Last updated March 1, 2024

This Everlong Policies, HIPAA, Consent, & Release Agreement for Everlong Inc., doing business as Everlong (“Everlong,” “we,” “us,” or “our“) describes how and why our practice policies and your consent and release agreement is required when you use our services (“Services“).

PRACTICE POLICIES

Session Length

To ensure you receive the full benefit of your session, it is important to be present for the entire scheduled time. Follow-up sessions are 55 minutes long. If you arrive late, the session will be shortened accordingly. If you leave early, your on-file payment method will be charged for the remaining time of the session for which you were not present.

No-Shows and Late-Cancellations

We carefully schedule appointments to ensure that each patient receives the personalized attention and care they deserve from our registered dietitians. To maintain this level of service, it is crucial that you attend your scheduled appointments. As a reminder, we provide multiple appointment notifications leading up to your session. However, if your plans change, we require at least 24 hours’ notice to adjust our schedule accordingly.

Failure to cancel or reschedule your appointment with at least 24 hours’ notice, or failure to attend your appointment at the scheduled start time, will result in a $150 No-Show/Late-Cancellation fee. This fee is not covered or reimbursable by your insurance company. It will be charged directly to your credit or debit card on file.

By acknowledging this policy, you agree to provide a credit or debit card number, which may be charged for any no-show or late-cancellation. To avoid this fee, please ensure that any appointment cancellations or rescheduling requests are made at least 24 hours in advance.

Quiet Space Requirements for Telehealth

To ensure the effectiveness and confidentiality of your telehealth session, it is essential that you are in a quiet, distraction-free environment. Please refrain from engaging in any other activities, such as driving, during your session.

Maintaining a peaceful and undisturbed setting helps protect the confidentiality of your discussion with your provider and ensures clear communication. This allows you to fully engage in your telehealth session and enables our healthcare professionals to provide you with the highest level of care and attention.

If you are not in a suitable environment or engage in behavior that is disrespectful or inappropriate towards the registered dietitian, we will not be unable to conduct the session. Please ensure that your surroundings are conducive to a productive and confidential consultation.

Dietitian Accessibility Between Sessions

For rescheduling and cancellations, please use the patient portal. It is important to note that our providers are available only during your scheduled session times. Everlong dietitians cannot offer ongoing support, consultations, or services through emails or text messages. Please use the patient portal for any appointment-related requests or inquiries.

Social Media and Telecommunication

To safeguard your confidentiality and maintain professional boundaries, Everlong does not accept friend or contact requests from current or former patients on social networking sites (e.g., Facebook, LinkedIn). Connecting with patients on these platforms could compromise your privacy and blur the lines of our professional relationship. We are committed to preserving the integrity of your care and our professional interactions.

Electronic Communication

We cannot guarantee the confidentiality of communications conducted through electronic media, including emails and text messages. To ensure your privacy and the security of your information, please refrain from using these methods to discuss session content or request emergency assistance. Electronic communication, including telephone, internet, facsimile, and email, falls under the category of telemedicine. Telehealth is broadly defined as the use of information technology to deliver medical services and information from one location to another. For details on how telehealth services are handled, please refer to our “Consent for Telehealth Consultation Policy” below.

Young Adults Ages 18-26 

If you are covered under your parent or guardian’s health insurance plan, or if they are providing financial support for our services, by clicking “Continue” in our appointment booking flow, you consent to allow us to discuss financial and insurance matters with them. This consent is specifically for purposes related to billing and insurance coverage.

Children Under 18 Must Have a Parent or Guardian Present for Their Initial Appointment

Children under the age of 18 cannot legally consent to their own treatment; such consent must be provided by a parent or legal guardian. For your child’s initial appointment, it is required that a parent or guardian be present. If you are unable to attend and must send your child with another individual, such as an older sibling, grandparent, or nanny, please be aware that these individuals do not have the legal authority to consent to treatment on your behalf. You must either send a signed letter of authorization with the individual attending the appointment with your child or provide written authorization in advance, which includes the name of the person(s) you approve to consent to treatment on your behalf. If your child attends the appointment alone and there is no authorization on file specifying the individual’s name, the appointment will cease and be considered canceled, and a $150 late-cancellation fee will be charged to the on-file payment method. If you need to provide this authorization, please request a Child Medical Consent Form from our staff.

