Online Scheduling Agreement

Below you will find information regarding your rights and responsibilities and established policies of this practice. Please read this carefully.



APPOINTMENTS

You agree to keep all scheduled appointments and be on time. If you cannot attend a scheduled session, you will call to cancel and/or reschedule. There will be no fee if phone message or conversation is received before 24 hours of the scheduled appointment time. You understand if you miss or cancel with less than 24 hours of notice, then you will be charged for the full price of the appointment.



FINANCIAL POLICY

You understand that you are obligated to ensure that our fees are paid in full. Payments will be due in full at the time of service. 



HIPAA NOTICE OF PRIVACY PRACTICES

We may use protected health information about you to provide you with, coordinate, or manage your medical treatment or services. We may disclose protected health information about you to doctors, nurses, technicians, medical students, or other personnel, including persons outside of our office who are involved in your medical care.



Our staff may also share protected health information about you in order to coordinate your care for such reasons as prescriptions, lab work, and x-rays.



We may use and disclose protected health information about you for health care operations, such as our quality assessment and improvement activities, case management, coordination of care, business planning, customer service, and other activities. These uses and disclosures are necessary to run the facility, reduce health care costs, and make sure that all of our clients receive quality care. For example, we use the HIPAA compliant web-based practice management and electronic medical record (EMR) Kalix for appointment scheduling, electronic record keeping and filing, electronic paperwork and coordination of care. Your protected health information is recorded, stored and transmitted in Kalix in an encrypted state.



Subject to applicable state law, the law allows or requires us to use or disclose your health information without your authorization in some limited situations for purposes beyond treatment, payment, and operations. We will disclose protected health information about you when required to do so by federal, state, or local law. We may disclose your protected health information to researchers when their research has been approved by an institutional review



To promote quality care, we operate an electronic medical record (EMR) Kalix. Our providers and some providers unaffiliated with Kalix Health may have access to the EMR. Your medical record may be comprised of information in the EMR as well as in a paper record. We are legally obligated to notify any individual whose protected health information is affected by a security breach.



We may use and disclose protected health information to contact you (by email, telephone, voice message and/or text (SMS) message) as a reminder (including automated reminders sent via Kalix EMR and Practice Management Solution) that you have an appointment. We may use and disclose protected health information to tell you about or recommend possible treatment options, treatment alternatives, or health-related benefits or services that may be of interest to you.



CONSENT TO TREATMENT

I have read through all the above information and have been clearly advised of my rights and responsibilities as a client of Kalix Health, including the HIPAA Notice of Privacy Practices.



I understand these rights and responsibilities and agree to abide by them. I consent to treatment, and I understand I have a right to receive a copy of this form upon request. I also understand that I can withdraw this consent in writing and terminate at any time.