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Informed Consent - Client Service Agreement

This document contains important information about professional services and business policies of Functional Medicine Services. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPM), a federal law that provides privacy protections and patient rights about the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations.  The terms “we”, “us”, “our,” “practitioner“, functional medicine practitioner and “Functional Medicine Services” refer to the person providing the service to you. The term “you”, “client” or “patient” refers to any person or entity that visits our practice or contributes, is present or takes part in a session.  Although these documents are long and sometimes complicated, it is essential that you understand them. When you agree to this document, it will then form an agreement between You (the client) and Us (Functional Medicine Services). We can discuss any questions you have at the time of consent or at any time in the future. The service provided is a relationship between people that works in part because of clearly defined rights and responsibilities held by each person. As a client of Functional Medicine Services, you have certain rights and responsibilities that are important for you to understand. There are also legal limitations to those rights that you should be aware of.  Functional Medicine Services, have corresponding responsibilities to you. These rights and responsibilities are described in the following sections.  Goals/outcomes of treatment There can be many goals for the client relationship. Some of these will be long term goals such as improving the quality of your health. Others may be more immediate goals such as decreasing symptoms, developing healthy habits, changing behaviour or decreasing/ending medication or supplement use. Whatever the goals for the service, they will be set by the clients according to what they want to work on in the session. Functional Medicine Services may make suggestions on how to reach that goal, but you decide where you want to go.  Risks/benefits of services Sessions are a personal process which can bring emotions to the surface. There are no guarantees that the treatment or session will work for you. Clients can sometimes make improvements only to revert back after a time. Progress may happen slowly. All our services require a very active effort on your part. To be most successful, you will have to work on things we discuss outside of sessions. However, there are many benefits to the sessions. Our services can help you reduce symptoms, make behavioural changes, improve the quality of your health and many other advantages. Appointments  New appointments will ordinarily be up to 40 minutes in duration; and any follow up appointments may be as often as once per week at a time we agree on, although some sessions may be more or less frequent as needed. The time scheduled for your appointment is assigned to you and you alone. If you need to cancel or reschedule a session, we ask that you provide a minimum of 24 hours notice. If you miss a session without cancelling or cancel with less than 24 hours notice, no refunds will be offered [unless we both agree that you were unable to attend due to circumstances beyond your control].  It is important to note that insurance companies do not provide reimbursement for cancelled sessions; thus, you will be responsible for the cancellation fee. In addition, you are responsible for arriving to your session on time; if you are late, your appointment will still need to end on time.  Confidentiality Functional Medicine Services will make every effort to keep your personal information private. If you wish to have information released, you will be required to sign a consent form before such information will be released. There are some limitations to confidentiality to which you need to be aware. We may consult with a supervisor or other professionals in our practice to give you the best service. In the event that we consult with another practitioner, no identifying information such as your name would be released.  Functional Medicine Services is required by law to release information when the client poses a risk to themselves or others and in cases of abuse to children or the elderly. If Functional Medicine Services receives a court order or subpoena, we may be required to release some information. In such a case, we will consult with other professionals and limit the release to only what is necessary by law. Confidentiality and Group Therapy  The nature of group therapy makes it difficult to maintain confidentiality. If you choose to participate in group therapy, be aware that Functional Medicine Services cannot guarantee that other group members will maintain your confidentiality. However, we will make every effort to maintain your confidentiality by reminding group members frequently of the importance of keeping what is said in group confidential. We also has the right to remove any group member from the group should she discover that a group member has violated the confidentiality rule.  Confidentiality and Technology  Some clients may choose to use technology in their sessions. This includes but is not limited to online sessions via Skype, telephone, email, text or chat. Due to the nature of online sessions, there is always the possibility that unauthorised persons may attempt to discover your personal information. Functional Medicine Services will take every precaution to safeguard your information but cannot guarantee that unauthorised access to electronic communications could not occur. Please be advised to take precautions with regard to authorised and unauthorised access to any technology used in sessions.  