Personal Information:
In Case of Emergency:
Family Physician:
Thank you for selecting Radiant Skin and Body Spa for your weight loss and weight maintenance needs. We are honored to be of service to you. This is to inform you of our financial policy. Please be advised that payment for all services will be due at the time they are rendered. For your convenience, we accept Visa, MasterCard, American Express, Discover, Care Credit, Flexible Spending Accounts (FSAs will be available at a later date), cash, and checks. A $25 fee will be charged for any returned checks.
All prepaid treatment regimens are non-refundable. In the event that you are unable to complete a prepaid treatment regimen, you can finish the treatment at a later date. (Up to one year after your last appoinment.)
All prepaid treatment regimens are non-refundable. In the event that you are unable to complete a prepaid treatment regimen, you can finish the treatment at a later date. (Up to one year after your last appoinment.)
I have read and understand all of the above and agree to these statements.
4. Please check all that apply:
6. please list the pharmacy name, location and phone number that you perfer to use.
Weight Loss Program Consent Form
I authorize Radiant Skin and Body Spa to help me in my weight reduction efforts. I understand that my program may consist of a balanced deficit diet, a regular exercise program, instruction in behavior modification techniques, and the use of appetite suppressant fasting techniques and/or medications. I further understand that if appetite suppressants are used, they may be used for durations exceeding those recommended in the medication package insert. It has been explained to me that these medications have been used safely and successfully in private medical practices as well as academic centers for periods exceeding those recommended in the product literature.
I understand that any medical treatment may involve risks as well as the proposed benefits. I also understand that are certain health risks associated with remaning overwight or obese. Risks of this program may include but are not limited to nervousness, sleeplessness, headaches, dry mouth, gastrointestinal disturbances, weakness, tiredness, psychological problems, high blood pressure, rapid heartbeat, and heart irregularities. These and other possible risks could, on occasion, be serious or even fatal. Risks associated with remaining overweight include tendencies to high blood pressure, diabetes, heart attack and heart disease, arthritis of the joints, including hips, knees, feet, and back, sleep apnea, and sudden death. I understand that the risks may be modest if Im not significantly overweight but will increase with additional weight gain.
I understand that much of the success of the program will depend on my efforts, and while there are no guarantees or assurances that the program will be successful, Innovatyve Wellness Solutions are doing their best to stand by me and my weight maintenance needs. As long as I am willing and committed, IWS is willing and committed too. I also understand that obesity may be a chronic, life long condition that may require changes in eating habits and permanent changes in behavior to be treated successfully.
I confirm that I am not pregnant or trying to get pregnant at this time. I understand that taking medications prescribed by the spa could be harmful or even fatal to a fetus. I will not try to get pregnant while taking any prescribed medications by the spa and I agree to hold Radiant Skin and Body Spa and Innovatyve Solutions Harmless form any claims or lawsuits if I should get pregnant while taking said medications.
I have read and fully understand this consent from and I realize I should not sign this form if all items have not been explained to me should I not understand. My questions have been answered to my complete satisfaction. I have been given all the time I need to read and understand this from.
If you have any questions regarding the risks or hazards of the proposed treatment, or any questions whatover concerning the proposed treatment or other possible treatments, ask our staff now before sining this fourm.
In order to provide you with the best posible care, we regularly communicate through convenient text messages to our patients about their health care and the products and services we offer. You will receive text messages for appointment reminders, information about your healthcare treatment and any specials we may run on products and services we offer.
We look forward to providing better and more convienient communications with you via text messaging. Our goal is to provide you with relevant and useful information about your healthcare and the products and services we offer for imporving your health. Thank you!
Radiant Skin and Body Spa Privacy Practices and HIPAA Policy Statement
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.
During your treatment with Radiant Skin and Body Spa (RSBS), members of its staff may gather information about your medical history and your current health. This notice explains how that information may be used and shared with others. It also explains your privacy rights regarding this kind of information. The terms of this notice apply to any health information that RSBS generates or receives. We are required by law to make sure that medical information that identifies you is kept private, post this notice of our legal duties and privacy practices with respect to medical information about you, and follow the terms of the notice that is currently in effect.
Your medical information may be used and disclosed for the following purpose:
Treatment: We may use your information to provide, coordinate, and manage your care and treatment. For example, a RSBS staff member may share your medical information with another health care provider for a consultation or referral.
Payment: We may use and disclose medical information about you so that the treatment and services you receive may be billed to and payment may be collected from, you, an insurance company or another third party. For example: We may need to give your health plan information about treatment you received at RSBS so your health plan will pay us or reimburse you for the treatment.
Healthcare Operations: We may use and disclose medical information about you for RSBS healthcare operations. Healthcare operations are the uses and disclosures of information that are necessary to run RSBS and to make sure that all of our customers receive quality care. For example: We may use medical information to evaluate the performance of our staff in caring for you.
Appointment reminders and other health information: We may use your medical information to send you reminders about future appointments. We may also contact you with information about new or alternative treatments or other healthcare services.
To people assisting in your care. If someone is taking care of you, helping you with financial obligations, or is one of your close family members or friends, RSBS will only disclose medical information to them if it is necessary for them to assist you and only to the extent that the law permits. We may, for example, provide limited medical information to allow a family member to pick up a hearing device for you. If you are able to make your own healthcare decisions, RSBS will ask your permission before using your medical information for these purposes. If you are unable to make healthcare decisions, RSBS will disclose relevant medical information to family members or other responsible people if we feel it is in your best interest to do so, including in an emergency situation.