Parental Access to Minors’ Treatment Information

As the parent or legal guardian of a minor, you may be legally entitled to certain information about your child’s treatment. We will work with you to determine what information is appropriate for you to receive and which aspects of the treatment are more appropriately kept confidential to protect the therapeutic relationship with your child.

Termination of Treatment

Ending a therapeutic relationship is a significant step and should be handled thoughtfully to ensure proper closure. The duration of the termination process may vary depending on the length and intensity of the treatment.

We may discontinue treatment if it becomes apparent that it is no longer effective or if there are issues related to payment default. Additionally, treatment may be terminated for other reasons, as deemed necessary. If you wish to seek care from another provider, we may be able to provide you with a list of qualified registered dietitians.

If you miss or fail to reschedule three consecutive appointments without prior arrangements, we will consider the professional relationship to be discontinued in accordance with legal and ethical guidelines.

Insurance and Credit Card Authorization

By acknowledging these “PRACTICE POLICIES,” you authorize Everlong to charge your credit or debit card for services rendered. 

You authorize Everlong to release your information to the insurance companies you provide in order to submit insurance claims on your behalf. This authorization extends to the extent necessary to obtain payment for the services provided to you and includes authorization to release information about your services and counseling sessions. In consideration of these services, you assign all benefits to Everlong, where applicable, and authorize your insurance companies or other third-party payers to make payments directly to Everlong.

You understand that you remain responsible for all amounts due, including but not limited to copays, coinsurance, deductible amounts, and services not covered by your insurance plan. This includes services for which you fail to obtain prior authorization and mutually agreed-upon services or fees deemed not medically necessary. You acknowledge that failure to pay an amount due within 14 days will result in our submitting the account to collections, that you remain responsible for either collections fees, which equal 35% of the total amount due, or a flat late fee of $52.50, depending on applicable state laws. You further understand that your credit score may be affected.

You also agree that your credit or debit card can be charged a cancellation fee of $150 for any session that is not canceled at least 24 hours prior to the scheduled session per the “No-Shows and Late-Cancellations Policy” above.

You understand that this authorization will remain in effect until you cancel it in writing, and you agree to notify Everlong in writing of any changes to your account information or termination of this authorization.

You certify that you are an authorized user of this credit or debit card and agree not to dispute these scheduled transactions with your bank or credit card company, provided the transactions correspond to the terms indicated in this authorization form. You understand that you remain responsible for any dispute fees charged to us by your bank or credit card company, and these fees will be submitted to collections along with the total amount due. You acknowledge that credit card transactions could be linked to Protected Health Information.

PROTECTED HEALTH INFORMATION (HIPAA)

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Our Pledge Regarding Health Information

We recognize that your health information is personal and confidential, and we are dedicated to safeguarding your health information. We create a record of the care and services you receive from us to ensure quality care and to meet legal requirements. This notice applies to all records generated by Everlong.

This notice details how we may use and disclose your health information. It also outlines your rights regarding your health information and our obligations concerning its use and disclosure. We are required by law to:

• Ensure that protected health information (PHI) that identifies you is kept private.

• Provide you with this notice detailing our legal duties and privacy practices concerning health information.

• Adhere to the terms of this notice that are in effect at the time.

• Update this notice as needed. Any changes will apply to all information we hold about you, and the updated notice will be available upon request via email.

1. Use and Disclosure of Health Information

The following categories describe different ways that we use and disclose health information. For each category, we will explain what it means and provide examples. Not every use or disclosure will be listed, but all permissible uses and disclosures will fall into one of these categories.

For Treatment, Payment, or Health Care Operations: Federal privacy rules allow us to use or disclose your personal health information without your written authorization for treatment, payment, or health care operations. We may also disclose your protected health information to other health care providers involved in your treatment. For example, if we need to consult with another licensed health care provider about your condition, we are permitted to share your personal health information to assist in the diagnosis and treatment of your condition.

