CONSENT TO TREAT

Consent to Treat.  You, for yourself, or as a personal representative of the patient, voluntarily consent to all medical treatment and health care-related services that the caregivers at MOOV Health and Wellness, Inc. (“MOOV”) consider to be necessary for the patient. You understand that caregivers include physicians, technicians, nurses, and other qualified personnel who shall perform services and procedures as may be necessary in accordance with the judgment of the attending medical provider(s).

You are aware that the practice of medicine and surgery is not an exact science; no guarantees have been made about the results of treatments or examinations. You have the right to discuss any treatment with my provider. You are encouraged to ask questions about any concerns.

You agree to review additional consents for individual service(s) and procedure(s).

This consent is valid until you revoke it in writing.

Acknowledgements

Receipt of Notice of Privacy Practices. You have received or have been offered a copy of the Notice of Privacy Practices which describes how the patient’s health information may be used or disclosed by MOOV. It is understood that this Notice is provided the first time the patient receives services and then only when a significant change is made.  Otherwise, it is available by request or on the clinic’s website.

Electronic Communication. You may also receive emails and text messages from us that will include updates on our clinic, general health news, and business updates. You can unsubscribe at any time using the link included on all emails.

By signing below, you or your personal representative has read and understands this Consent to Treat, Telehealth Consent, and Notice of Privacy Practices, and accepts the terms and conditions.

TELEHEALTH CONSENT

Consent to Telehealth
Telehealth is a way to visit healthcare providers involving the use of electronic communications. You can talk to your provider from any place, including your home, without going to a clinic or hospital. The information may be used for diagnosis, therapy, follow-up and/or education, and may include live two-way audio and video and other materials (e.g. medical records, data from medical devices).

You understand that you have the following rights with respect to the telehealth visit:

• The laws that protect the confidentiality of your medical information also apply to telehealth. As such, you understand that the information disclosed by you during the session is generally confidential. There are both mandatory and permissive exceptions to confidentiality which are outlined in the Notice of Privacy Practices.
• You understand that there are risks and consequences from telehealth, including, but not limited to, the possibility, despite reasonable efforts on the part of my provider that: the transmission of your medical information could be disrupted or distorted by technical failures; the transmission of your medical information could be interrupted by unauthorized persons; and/or the electronic storage of your medical information could be accessed by unauthorized persons. In addition, you understand that telehealth-based services and care may not be as complete as face-to-face services. You also understand that if your provider believes you would be better served by face-to-face services, you may be referred to a provider who can provide such services.
• You understand that electronic communication should never be used for emergency communications or urgent requests. Emergency communications should be made to the existing emergency 911 services in your community.

By signing below, you or your personal representative has read and understands this Consent to Treat, Telehealth Consent, and Notice of Privacy Practices, and accepts the terms and conditions.

MOOV Health and Wellness, Inc.
NOTICE OF PRIVACY PRACTICES (NPP)

Your Rights:  You have the right to:

Your Choices

You have some choices in the way that we use and share information with family and friends about your condition.

Our Uses and Disclosures:  We may use and share your information as we:

We will not market or sell your health information.

Get an electronic or paper copy of your medical record

• You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.
• We will provide a copy or a summary of your health information within 15 days of your request. We may charge a reasonable, cost-based fee.

Ask us to correct your medical record

• You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
• We may say “no” to your request, but we will tell you why in writing within 60 days.

Request confidential communications

• You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
• We will say “yes” to all reasonable requests.

Ask us to limit what we use or share

• You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.
• If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.

Get a list of those with whom we have shared information

• You can ask for a list (and “accounting of disclosures”) of the times we have shared your health information for six years prior to the date you ask, who we shared it with, and why.
• We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We will provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of this privacy notice

• You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

Choose someone to act for you

• If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
• We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated

• You can complain if you feel we have violated your rights by contacting us using the contact information below.
• You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting hhs.gov/ocr/privacy/hipaa/complaints/.
• We will not retaliate against you for filing a complaint.

To treat you

We can use your health information and share it with other professionals who are treating you.

Example: A doctor treating you for an injury asks another doctor about your overall health condition.

To run our organization

We can use and share your health information to run our practice, improve your care, and contact you when necessary.

Example: We use health information about you to manage your treatment and services.

To bill for your services

We can use and share your health information to bill and get payment from health plans or other entities.

Example: We give information about you to your health insurance plan so it will pay for your services.

How else can we use or share your health information?

We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information, see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

To help with public health and safety issues

We can share health information about you for certain situations such as:

To do research

We can use or share your de-identified information for health research. De-identified information means information which does not reveal your identity.

To comply with the law

We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we are complying with federal privacy law.

To respond to organ and tissue donation requests

We can share health information about you with organ procurement organizations.

To work with a coroner, medical examiner, or funeral director

We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

To address workers’ compensation, law enforcement, and other government requests

We can use or share health information about you:

Respond to lawsuits and legal actions

We can share health information about you in response to a court or administrative order, or in response to a subpoena.

Changes to the Terms of this Notice

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site, MOOV.com.

Compliance Contact Information   You may:

• Reach our Compliance Team at compliance@MOOV.health
• Contact our Chief Compliance and Privacy Officer, Emily Wang Zahn, JD, by email at zahn@vituity.com or by phone at 209-484-0112.
• Anonymously report a violation through our toll-free hotline 24/7 at 1-877- 3ETHICS (1-877-338-4427)

Effective Date of this Notice:  September 15, 2024