Everlong Policies, HIPAA, Consent, & Release Agreement

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

It is important that you are present for the entire length of your session. Follow-up sessions are 55 minutes long. If you are late for a session, you may lose some of that session time. If you fail to be present for your entire session and leave early, your on-file payment method will be charged for the remaining time of your session for which you were not present. 

No-Shows and Late Cancellations

We schedule our appointments so that each patient receives the right amount of time to be seen by our registered dietitians. That’s why it is very important that you keep your scheduled appointment with us. As a courtesy, and to help patients remember their scheduled appointments, Everlong sends multiple appointment reminders. If your schedule changes and you cannot keep your appointment, we require at least a 24-hour notice. 

If you do not cancel or reschedule your appointment with at least 24 hours’ notice, or you do not show for your scheduled appointment, you will be charged a $150 No-Show/Late-Cancellation fee. This No-Show/Late-Cancellation fee is not reimbursable by your insurance company. You will be charged directly for it. 

I understand the No-Show/Late-Cancellation policy of Everlong and agree to provide a credit card number, which may be charged for any no-show/late-cancellation of a scheduled appointment. I understand that I must cancel or reschedule any appointment at least 24 hours in advance in order to avoid a charge to the credit card provided.

Quiet Space Requirements for Telehealth

In adherence to our policies and to ensure the utmost effectiveness of your telehealth session, it is essential that you find yourself in a quiet and distraction-free environment and refrain from engaging in any other activities, such as driving, during your session. This will help maintain the confidentiality of your discussion with your provider and ensure clear communication. By minimizing background noise and disturbances, you can fully engage in your telehealth session, enabling our healthcare professionals to provide you with the best possible care and attention. We are not able to conduct a session if you are engaging in any behavior that is not respectful or appropriate toward the registered dietitian.

Dietitian Accessibility Between Sessions

For rescheduling and cancellations, please use the client portal. Please note, services will only be provided during your scheduled session time. Everlong providers are unable to provide any services or ongoing support via emails and text messages.

Social Media and Telecommunication

Due to the importance of your confidentiality and the importance of minimizing dual relationships, we do not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, etc). We believe that adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of our provider and client relationship.

Electronic Communication

We cannot ensure the confidentiality of any form of communication through electronic media, including emails and text messages. We request that you do not use these methods of communication to discuss session content and/or request assistance for emergencies. Services by electronic means, including, but not limited to, telephone communication, the Internet, facsimile machines, and email are considered telemedicine. Telehealth is broadly defined as the use of information technology to deliver medical services and information from one location to another. Please refer to our “Consent for Telehealth Consultation Policy” below for additional information.

Young Adults Ages 18-26 

If you are currently on your parent/guardian’s health insurance, and/or they are providing financial assistance to pay for our services, by clicking “Continue” in our appointment booking flow, you are providing your consent to allow us to speak with them for financial and insurance reasons.

Children Under 18 Must Have a Parent or Guardian Present

Children under the age of 18 cannot legally consent to their own treatment. Treatment can only be approved by a parent or legal guardian. If you cannot attend their appointment and must send your child(ren) alone or with an older sibling, grandparent, or nanny, please be aware that they have no legal authority to provide a “consent to treatment” for your child. You must send a SIGNED LETTER OF AUTHORIZATION WITH THEM or give us written authorization naming the person(s) you approve in advance to consent to treatment on your behalf. If you wish to do this, please request an AUTHORIZATION FORM from our staff.

Minors

If you are a minor, your parents may be legally entitled to some information about your treatment. We will discuss with you and your parents what information is appropriate for them to receive and which issues are more appropriately kept confidential.

Termination

Ending relationships can be difficult. Therefore, it is important to have a termination process in order to achieve some closure. The appropriate length of the termination depends on the length and intensity of the treatment. We may terminate treatment if we determine that the treatment is not being effectively used or if you are in default on payment. Treatment may be terminated for any reason. If you request another provider, we may be able to provide you with a list of qualified registered dietitians to treat you. Should you fail to reschedule or show for an appointment for three consecutive sessions, unless other arrangements have been made in advance, for legal and ethical reasons, we must consider the professional relationship discontinued.

Insurance and Credit Card Authorization

By acknowledging these “PRACTICE POLICIES,” you are authorizing charges to your credit card from Everlong for services rendered. 

You authorize Everlong to release your information to the insurance companies provided by you 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 the services provided to you, you assign all benefits to Everlong, if accepted, 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 all services not covered by your insurance plan, including those for which you fail to obtain prior authorization, and mutually agreed-upon services or fees that are deemed not medically necessary. You acknowledge that failure to pay an amount due within 14 days will result in our submitting it to collections, that you remain responsible for all collections fees, which equal 35% of the total amount due, and that your credit score may be affected.

You also agree that your credit 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 card and will not dispute these scheduled transactions with your bank or credit card company as long as 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 that 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.

My Pledge Regarding Health Information

Everlong (“We”) understand that health information about you and your health care is personal. We are committed to protecting health information about you. We create a record of the care and services you receive from Everlong. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this practice. This notice will tell you about the ways in which we may use and disclose health information about you. We also describe your rights to the health information we keep about you and describe certain obligations we have regarding the use and disclosure of your health information. We are required by law to:

• Make sure that protected health information (“PHI”) that identifies you is kept private.

• Give you this notice of our legal duties and privacy practices with respect to health information.

• Follow the terms of the notice that is currently in effect.

• Make updates to the terms of this notice, and such changes will apply to all information we  have about you. The new notice will be available upon request via email. 