Be aware of any friends, family members, significant others or co-workers who may have access to your computer, phone or other technology used in your session. Record-Keeping  Functional Medicine Services may keep records of your appointments, sessions and treatment plan which includes goals for your session. These records are kept to ensure a direction to your sessions and continuity in service. They will not be shared except with respect to the limits to confidentiality discussed in the Confidentiality section. Should the client wish to have their records released, they are required to sign a release of information which specifies what information is to be released and to whom.  Records will be kept for at least 7 years but may be kept for longer. Records will be kept either electronically on a USB flash drive or electronically on our online servers or client portals.  Professional Fees You are responsible for paying at the time of your session unless prior arrangements have been made. Payment must be made by credit card or cash. If you refuse to pay your debt, we reserve the right to use an attorney or collection agency to secure payment. If you anticipate becoming involved in a court case, I recommend that we discuss this fully before you waive your right to confidentiality. If your case requires our participation, you will be expected to pay for the professional time required. Fees are non-negotiable. To receive sliding scale fees, you must present proof of income through recent pay stubs or tax forms. Fees are subject to change at Functional Medicine Services’ discretion.  Fee Schedule  Our full fee structure can be found on our website on the appointments page Packages Pre paid packages or appointments are valid for 6 months from the date of purchase. Insurance If you have a health insurance policy, it usually does not provide coverage for functional medicine treatment. You are responsible for knowing your coverage and for letting Functional Medicine Services know if/when your coverage changes.  By signing this Agreement, you agree that I can provide requested information to your carrier if you plan to pay with insurance. We reserve the right to change this consent from time to time. Limitation of Liability To the maximum extent permitted by law, We accept no liability for any direct or indirect loss or damage, foreseeable or otherwise, including any indirect, consequential, special or exemplary damages arising from the use of the Website or any information contained therein. You should be aware that you use the Website and its Content at your own risk.Nothing in these Terms and Conditions excludes or restricts Functional Medicine Services’ liability for any direct or indirect loss or damage arising out of the incorrect provision of Services or out of reliance on incorrect information included on the Website. In the event that any of these terms are found to be unlawful, invalid or otherwise unenforceable, that term is to be deemed severed from these Terms and Conditions and shall not affect the validity and enforceability of the remaining Terms and Conditions. This term shall apply only within jurisdictions where a particular term is illegal. You have read and understood our disclaimer and understand that the use of this site and the information herewith is for educational purposes only. Disclaimers We make no warranty or representation that the Website will meet your requirements, that it will be of satisfactory quality, that it will be fit for a particular purpose, that it will not infringe the rights of third parties, that it will be compatible with all systems, that it will be secure and that all information provided will be accurate. We make no guarantee of any specific results from the use of our Service or Services. No part of this Website is intended to constitute advice and the Content of this Website should not be relied upon when making any decisions or taking any action of any kind. No part of this Website is intended to constitute a contractual offer capable of acceptance. Whilst we use reasonable endeavours to ensure that the Website is secure and free of errors, viruses and other malware, you are strongly advised to take responsibility for your own internet security, that of your personal details and your computers. Availability of the Website The Website is provided “as is” and on an “as available” basis. Functional Medicine Services uses industry best practices to provide a high uptime, including a fault-tolerant architecture hosted in cloud servers. We give no warranty that the Website or Facilities will be free of defects and / or faults and we do not provide any kind of refund for outages. We provide no warranties (express or implied) of fitness for a particular purpose, accuracy of information, compatibility and satisfactory quality. We accept no liability for any disruption or non-availability of the Website resulting from external causes including, but not limited to, ISP equipment failure, host equipment failure, communications network failure, power failure, natural events, acts of war or legal restrictions and censorship. Services, Pricing and Availability Whilst every effort has been made to ensure that all general descriptions of Services available from Functional Medicine Services correspond to the actual Services that will be provided to you, We are not responsible for any variations from these descriptions as the exact nature of the Services may vary depending on your individual requirements and circumstances. This does not exclude Our liability for mistakes due to negligence on Our part and refers only to variations of the correct Services, not different Services