By reading and signing this document, I, the undersigned patient (or authorized representative) consent to and authorize the medical care and treatment rendered to the patient as deemed necessary or advisable in the judgment of the Intuitive Minds Wellness, LLC (the “Practice”) physician or other health care provider. I understand that, prior to rendering treatment, the Practice physician or other health care provider will thoroughly explain the proposed medical care and treatment, including an explanation of treatment alternatives and the risks associated with such treatment. I acknowledge and consent to the following:

1. PAYMENT FOR SERVICES: I agree to pay the Practice for services rendered to the patient, pursuant to the terms set forth in the Practice’s Services Agreement.

3. HIPAA CONSENT: The Department of Health and Human Services has established a “privacy rule” or “HIPAA”, to help ensure that personal health information (“PHI”) is protected and secure. I authorize the Practice to use or disclose my PHI for purposes of treatment, payment, and health are operations. I understand I have the right to refuse such use and disclosure upon a written request, and the Practice may accept or reject my request. Actions that have already been taken reliance on this signed form, or a previously signed consent, cannot be revoked. If you have any objections to this paragraph, please ask to speak to the Practice’s Privacy Officer.

4. CONSENT FOR PHOTOGRAPHING AND OTHER SECURE RECORDINGS. I consent to photographs, digital or audio recordings, and/or images of the patient being recorded for patient care, security purposes and/or the Practice’s health care operations purposes (e.g., quality improvement activities). I understand that the Practice retains the ownership rights to the images and/or recordings. I will be allowed to request access to or copies of the images and/or recordings when technologically feasible unless otherwise prohibited by law. I understand that these images and/or recordings will be securely stored and protected. Images and/or recordings in which the patient is identified will not be released and/or used outside the Practice without a specific written authorization from the patient or the patient’s legal representative unless otherwise permitted or required by law.

5. CONTROLLED SUBSTANCES. While the Practice is able to prescribe necessary controlled substances, it is important to disclose our philosophy regarding some of the stronger and potentially harmful pain relief medication. The Practice is aware of the potential side effects of Schedule II Controlled Substances for the treatment of pain (particularly benzodiazepines and opiates). The Practice will do its best to curb the use of such substances or find less potentially harmful pharmacological options. Please do not join the Practice with the assumption that the Practice will prescribe controlled substances for the treatment of pain on the initial visit. I understand the Practice may refer the patient to a local pain management specialist in lieu of prescribing such controlled substances; however, if the Practice prescribes Schedule II Controlled Substances to the patient for the treatment of pain, I understand I may be asked to enter into a Controlled Substances Agreement with the Practice.

6. PRACTICE’S CANCELLATION POLICY. To promote efficient access to treatment, the Practice requires all scheduled appointments to be cancelled at least twenty-four (24) hours in advance of the appointment, and seventy-two (72) hours in advance of an appointment scheduled on a Monday. In the event an appointment is cancelled with less than twenty-four 24 hours’ notice (or 72 hours’ notice, as applicable) or no notice at all, I understand the Practice will charge a missed appointment fee in an amount equal to the cost of the visit.

7. NOTICES OF PRIVACY PRACTICES: I acknowledge I have received a copy of the Practice’s Notice of Privacy Practices.

8. PATIENT BILL OF RIGHTS AND RESPONSIBILITIES. I acknowledge I have received a copy of the Practice’s Patient Bill of Rights and Responsibilities.

9. RIGHT TO SHARE INFORMATION WITH FAMILY AND FRIENDS. The Practice reserves the right to disclose PHI as described in the Notice of Privacy Practices. In order to have your PHI shared in other circumstances with members of your family or friends, please list those individuals with whom the Practice is authorized to release information:

By signing this document, I certify that I have read, understand and agree to its contents and that information provided by me is accurate and complete. I represent, warrant, and agree that I am authorized to consent to the rendition of the services described herein.

Instructions: Please complete the appropriate boxes below and sign at the bottom.

I hereby authorize any health care provider who previously rendered health care services to me (referred to individually as the “Practice”) to use and/or disclose certain protected health information about me to Intuitive Minds Wellness, LLC (“Intuitive Minds”) for purposes related to my treatment.

I authorize release of all medical records and other information regarding my treatment, even though the confidentiality of the information may be protected by Federal or State law. I understand the information to be released may include records related to behavior and/or mental health care, alcohol and drug abuse treatment, HIV/AIDS, and genetics. I further understand this authorization may be revoked at any time except to the extent that action has been taken in reliance upon it. Revocation must be made in writing to Intuitive Minds. Intuitive Minds will not condition treatment on whether I sign the authorization. I may be charged for copies of my medical record in accordance with applicable state and federal law. I understand information used or disclosed pursuant to this authorization may be subject to disclosure by the recipient and may no longer be protected by applicable law. This authorization shall remain in effect from the date signed below until the termination of service with Intuitive Minds.

ATTENTION: This is a legal document. Please read carefully. By signing, you agree that you understand and accept the terms on this form.

If the patient is 18 years of age or older, the patient must sign and date the form.

