solely on my thermal scan.

By participating in this risk-assessment screening, I acknowledge that this procedure is solely for informational and screening purposes.  I understand and acknowledge that Carolina Thermascan’s personnel are not rendering medical care or services.  I understand that a report of my screening scan is created by a licensed physician with the results being sent to me.  I HEREBY FOREVER RELEASE AND DISCHARGE CAROLINA THERMASCAN OR THE CAROLINA CENTER FOR INTEGRATIVE MEDICINE FROM ANY LIABLITY FOR ANY CLAIMS BASED ON THE FAILURE TO DETECT OR DIAGNOSE ANY MEDICAL CONDITION.  I understand that the responsibility for confirming the results of the screening, initiating follow-up care, and obtaining professional medical assistance is mine, and not that of any organization associated with this screening.  Carolina Thermascan has instructed me to communicate the screening results and presence of any issues indicated directly to my own physician. 

I understand and acknowledge that Carolina Thermascan does not participate in the Medicare and Medicaid program and that these screening services are not reimbursable by either entity.  I am aware that other insurance providers may not reimburse me for the cost of this test. I understand that payment is due at the time service is rendered.  Having been informed of the purpose for the use of breast thermography and how it is not meant to replace any diagnostic tools, I hereby request to undergo this procedure performed by the staff of Carolina Thermascan, LLC. 

Infrared imaging is a non-contact, non-invasive test that illustrates physiological patterns and changes. It is not a stand-alone diagnostic test. The information provided by your thermascan is used along with your medical history and other procedures to enable your health care provider to plan an approach to your care.  A medical practitioner licensed in North Carolina is the only qualified person to read your thermagram.   I understand that Carolina Thermascan, LLC is only a provider of risk-assessment screening services and is not responsible for any medical treatment or care as a result of the findings from the scan. 

I have read the above information and I understand that I am not receiving a diagnosis of any condition based solely on my thermal scan.

I am aware that my insurance provider will not reimburse me for the cost of this test. I understand that payment is due at the time services are rendered.

If you wish to have your report sent to any health care providers or other individuals, please provide their name, fax number and if available, their email address.

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.

 If you have any questions about this Notice please contact
our Privacy Officer, Andrea Williams

This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law.  It also describes your rights to access and control your protected health information.  “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.

We are required to abide by the terms of this Notice of Privacy Practices.  We may change the terms of our notice, at any time.  The new notice will be effective for all protected health information that we maintain at that time.  Upon your request, we will provide you with any revised Notice of Privacy Practices.  You may request a revised version by accessing our website, or calling the office and requesting that a revised copy be sent to you in the mail or asking for one at the time of your next appointment.

1.             Uses and Disclosures of Protected Health Information

Your protected health information may be used and disclosed by your physician, our office staff and others outside of our offices who are involved in your care and treatment for the purpose of providing health care services to you.  Your protected health information may also be used and disclosed to pay your health care bills and to support the operation of your physician’s practice.

Following are examples of the types of uses and disclosures of your protected health information that your physician’s office is permitted to make. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by our office.

Treatment:  We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services.  This includes the coordination or management of your health care with another provider. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you.  We will also disclose protected health information to other physicians who may be treating you. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.  In addition, we may disclose your protected health information from time-to-time to another physician or health care provider (e.g., a specialist or laboratory) who, at the request of your physician, becomes involved in your care by providing assistance with your health care diagnosis or treatment to your physician.

Payment:  Your protected health information will be used and disclosed, as needed, to obtain payment for your health care services provided by us or by another provider.  This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services we recommend for you such as: making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities.  For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission. 

Health Care Operations:  We may use or disclose, as needed, your protected health information in order to support the business activities of your physician’s practice.  These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, fundraising activities, and conducting or arranging for other business activities.

We will share your protected health information with third party “business associates” that perform various activities (for example, billing or transcription services) for our practice.  Whenever an arrangement between our office and a business associate involves the use or disclosure of your protected health information, we will have a written contract that contains terms that will protect the privacy of your protected health information.

We may use or disclose your protected health information, as necessary, to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you.  You may contact our Privacy Officer to request that these materials not be sent to you.

We may use or disclose your demographic information and the dates that you received treatment from your physician, as necessary, in order to contact you for fundraising activities supported by our office.  If you do not want to receive these materials, please contact our Privacy Officer and request that these fundraising materials not be sent to you.

Other Permitted and Required Uses and Disclosures That May Be Made Without Your Authorization or Opportunity to Agree or Object 

We may use or disclose your protected health information in the following situations without your authorization or providing you the opportunity to agree or object.  These situations include:

Required By Law:  We may use or disclose your protected health information to the extent that the use or disclosure is required by law.  The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law.  You will be notified, if required by law, of any such uses or disclosures.

Public Health:  We may disclose your protected health information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information.  For example, a disclosure may be made for the purpose of preventing or controlling disease, injury or disability.

Communicable Diseases:  We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.

Health Oversight:  We may disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections.  Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws. 

Abuse or Neglect:  We may disclose your protected health information to a public health authority that is authorized by law to receive reports of child abuse or neglect.  In addition, we may disclose your protected health information if we believe that you have been a victim of abuse, neglect or domestic violence to the governmental entity or agency authorized to receive such information.  In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.