Research: Federal law permits RSBS to use and disclose medical information about you for research purposes, either with your specific, written authorization or, where allowed by state law, when the study has been reviewed for privacy protection by an institutional Review Board or privacy board before the research begins. In some cases, researchers may be permitted to use information in a limited way to determine whether the study or the potential participants are appropriate. If required to do so by applicable law, we will obtain your consent before we disclose your health information to an outside researcher.
To business associates: Some services are provided by or to RSBS through contracts with business associates. Examples include RSBS attorneys, consultants, collection agencies, and accreditation organizations. We may disclose information about you to our business associates so that they can perform the job we have contracted with them to do.
Your medical information may be released in the following special situations:
1. We may use or disclose your information, without your permission, for the following purposes to the extent permitted or required by law.
2. Under emergency conditions, to government or other groups assisting in emergencies or disasters.
3. When required by law.
4. For public health activities including without limitation, to report disease an vital statistis, child abuse, and adult abuse or neglect or domestic violence.
5. For health oversight activities such as activities of state licensing and peer review authorities and fraud prevention enforcement agencies.
6. For judicial and administrative proceeding.
7. To avert a serious threat to health or safety
8. To law enforcement officials with regard to crime victims, crimes on our premises, crime reporting in emergencies, and identifying and locating suspects or other persons.
9. For certain
specialized government functions, such as military discharge.
10. To the military, to federal officials for lawful intelligence, counterintelligence, national security activities, and to correctional institutions and law enforcement regarding persons lawful custoday.
11. As authorized by the state's workers compensation laws.
In all of the situations described above where required to do so by law, RSBS will obtain your specific written permission prior to disclosing HIV-related information, mental health records, drug or alcohol substance abuse records, or any other type of record given explicit additional protection under applicable state law. You have the following rights regarding medical information we maintain about you:
Right to inspect and copy: You have the right to inspect and receive a copy of your medical information that is used to make decisions about your care. Usually, this includes medical and billing records maintained by RSBS.
If you wish to inspect and copy medical information, you must complete and return a request to inspect and copy form. If you request a copy of the information, we may charge a fee for the cost of copying, mailing, or other supplies associated with your request, to the extent permitted by state and federal law. We may deny your request to inspect and copy your information in certain very limited circumstances. For example: We may deny access if your physician believes it will be harmful to your health or could pose a threat to others. If you are denied access to medical information, You may request that the denial be reviewed.
Another health care provider chosen by RSBS reviewed your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review. Right to request amendment: If you believe that the medical information we have about you is incorrect or incomplete, you have the right to ask us to change the information. You have the right to request an amendment for as long as the information is kept by the RSBS. To request a change to your information, you must complete and return a Request for Amendment Form (a copy of which is available upon request). In addition, you must provide a reason to support your request.
RSBS may deny your request for an amendment if it is not in writing or does not include a reason to support your request. In addition, we may deny your request if you ask us to amend information that:
1. Was not created by RSBS, unless the person or entity that created the information is no longer available to make the amendment.
2. Is not part of the medical information kept by or for RSBS
3. Is not part of the information which you would be permitted to inspect or copy
4. Is accurate and complete
Right to an Accounting of Disclosures: You have the right to request an "accounting of disclosures." This is a list of the disclosures we made of medical information about you. This list will not include disclosures for treatment, payment, and health care operations; disclosures that you have authorized or that have been made to you; disclosures for facility directories; disclosures for national security or intelligence purposes; disclosures to correctional institutions or law enforcement with custody of you; disclosures that took place before April 14, 2003; and certain other disclosures. To request this list of disclosures, you must complete and return a Request for Accounting of Disclosures Form (a copy of which is available upon request).
Your request must state the time period for which you would like the accounting. The accounting period may not go back further than six years from the date of the request, and it may not include dates before April 14, 2003. You may receive one free accounting in any 12-month period. We will charge you for additional requests.
Right to Request Restrictions: you have the right to request a restriction or limitation on the medical information we use or disclose about you. For example, you could ask that we not use or disclose information about treatment you received to other health care providers or to your insurance company. We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you with emergency treatment. To request a restriction, you must complete and return a Request for Restrictions Form (a copy of which is available upon request).
Right to Request Confidential Communications: You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. To request confidential communications, you must complete and return a Confidential Communication Request Form (a copy of which is available upon request). We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted, and we may require you to provide information about how payment will be handled. Right to a Paper Copy of the Notice: You have the right to receive a paper copy of this notice. You may ask us to give you a copy of this notice at any time.
Changes to This Notice: The effective date of this notice is April 14, 2023. We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for medical information we already have about you, as well as any information we receive in the future. If the terms of this notice are changed, RSBS will provide you with a revised notice upon request, and we will post the revised notice on our website and in designated locations at RSBS.
Complaints: If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the Department of Health and Human Services. To file a complaint with RSBS, please complete and return a Complaint Form (a copy of which is available upon request) or contact our Compliance Officer. All complaints must be submitted in writing. You will not be penalized for filing a complaint.
Other Uses of Medical Information: Except as described anove, RSBS will not use or disclose your protected health information without a specific written authorization from you. If you provide us with this written authorization to use or disclose medical information about you, you may also revoke that authorization, in writing , at any time. IF you revoke your authorization, we will no longer use or disclose medical information about you for the reasons covered by your written authorization, exept to the extent we have alrady relied on your authorization. We are unable to take back any disclosures we have already made with your permission, and we are required to retain our records of the care that we provide to you.
Radiant Skin and Body Spa Privacy Practices and HIPAA Policy Statement
Notice of Privacy Practices and HIPAA Policy Statement
Acknowledgement of Receipt Form
I have read or received a copy of the RSBS Privacy Practice Policy
If signed by a Personal Representative:
