Terms of Service / Consent Form
I, (PATIENT OR LEGAL GUARDIAN), give consent for the following individuals in my family to be treated by Nurse For That LLC. The additional signed consent for Treatment, HIPAA, Privacy Policy, IV/IM, and Telemedicine services apply to each person listed in the patient intake form.
CONSENT FOR TREATMENT
I, (PATIENT OR LEGAL GUARDIAN) hereby consent and authorize Nurse For That LLC and its associated contract providers to perform medical examination and procedures. This may include basic nursing care, routine testing, ordering of radiology/laboratory procedures, and wound repair. Treatment modalities may include oral, intravenous, intramuscular, subcutaneous, inhaled medications, wound care, and bio-occlusive glue. I authorize my medical provider(s) to perform other additional or extended services in emergency situations if it may be necessary or advisable in order to preserve my life or health. I understand that my care is directed by my medical provider (Nurse Practitioner) and that other personnel (RN's) render care and services to me according to the medical provider(s) instructions as directed by the Texas Board of Nursing.
I am aware that the practice of medicine and surgery is not an exact science and I acknowledge that no guarantees or promises have been made to me with respect to results of such diagnostic procedure or treatment.
I understand that samples of bodily fluids and/or tissues may be withdrawn from me (the patient) during routine diagnostic procedures. I authorize Nurse For That LLC to dispose of the bodily fluids. In the case of my bodily fluid exposure to a healthcare employee, I consent to testing, which may include, but are not limited to, HIV or Hepatitis, to determine the presence of any communicable disease for the benefit of the exposed employee. I understand that these test results do not become a part of my medical record.
I am aware that my appointment may be subject to cancellation at any time if the personnel rendering care and services to me feels unsafe and/or uncomfortable at any time during the appointment. I am also aware that I can withdraw my consent and discontinue participation in these procedures at any time.
I grant permission for Nurse For That LLC to send me text messages regarding wait times, my appointments, and follow up questions regarding care.
I grant permission for Nurse For That LLC to take photographs, should the need arise, for the purpose of my treatment during my health evaluation and treatment. 6. Although the facility will make all reasonable efforts in safeguarding my valuables, I understand that Nurse For That LLC is not responsible for the loss or damage of personal valuables.
HIPAA
I hereby authorize Nurse For That LLC and its affiliates, its employees and agents, to use and disclose protected health information (e.g., information relating to the diagnosis, treatment, and health care services provided or to be provided to me and which identifies my name, address, social security number, Member ID number) for the purpose of helping me to resolve claims and health benefit coverage issues or to collaborate care between healthcare providers.
Nurse For That LLC is required by law to maintain the privacy of our patients' protected health information and to provide patients with notice of our legal duties and privacy practices with respect to protected health information.
We take very seriously the confidentiality of our patients' information, and we are required by law to protect the privacy and security of your protected health information through appropriate safeguards. We are required to notify you in the event of a breach of your protected health information.
We will not use or disclose your protected health information for any purpose other than treatment, payment, or health care operations unless you have signed a form authorizing such use or disclosure. You have the right to revoke such authorization in writing.
We may forward information regarding your medical procedures and treatment to your insurance company to arrange payment for the services provided to you. 4. For protected health information that we maintain in any electronic designated record set, you may request a copy of such health information in a reasonable electronic format, if readily producible. We are permitted and/or required by law to make certain other uses and disclosures of your protected health information without your consent or authorization for the following:
Any purpose required by law;
Public health activities such as required reporting of immunizations, disease, injury, birth and death, or in connection with public health investigations;
If we suspect child abuse or neglect; if we believe you to be a victim of abuse, neglect or domestic violence;
To the Food and Drug Administration to report adverse events, product defects, or to participate in product recalls;
To your employer when we have provided health care to you at the request of your employer;
To a government oversight agency conducting audits, investigations, civil or criminal proceedings;
Court or administrative ordered subpoena or discovery request;
To law enforcement officials as required by law if we believe you have been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law;
To coroners and/or funeral directors consistent with law;
If necessary, to arrange an organ or tissue donation from you or a transplant for you;
If you are a member of the military, we may also release your protected health information for national security or intelligence activities; and
To workers' compensation agencies for workers' compensation benefit determination.