altogether. Where appropriate, you may be required to select the required Plan of Services. We neither represent nor warrant that such Services will be available at all times and cannot necessarily confirm availability until confirming your Order. Availability indications are not provided on the Website. All pricing information on the Website is correct at the time of going online. We reserve the right to change prices and alter or remove any special offers from time to time and as necessary. In the event that prices are changed during the period between an order being placed for Services and Us processing that order and taking payment, then the price that was valid at the time of the order shall be used. Early bird pricing is non-refundable. Accounts In order to procure Services on this Website and to use certain other parts of the System, you are required to create an Account which will contain certain personal details and Payment Information which may vary based upon your use of the Website as We may not require payment information until you wish to make a purchase. By continuing to use this Website you represent and warrant that: all information you submit is accurate and truthful; you have permission to submit Payment Information where permission may be required; and you will keep this information accurate and up-to-date. Your creation of an Account is further affirmation of your representation and warranty. It is recommended that you do not share your Account details, particularly your username and password. We accept no liability for any losses or damages incurred as a result of your Account details being shared by you. If you use a shared computer, it is recommended that you do not save your Account details in your internet browser. If you have reason to believe that your Account details have been obtained by another person without consent, you should contact Us immediately to suspend your Account and cancel any unauthorised orders or payments that may be pending. Please be aware that orders or payments can only be cancelled up until provision of Services has commenced. In the event that an unauthorised provision commences prior to your notifying Us of the unauthorised nature of the order or payment then you shall be charged for the period from the commencement of the provision of services until the date you notified us and may be charged for a billing cycle of one month. Termination and Cancellation of Accounts Either Functional Medicine Services or you may terminate your Account. If We terminate your Account, you will be notified by email and an explanation for the termination will be provided. Notwithstanding the foregoing, We reserve the right to terminate without giving reasons. If We terminate your Account, any current or pending orders or payments on your Account will be cancelled and provision of Services will not commence. Intellectual Property All Content included on the Website, unless uploaded by Users, including, but not limited to, text, graphics, logos, icons, images, sound clips, video clips, data compilations, page layout, underlying code and software is the property of Functional Medicine Services, our affiliates or other relevant third parties. By continuing to use the Website you acknowledge that such material is protected by applicable Australian, UK and International intellectual property and other laws. You may not reproduce, copy, distribute, store or in any other fashion re-use material from the Website unless otherwise indicated on the Website or unless given Our express written permission to do so. Third Party Intellectual Property Unless otherwise expressly indicated, all Intellectual Property rights including, but not limited to, Copyright and Trademarks, in product images and descriptions belong to the manufacturers or distributors of such products as may be applicable. You may not reproduce, copy, distribute, store or in any other fashion re-use such material unless otherwise indicated on the Website or unless given express written permission to do so by the relevant manufacturer or supplier. Fair Use of Intellectual Property We respectfully request that you attribute quotes or information you have been given as a result of our training to us in any social media post or repost. To this end, your social media profile(s) must be made visible to us at all times.   If we detect a pattern in your use of our intellectual property that in our reasonable opinion violates any aspect of our terms and conditions, we will contact you once to rectify, and we reserve the right to suspend or terminate your affiliate or user account (or both) including any online access to previous course purchases and cancel all outstanding commission payments due. Links to Other Websites This Website may contain links to other sites. Unless expressly stated, these sites are not under the control of Functional Medicine Services or that of Our affiliates. We assume no responsibility for the content of such websites and disclaim liability for any and all forms of loss or damage arising out of the use of them. The inclusion of a link to another site on this Website does not imply any endorsement of the sites themselves or of those in control of them. If you do not agree to be bound by these Terms and Conditions, you should stop using the Website immediately. Refund Policy No refunds will be issued for the delivery of a digital product. Your enrolment and logging in is viewed as acceptance of delivery of that product. No refunds will be issued for appointments which have been missed on your behalf. There are no refunds once an online consultation has been completed. We are not responsible for any delays in shipping or items which are out of stock.