Food and Drug Administration:  We may disclose your protected health information to a person or company required by the Food and Drug Administration for the purpose of quality, safety, or effectiveness of FDA-regulated products or activities including, to report adverse events, product defects or problems, biologic product deviations, to track products; to enable product recalls; to make repairs or replacements, or to conduct post marketing surveillance, as required

Legal Proceedings:  We may disclose protected health information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), or in certain conditions in response to a subpoena, discovery request or other lawful process. 

Law Enforcement:  We may also disclose protected health information, so long as applicable legal requirements are met, for law enforcement purposes.  These law enforcement purposes include (1) legal processes and otherwise required by law, (2) limited information requests for identification and location purposes, (3) pertaining to victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) in the event that a crime occurs on the premises of our practice, and (6) medical emergency (not on our practice’s premises) and it is likely that a crime has occurred. 

Coroners, Funeral Directors, and Organ Donation:  We may disclose protected health information to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law.  We may also disclose protected health information to a funeral director, as authorized by law, in order to permit the funeral director to carry out their duties.  We may disclose such information in reasonable anticipation of death.  Protected health information may be used and disclosed for cadaveric organ, eye or tissue donation purposes.

Research:  We may disclose your protected health information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information.

Criminal Activity:  Consistent with applicable federal and state laws, we may disclose your protected health information, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.  We may also disclose protected health information if it is necessary for law enforcement authorities to identify or apprehend an individual. 

Military Activity and National Security:  When the appropriate conditions apply, we may use or disclose protected health information of individuals who are Armed Forces personnel (1) for activities deemed necessary by appropriate military command authorities; (2) for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits, or (3) to foreign military authority if you are a member of that foreign military services.  We may also disclose your protected health information to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally authorized. 

Workers’ Compensation:  We may disclose your protected health information as authorized to comply with workers’ compensation laws and other similar legally-established programs.

Inmates:  We may use or disclose your protected health information if you are an inmate of a correctional facility and your physician created or received your protected health information in the course of providing care to you.

Uses and Disclosures of Protected Health Information Based upon Your Written Authorization

Other uses and disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law as described below.  You may revoke this authorization in writing at any time.  If you revoke your authorization, we will no longer use or disclose your protected health information for the reasons covered by your written authorization.  Please understand that we are unable to take back any disclosures already made with your authorization.

Other Permitted and Required Uses and Disclosures That Require Providing You the Opportunity to Agree or Object

We may use and disclose your protected health information in the following instances.  You have the opportunity to agree or object to the use or disclosure of all or part of your protected health information.  If you are not present or able to agree or object to the use or disclosure of the protected health information, then your physician may, using professional judgement, determine whether the disclosure is in your best interest.

Facility Directories: Unless you object, we will use and disclose in our facility directory your name, the location at which you are receiving care, your general condition (such as fair or stable), and your religious affiliation.  All of this information, except religious affiliation, will be disclosed to people that ask for you by name.  Your religious affiliation will be only given to a member of the clergy, such as a priest or rabbi.

Others Involved in Your Health Care or Payment for your Care:  Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your protected health information that directly relates to that person’s involvement in your health care.  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 protected health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition or death.  Finally, we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care.

2.             Your Rights

Following is a statement of your rights with respect to your protected health information and a brief description of how you may exercise these rights.

You have the right to inspect and copy your protected health information.  This means you may inspect and obtain a copy of protected health information about you for so long as we maintain the protected health information.  You may obtain your medical record that contains medical and billing records and any other records that your physician and the practice use for making decisions about you.  As permitted by federal or state law, we may charge you a reasonable copy fee for a copy of your records. 

Under federal law, however, you may not inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding; and laboratory results that are subject to law that prohibits access to protected health information. Depending on the circumstances, a decision to deny access may be reviewable.  In some circumstances, you may have a right to have this decision reviewed.  Please contact our Privacy Officer if you have questions about access to your medical record. 

You have the right to request a restriction of your protected health information.  This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or health care operations.  You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices.  Your request must state the specific restriction requested and to whom you want the restriction to apply. 

Your physician is not required to agree to a restriction that you may request.  If your physician does agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment.  With this in mind, please discuss any restriction you wish to request with your physician.  You may request a restriction in writing to the physician describing why you would like the restriction.  

You have the right to request to receive confidential communications from us by alternative means or at an alternative location. We will accommodate reasonable requests. We may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact.  We will not request an explanation from you as to the basis for the request. Please make this request in writing to our Privacy Officer.

You may have the right to have your physician amend your protected health information.   This means you may request an amendment of protected health information about you in a designated record set for so long as we maintain this information.  In certain cases, we may deny your request for an amendment.  If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.  Please contact our Privacy Officer if you have questions about amending your medical record.  

You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information.  This right applies to disclosures for purposes other than treatment, payment or health care operations as described in this Notice of Privacy Practices.  It excludes disclosures we may have made to you if you authorized us to make the disclosure, for a facility directory, to family members or friends involved in your care, or for notification purposes, for national security or intelligence, to law enforcement (as provided in the privacy rule) or correctional facilities, as part of a limited data set disclosure.  You have the right to receive specific information regarding these disclosures that occur after April 14, 2003. The right to receive this information is subject to certain exceptions, restrictions and limitations. 

You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice electronically.

3.             Complaints

You may complain to us or to the Secretary 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 our Privacy Officer of your complaint.  We will not retaliate against you for filing a complaint.

You may contact our Privacy Officer, Andrea Williams at (919) 571- 4391 for further information about the complaint process. 

This notice was published and becomes effective on October 18th, 2022