NOTICE OF PRIVACY POLICY
Nurse For That LLC's Notice of Privacy Practices provides information about how protected health information about me (the patient) - including information about human immunodeficiency virus (HIV), AIDS-related complex (ATC) and acquired immunodeficiency (AIDS); including substance abuse treatment records protected under the regulation 42 Part 2, in the Code of Federal Regulations (if any); and psychological and social services records, including communication made to me, a social worker, or psychologist (if any) may be disclosed. I have been offered an opportunity to review the Notice before signing this consent. I understand that the terms of the Notice may change, and I may obtain a revised copy by contacting the Nurse For That LLC office.
I understand that I have the right to request restrictions on how my protected health information is used or disclosed for treatment, payment, or healthcare operations. My provider(s) from Nurse For That LLC. are not required to agree to this restriction, but if they agree, will be bound by the agreement. I acknowledge that I have been offered and/or received Nurse For That LLC's notice of privacy practices.
The right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or healthcare operations.
I understand that Nurse For That LLC is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereon. I also understand that by refusing to sign this consent or revoking this consent, this organization may refuse to treat me as permitted by Section 164.506 of the Code of Federal Regulations.
I further understand that Nurse For That LLC reserves the right to change its notice and practices, in accordance with Section 164.520 of the Code of Federal Regulation. Should Nurse For That LLC change its notice, it will send a copy of any revised notice to the address I have provided (whether U.S. mail or, if I agree, via email).
If you have questions, need further assistance regarding or would like to submit a request pursuant to this Notice, you may contact the Nurse For That LLC Privacy Officer by phone at (903) 720-5575 or at the address immediately below.
I understand that I have a right to revoke this authorization by providing written notice to:
Nurse For That LLC
6305 Klamath Road
Fort Worth, Texas 76116
IV/IM NUTRITION/HYDRATION THERAPY
This document is intended to serve as informed consent for your Intravenous (IV) Infusion Therapy should this service be utilized by the patient(s) and procedure performed by Nurse For That LLC and its associated contract provider(s).
I have informed the provider(s) (nurse, nurse practitioner and/or physician) of any known allergies to medications or other substances. I have informed the provider(s) of all current medications and supplements. I have fully informed the provider(s) of my medical/surgical history. IV infusion therapies and any claims made about these infusions have not been evaluated by the US Food and Drug Administration (FDA) and are not intended to diagnose, treat, cure, or prevent any medical disease. These IV infusions are not a substitute for your physician's medical care.
I understand that I have the right to be informed of the procedure, any feasible alternative options, and the risks and benefits. Except in emergencies, procedures are not performed until I have an opportunity to receive such information and to give my informed consent.
I understand that:
The procedure involves inserting a needle into the vein and injecting the solution.
Alternatives to IV therapy are oral supplements, intramuscular supplements, or dietary and lifestyle changes
Risks of IV therapy include but not limited to: a) Occasionally: discomfort, bruising and pain at the site of injection. b) Rarely: inflammation of the vein used for injection, phlebitis, metabolic disturbances, and injury. c) Extremely Rare: Severe allergic reaction, anaphylaxis, infection, cardiac arrest, and death.
Benefits if IV therapy include: a) Injectables are not affected by stomach, or intestinal absorption problems b) Total amount of infusion is available to the tissue. c) Nutrients are forced into cells by means of high concentration gradient. d) Higher doses of nutrients can be given more possible by mouth without intestinal irritation.
I have the right to consent to or refuse the proposed treatment at any time prior to and during its performance.