Treatment: This includes activities such as coordinating and managing health care providers, consultations between health care providers, and referrals. Disclosures for treatment purposes are not restricted by the minimum necessary standard, as other providers may need access to the full record to offer quality care.

Payment: We may use or disclose your health information to obtain payment for the services we provide, such as submitting claims to your insurance company.

Health Care Operations: This includes activities necessary to run our company, such as quality assessment, auditing, and administrative services.

Disclosures with Your Explicit Consent: We may disclose your health information to third parties if you provide explicit consent. This consent can be given in writing or through other documented means. For example, if you request that we share your health information with a family member or another provider not directly involved in your care, we will need your explicit consent to do so.

Lawsuits and Disputes: If you are involved in a lawsuit, we may disclose your health information in response to a court or administrative order. We may also disclose health information in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, provided we have made efforts to notify you of the request or obtain an order protecting the information.

2. Certain Uses and Disclosures Require Your Authorization

We keep “Session Notes” related to your care. Any use or disclosure of these notes requires your authorization unless it is for:

1. Treatment by our team or coordination with other healthcare providers.
2. Training or supervising our associates to improve their clinical skills.
3. Legal proceedings initiated by you, where we are defending ourselves.
4. Compliance investigations by the Secretary of Health and Human Services.
5. Legal requirements, limited to what is necessary to meet the legal requirements.
6. Health oversight activities related to the originator of the session notes.
7. Duties of a coroner authorized by law.
8. Averting a serious threat to the health and safety of others.

We will not use or disclose your PHI for marketing purposes.

We will not sell your PHI in the regular course of our business.

3. Certain Uses and Disclosures Do Not Require Your Authorization

Subject to certain legal limitations, we may use and disclose your PHI without your authorization for the following reasons:

1. When disclosure is required by state or federal law, in compliance with and limited to the relevant requirements of such law.
2. To report suspected abuse (child, elder, or dependent adult) or to prevent or reduce a serious threat to health or safety.
3. For activities such as audits and investigations.
4. To respond to court or administrative orders. While we may disclose your PHI in these cases, we prefer to obtain your authorization whenever possible.
5. To report crimes occurring on our premises.
6. To cooperate with coroners and medical examiners performing duties authorized by law.
7. For research purposes, including studies comparing different treatments for the same condition.
8. For purposes such as military missions, presidential protection, intelligence operations, or ensuring the safety of individuals in correctional institutions.
9. To comply with workers’ compensation laws. Although we prefer to obtain your authorization, we may disclose your PHI as required by these laws.
10. To remind you of appointments or inform you about treatment alternatives and healthcare services we offer.

In situations where your authorization is not required, we will still strive to handle your PHI with the utmost care and respect for your privacy.

4. Certain Uses and Disclosures Require You to Have the Opportunity to Object 

We may provide your PHI to a family member, friend, or other person you indicate is involved in your care or the payment for your healthcare, unless you object in whole or in part. In emergency situations, we may obtain your consent retroactively if it was not possible to obtain it beforehand.

5. You Have the Following Rights With Respect to Your PHI

1. The Right to Request Limits on Uses and Disclosures: You have the right to ask us not to use or disclose certain PHI for treatment, payment, or healthcare operations purposes. While we are not required to agree to your request and may deny it if we believe it could impact your healthcare, we will consider your request carefully.
2. The Right to Request Restrictions for Out-of-Pocket Expenses Paid in Full: You have the right to request restrictions on disclosures of your PHI to health plans for payment or healthcare operations if the PHI pertains solely to healthcare items or services you have paid for out-of-pocket in full.
3. The Right to Choose How We Send PHI to You: You have the right to request that we contact you in a specific way (e.g., home or office phone) or send mail to a different address. We will accommodate all reasonable requests.
4. The Right to See and Get Copies of Your PHI: Except for session notes, you have the right to obtain an electronic or paper copy of your medical record and other information we have about you. We will provide a copy or a summary of your record within 30 days of receiving your written request. A reasonable, cost-based fee may apply.
5. The Right to Get a List of Disclosures: You have the right to request a list of instances where we have disclosed your PHI for purposes other than treatment, payment, or healthcare operations, or based on your authorization. We will respond to your request within 60 days, providing a list of disclosures made in the last six years unless you request a shorter time period. The list will be provided at no charge, but a reasonable cost-based fee may apply for additional requests within the same year.
6. The Right to Correct or Update Your PHI: If you believe your PHI contains mistakes or is missing important information, you have the right to request corrections or additions. We may deny your request but will provide a written explanation within 60 days of receiving it.
7. The Right to Get a Paper or Electronic Copy of This Notice: You have the right to receive a paper copy of this notice and an electronic copy if requested.