This notice of privacy practices (“notice”) describes how medical information about a patient (“you”) may be used and disclosed and how you can get access to this information. Please review it carefully.

The Health Insurance Portability & Accountability Act of 1996 (“HIPAA”) is a federal program that requires the Provider, and its physicians, health care professionals, employees, staff and other personnel rendering services for the Provider (referred to as “we”, “our” or “us”), to maintain the confidentiality of any information in our possession that would allow someone to identify you and learn something about your health, including information contained in medical records and other individually identifiable health information (the “Protected Health Information”). It does not apply to information that could not reasonably be used to identify you. HIPAA gives you the right to understand and control how your Protected Health Information is used. There are penalties for covered entities that misuse Protected Health Information.

As required by HIPAA, we have prepared this Notice to explain our responsibilities, how we may use and disclose your Protected Health Information, and your rights under HIPAA.

OUR RESPONSIBILITIES

We are required by law to maintain the privacy and security of your Protected Health Information.

We are required to let you know promptly if a breach occurs that may have compromised the privacy or security of your Protected Health Information.

We are required to provide this Notice to anyone who asks for it.

We are required to abide by the terms of this Notice if and until we officially adopt a new notice.

PERMISSIBLE USES OR DISCLOSURES YOUR PROTECTED HEALTH INFORMATION

We may use and disclose your Protected Health Information for a number of different reasons. This Notice describes each category of reasons we may use or disclose your Protected Health Information. For each category, we have provided a brief explanation and, in many cases, have provided examples. The examples given do not include all of the specific ways we may use or disclose your Protected Health Information. However, any time we use or disclose your Protected Health Information, it will be for one of the categories listed below. We may also create and distribute de-identified health information by removing all references to individually identifiable information.

Treatment. We will use your Protected Health Information to provide you with medical care and services. For instance, a medical assistant may read your medical chart in order to care for you properly. We will also give your information to others who need it in order to provide you with medical treatment or services. For instance, we may send your doctor the results of laboratory tests or x-rays we perform.

Payment. We will use your Protected Health Information, and disclose it to others, as necessary to obtain payment for the services we provide to you. We will not use or disclose more information for payment purposes than is necessary.

Health Care OperationsWe may use your Protected Health Information for activities that are necessary to operate this organization. This includes reading your Protected Health Information to review the performance of our personnel. We may also use your information and the information of other patients to determine what services we need to provide, expand, or reduce. For example, we may disclose your Protected Health Information to a company that assists us with quality assurance. We may disclose your Protected Health Information as necessary to others who we contract with to provide administrative services. This includes our lawyers, auditors, accreditation services, and consultants, for instance.

To Business Associates. The Provider may hire third parties that may need your Protected Health Information to perform certain services on behalf of the Provider. These third parties are “Business Associates” of the Provider. Business Associates must protect any Protected Health Information they receive from, or create and maintain on behalf of, the Provider.

Family and Friends. We may disclose your Protected Health Information to a member of your family or to someone else who is involved in your medical care or payment for care. We may notify family or friends if you are in the hospital, and tell them your general condition. In the event of a disaster, we may provide information about you to a disaster relief organization so they can notify your family of your condition and location. We will not disclose your information to family or friends if you object. We may also disclose to your personal representatives who have authority to act on your behalf (for example, to parents of minors or to someone with a power of attorney).

Public Health Oversight. We may disclose your Protected Health Information to a public health oversight agency for oversight activities authorized by law. This includes uses or disclosures in civil, administrative or criminal investigations; licensure or disciplinary actions (for example, to investigate complaints against health care providers); inspections; and other activities necessary for appropriate oversight of government programs (for example, to investigate Medicaid fraud).

To Report Abuse. We may disclose your Protected Health Information when the information relates to a victim of abuse, neglect or domestic violence. We will make this report only in accordance with laws that require or allow such reporting, or with your permission.

Legal Requirement to Disclose Information. We will disclose your Protected Health Information when we are required by law to do so. This includes reporting information to government agencies that have the legal responsibility to monitor the health care system.

Law Enforcement. We may disclose your Protected Health Information for law enforcement purposes. This includes providing information to help locate a suspect, fugitive, material witness or missing person, or in connection with suspected criminal activity. We must also disclose your Protected Health Information to a federal agency investigating our compliance with federal privacy regulations.

For Lawsuits and Disputes. We may disclose Protected Health Information in response to an order of a court or administrative agency, but only to the extent expressly authorized in the order. We may also disclose Protected Health Information in response to a subpoena, a lawsuit discovery request, or other lawful process, but only if we have received adequate assurances that the information to be disclosed will be protected.

Specialized Purposes. We may disclose your Protected Health Information for a number of other specialized purposes. We will only disclose as much information as is necessary for the purpose. For instance, we may disclose your information to coroners, medical examiners and funeral directors; to organ procurement organizations (for organ, eye, or tissue donation); or for national security and intelligence purposes. We may disclose the Protected Health Information of members of the armed forces as authorized by military command authorities. We also may disclose Protected Health Information about an inmate to a correctional institution or to law enforcement officials to provide the inmate with health care, to protect the health and safety of the inmate and others, and for the safety, administration, and maintenance of the correctional institution. We may also disclose your Protected Health Information to your employer for purposes of workers’ compensation and work site safety laws (OSHA, for instance). We may disclose Protected Health Information to organizations engaged in emergency and disaster relief efforts.