The procedure will be performed by or under the direction of Nurse For That LLC
By signing this form, I attest that I (1) have personally read this form (or had it explained to me) and fully understand and agree to its contents; (2) have had my questions answered to my satisfaction, and the risks, benefits, and alternatives to Intravenous (IV) infusion therapy shared with me in a language I understand; (3) I have received all the information and explanation I desire concerning the procedure; (4) I authorize and consent to the performance of Intravenous (IV) Infusion Therapy; and (5) I release Nurse For That LLC, and all the medical providers including contract Registered Nurses from all liabilities for any complications or damages associated with my Intravenous (IV) Infusion Therapy.
TELEMEDICINE
Telemedicine services involve the use of secure interactive videoconferencing equipment and devices that enable health care providers to deliver health care services to patients when located at different sites. I understand that the same standard of care applies to a telemedicine visit as applies to an in-person visit. I am authorizing Nurse For That LLC and its Healthcare Providers to provide me with their observations, treatments, and recommendations regarding my medical condition. I agree to not hold Nurse For That LLC or any of its Healthcare Providers liable for opinions, diagnostic or therapeutic, provided based on these consultations.
I understand that I will not be physically in the same room as my health care provider. I will be notified of and my consent obtained for anyone other than my healthcare provider present in the room.
I understand that there are potential risks to using technology, including service interruptions, interception, and technical difficulties.
Security protocols could fail which could cause a breach of privacy of personal health information
A lack of access to complete medical records may result in adverse drug interactions or reactions or other medical judgment errors
If it is determined that the videoconferencing equipment and/or connection is not adequate, I understand that my healthcare provider or I may discontinue the telemedicine visit and make other arrangements to continue the visit.
Not every medical condition can be evaluated using telemedicine. The Healthcare Provider will inform you if a house call is medically necessary to further diagnose your condition. This may incur additional fees.
I understand that my condition may require a referral to a specialist. I understand my provider may also refer me to the emergency room or to call 911 at any point during the telemedicine visit.
I understand that I have the right to refuse to participate or decide to stop participating in a telemedicine visit, and that my refusal will be documented in my medical record. I also understand that my refusal will not affect my right to future care or treatment.
I understand that the laws that protect privacy and the confidentiality of healthcare information apply to telemedicine services.
I understand that my health care information may be shared with other individuals for scheduling and billing purposes.
I understand that my insurance carrier will have access to my medical records for quality review/audit.
I understand that this document will become a part of my medical record.
By signing this form, I attest that I (1) have personally read this form (or had it explained to me) and fully understand and agree to its contents; (2) have had my questions answered to my satisfaction, and the risks, benefits, and alternatives to telemedicine visits shared with me in a language I understand; and (3) am located in the state of Texas and will be in Texas during my telemedicine visit(s).
PERSONS FOR WHOM PRACTICE IS NOT LIABLE
I understand that Nurse For That LLC is only responsible for the acts of its employees acting within the scope of their practice. I understand that persons who are not employed by Nurse For That LLC may be involved in my care or treatment, including but not limited to other practitioners, laboratories, diagnostic testing facilities, contractors, vendors, product technicians, etc. I understand that Nurse For That LLC is not liable for the acts or omissions of non-employees or Tribe employees acting outside the course and scope of their duties.
FINANCIAL RESPONSIBILITY
Agreed upon payment is due at time of service. We accept credit cards, debit cards, FSA/HSA, and cash. Upon completion of payment, a superbill will be posted to the patient portal. I understand it is my responsibility to submit this document to insurance for possible reimbursement. Nurse For That LLC is not held responsible for any financial decisions made by the insurance company.
AGREEMENT
I have fully read, understand, and agree to this Consent of Treatment, HIPAA disclosure, Notice of Privacy Practices, Intravenous services, Telemedicine services, and Financial Policy. I certify that I am either the Patient or the Patient's legally authorized representative and have authority to execute this Consent and Agreement on behalf of the PATIENT. I have had the opportunity to ask questions and have had my questions answered to my satisfaction.
Last updated - 6/17/24