1. Promise to Pay: I hereby and authorize payment directly to Divine Care Now for the patient unless the account for Divine Care Now is paid in full upon completion of the terms. I understand I am responsible to pay any account balance for applicable amounts in accordance with the regular rates and terms of Divine Care Now.
I understand that I am obligated to pay the account of Divine Care Now in accordance with regular rates and terms of Divine Care Now. If I fail to make payment when due and the account becomes delinquent or is turned over to collection agency, or an attorney for collection, I agree to pay all collection agency fees, court costs and attorney’s fees. I also agree that any patient or guarantor overpayments on the above Divine Care Now may be applied directly to any delinquent account for which I or my guarantor is legally responsible at the time of the collection of the overpayment.
Patient consent for E-prescribing of vitamins: I have been made aware and understand that Divine Care Now may use electronic services to send vitamins and supplements which allows related information to be electronically sent between my provider and myself. I have been informed and understand that when using this system by Divine Care Now using the electronic prescribing system will be able to see personal information. I give my consent to Divine Care Now to see this protected health information.
Notice of Privacy : Practice: Required pursuant to Health Insurance Portability and Accountability Act of 1996 (HIPPA). I acknowledge that I have received a copy of Divine Care Now privacy practices. I hereby consent to the use and disclosure of my protected health information, including information generated through use of virtual health or telemedicine services as described in the notice of privacy practices. This will include all of my protected health information.
General Consent for treatment services: I have been informed of the treatment procedures and considered necessary for me and that the treatments will be directed by an Advanced Practitioner, in accordance with state laws, scope of practice, and licensure. I, Danika Watson, Advance Practitioner, hold the right to refer the client to his or her primary care provider if I so feel he/she should be seen in person.
Consent for virtual health services: I hereby consent to engage in virtual health services, where available, as part of my treatment. I understand that “virtual health” services includes the practice of health care delivery, diagnosis and consultations, treatment and educational coaching using interactive audio, video or data communications when the provider and patient are not in the same physical location. The interactive electronic systems used for these services will NOT incorporate network and software security protocols.
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