To Avert a Serious Threat. We may disclose your Protected Health Information if we decide that the disclosure is necessary to prevent serious harm to the public or to an individual. The disclosure will only be made to someone who is able to prevent or reduce the threat.

Research. We may disclose your Protected Health Information in connection with medical research projects if allowed under federal and state laws and rules. The Provider may disclose Protected Health Information for use in a limited data set for purposes of research, public health or health care operations, but only if a data use agreement has been signed.

Information to Patients. We may contact you, or your personal representative, to provide additional information, including appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

Prior Authorization. All uses and disclosures other than the foregoing uses and disclosures will be made only with your prior written authorization. In addition, we will not use or disclose your health information in the sale of Protected Health Information or for marketing activities without your prior written authorization, and we will not disclose certain psychotherapy notes without your prior written authorization. We may contact you for fundraising efforts, but you can tell us not to contact you again.

YOUR RIGHTS

You have the following rights with respect to your Protected Health Information, which you can exercise at any time by presenting a written request to the Privacy Official identified at the end of this notice.

Revoke Authorization. If you authorize us to use your Protected Health Information, you have the right to revoke such authorization. We are required to honor and abide by that written request except to the extent that we have already taken actions relying on your authorization.

Request Restrictions. You have the right to request restrictions on certain uses and disclosures of Protected Health Information, including those disclosures related to treatment, payment, or our operations. We will consider your request but we are not required to agree to a requested restriction if it would affect your care. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it. We cannot agree to restrict disclosures that are required by law.

Communication. You have the right to request to receive confidential communications of Protected Health Information from us in a certain way or at a certain location. For example, you may ask that we contact you only at home or only by mail. If you want us to communicate with you in a special way, you will need to give us details about how to contact you, including a valid alternative address. We will honor reasonable requests.

Access to and Copies of Health Information. You have the right to inspect and receive a paper or electronic copy your Protected Health Information that we have in our records. We will respond to your request within thirty (30) days. If we cannot respond to your request within thirty (30) days, an additional thirty (30) days is allowed if we provide you with a written statement of the reason(s) for the delay and the date by which access will be provided. We may charge a reasonable, cost-based fee for copying, mailing, and transmitting the records, and the cost of any specific media you request, to the extent allowed by state and federal law.

Amended Health Information. You have the right to amend your Protected Health Information in our records which you believe is not correct or not complete. We will respond to your request in writing within thirty (30) days. We may deny your request and will provide a written explanation of such denial.

Accounting of Disclosures. You have the right to receive an accounting of the times we’ve shared your Protected Health Information for six (6) years prior to the date of the request, to whom the Protected Health Information was shared, a description of the Protected Health Information and the reason for the disclosure. We will provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another accounting within twelve (12) months. We will include all the disclosures except for those about treatment, payment, and health care operations, disclosures incident to a permitted use or disclosure; disclosures as part of a limited data set; disclosures to your family members, other relatives, or friends who are involved in your care or who otherwise need to be notified of your location, general condition, or death; disclosures for national security purposes; certain disclosures to correctional or law enforcement personnel; disclosures that you have authorized; and disclosures made directly to you or your representatives.

Choose Someone to Act for You. You have the right to give someone medical power of attorney, or if someone is your legal guardian, that person can exercise your rights and make choices about your Protected Health Information.

State Rights More Stringent Than HIPAA. In certain instances, protections afforded under applicable state law may be more stringent than those provided by HIPAA and are therefore not preempted. For instance, certain substance abuse records and certain mental health records are subject to more stringent protections under Florida law.

Paper Copy of this Privacy Notice. You have the right to obtain a paper copy of this notice from us upon request.

Complaints. You have the right to file written complaint with our office, or with the Department of Health and Human Services, Office of Civil Rights, about violations of the provisions of this notice or the policies and procedures of our office. We will not retaliate against you for filing a complaint. We are required to abide by the terms of the Notice currently in effect. We reserve the right to change the terms of our Notice and to make the new notice provisions effective for all Protected Health Information that we maintain. We will post a copy of the Notice in our office, and you may request a written copy of a revised Notice from the Privacy Official.

CONTACT THE PRIVACY OFFICER FOR MORE INFORMATION

If you have any questions regarding this Notice or if you wish to exercise any of your rights described in this Notice, you may contact the Privacy Official at:

Kate D. Remauro, PMHNP-BC
INTUITIVE MINDS WELLNESS, LLC
7901 4th Street North, Suite 101
St. Petersburg, FL 33602
813-434-0036

providing, soliciting, or arranging to provide health care services, including, without limitation, the referral of the patient to another health care provider

providing emergency treatment

prescribing, refilling, and renewing prescriptions for medicinal drugs

providing phone consultations

I understand this consent shall remain valid unless I provide written notice of revocation to the Practice signed and dated by me.