Acknowledgement of Receipt of Privacy Notice

Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. By acknowledging this “PROTECTED HEALTH INFORMATION (HIPAA)” notice, you confirm that you have read, understood, and agreed to all the terms outlined in this notice.

CONSENT TO TREAT, WAIVER, AND RELEASE

Informed Consent for Nutrition Services

You are engaging the services of Everlong to receive information and guidance on health factors within your control, such as diet, nutrition, and related behaviors, to support your overall health and wellness.

You acknowledge that the providers at Everlong are dietitians, not physicians. They do not provide medical advice or prescribe treatments. Instead, they offer educational support to enhance your understanding of health as it relates to foods, dietary supplements, and eating behaviors. While nutritional support can complement medical care, it does not replace the diagnosis, treatment, or care provided by a medical provider. You understand that medicine is not an exact science and that there are inherent risks and benefits associated with medical treatments. You agree that no guarantees are made regarding the results or outcomes of the nutrition counseling provided by Everlong’s registered dietitians.

Nutritional evaluations or tests conducted during counseling are not intended to diagnose disease. These assessments are designed to guide the development of a suitable health-supportive program and to monitor progress toward your goals.

By agreeing to these terms, you hold Everlong harmless from any claims or damages related to the services provided. This agreement serves as a contract and a release of potential liability between you and Everlong.

Consent for Telehealth Consultation

You understand that Everlong offers the option for a telehealth consultation, allowing you to interact with your health and wellness provider via an interactive video connection. This method enables you to discuss your health and wellness concerns with the provider using the Healthie telehealth platform.

You acknowledge that your provider has explained how telehealth will be used for your consultation and how it will be employed throughout your engagement with Everlong.

You are aware of the potential risks associated with telehealth technology, which may include:

• The video connection may fail or become unstable during the consultation.

• The video or information transmitted may lack sufficient clarity, affecting the consultation’s effectiveness.

Despite these risks, telehealth offers several benefits, including:

• Eliminating the need for travel to the consultation location.

• Providing access to specialized care that might otherwise be unavailable.

By proceeding with this telehealth consultation, you consent to using this technology for your health and wellness services.

Consent to Use Zoom for Telehealth

Zoom is the platform we will use for conducting telehealth video appointments. It is user-friendly and does not require passwords to log in. By acknowledging this document, you agree to the following:

• Zoom is not an emergency service. In the event of an emergency, you should call 911 using a phone.

• Zoom facilitates video conferencing and is not responsible for delivering healthcare, medical advice, or care. You should not assume that your provider has access to or is responsible for any technical information within Zoom. Your provider will not have access to this information, and it should not be relied upon for your care.
• To maintain confidentiality, you agree not to share your telehealth appointment link with anyone who is not authorized to attend the appointment.

By agreeing to this “CONSENT TO TREAT, WAIVER, AND RELEASE,” agreement, you confirm that you have read and understood the information, are aware of the risks and benefits associated with telehealth, and have had the opportunity to ask questions about the procedure. You consent to participate in telehealth sessions under the terms outlined in this document.

BY ADVANCING IN EVERLONG’S INTAKE FLOW, YOU ACKNOWLEDGE THAT YOU HAVE READ, UNDERSTOOD, AND AGREED TO ALL THE TERMS CONTAINED IN THIS ENTIRE DOCUMENT.