1. How We May Use and Disclose Health Information About You

The following categories describe different ways that we use and disclose health information. For each category of uses or disclosures, we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.

For Treatment Payment or Health Care Operations: Federal privacy rules (regulations) allow health care providers, who have direct treatment relationship with the patient/client, to use or disclose the patient/client’s personal health information without the patient’s written authorization to carry out the health care provider’s own treatment, payment, or health care operations. We may also disclose your protected health information for the treatment activities of any health care provider. This, too, can be done without your written authorization. For example, if a health care provider were to consult with another licensed health care provider about your condition, we would be permitted to use and disclose your personal health information, which is otherwise confidential, in order to assist the health care provider in diagnosis and treatment of your condition.

Disclosures for treatment purposes are not limited to the minimum necessary standard because other health care providers need access to the full record and/or full and complete information in order to provide quality care. The word “treatment” includes, among other things, the coordination and management of health care providers with a third party, consultations between health care providers, and referrals of a patient for health care from one health care provider to another.

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

2. Certain Uses and Disclosures Require Your Authorization

Session Notes: We do keep “Session Notes,” and any use or disclosure of such notes requires your authorization unless the use or disclosure is:

1. For our use in treating you.
2. For our use in training or supervising associates to help them improve their clinical skills.
3. For our use in defending ourselves in legal proceedings instituted by you.
4. For use by the Secretary of Health and Human Services to investigate our compliance with HIPAA.
5. Required by law, and the use or disclosure is limited to the requirements of such law.
6. Required by law for certain health oversight activities pertaining to the originator of the session notes.
7. Required by a coroner who is performing duties authorized by law.
8. Required to help avert a serious threat to the health and safety of others.

Marketing Purposes: As a healthcare provider, we will not use or disclose your PHI for marketing purposes.

Sale of PHI: As a healthcare provider, 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 limitations in the law, we can use and disclose your PHI without your authorization for the following reasons:

1. When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law.
2. For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone’s health or safety.
3. For health oversight activities, including audits and investigations.
4. For judicial and administrative proceedings, including responding to a court or administrative order, although our preference is to obtain an authorization from you before doing so.
5. For law enforcement purposes, including reporting crimes occurring on our premises.
6. For cooperation with coroners or medical examiners, when such individuals are performing duties authorized by law.
7. For research purposes, including studying and comparing the patients who received one form of care versus those who received another form of care for the same condition.
8. For specialized government functions, including ensuring the proper execution of military missions, protecting the President of the United States, conducting intelligence or counterintelligence operations, or helping to ensure the safety of those working within or housed in correctional institutions.
9. For workers’ compensation purposes. Although our preference is to obtain an authorization from you, we may provide your PHI in order to comply with workers’ compensation laws.
10. For appointment reminders and health related benefits or services. We may use and disclose your PHI to contact you to remind you that you have an appointment with us. We may also use and disclose your PHI to tell you about treatment alternatives or other healthcare services or benefits that we offer.

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 that you indicate is involved in your care or the payment for your healthcare, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.

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

1. The right to request limits on uses and disclosures of your PHI: You have the right to ask us not to use or disclose certain PHI for treatment, payment, or healthcare operations purposes. We are not required to agree to your request, and we may deny your request if we believe it would affect your health care.
2. The right to request restrictions for out-of-pocket expenses paid for in full: You have the right to request restrictions on disclosures of your PHI to health plans for payment or healthcare operations purposes if the PHI pertains solely to a healthcare item or a healthcare service that 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 ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and we will agree to all reasonable requests.
4. The right to see and get copies of your PHI: Other than session notes, you have the right to get an electronic or paper copy of your medical record and other information that we have about you. We will provide you with a copy of your record, or a summary of it, if you agree to receive a summary, within 30 days of receiving your written request, and we may charge a reasonable, cost-based fee for doing so.
5. The right to get a list of the disclosures we have made: You have the right to request a list of instances in which we have disclosed your PHI for purposes other than treatment, payment, or healthcare operations, or for which you provided us with an authorization. We will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list we will give you will include disclosures made in the last six years unless you request a shorter time. We will provide the list to you at no charge, but if you make more than one request in the same year, we will charge you a reasonable cost-based fee for each additional request.
6. The right to correct or update your PHI: If you believe that there is a mistake in your PHI or that a piece of important information is missing from your PHI, you have the right to request that we correct the existing information or add the missing information. We may deny your request, but we will explain in writing within 60 days of receiving your request.
7. The right to get a paper or electronic copy of this notice: You have the right to get a paper copy of this notice, and you have the right to get a copy of this notice by email. 

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 are agreeing that you have read, understood, and agreed to all of the items contained within this notice.

CONSENT TO TREAT, WAIVER, AND RELEASE

Informed Consent for Nutrition Services

You are employing the counseling services of Everlong so that you can obtain information and guidance about health factors within your own control (diet, nutrition, and related behaviors) in order to nourish and support your health and wellness.

You understand that the providers at Everlong are Dietitians/Nutritionists — not physicians — and they do not dispense medical advice nor prescribe treatment. Rather, they provide education to enhance your knowledge of health as it relates to foods, dietary supplements, and behaviors associated with eating. While nutritional support can be an important complement to your medical care, you understand that nutrition counseling is not a substitute for the diagnosis, treatment, or care of disease by a medical provider. You understand that the practice of medicine is not an exact science and that there are risks and benefits associated with receiving medical treatment. You acknowledge and agree that no guarantees are made to you concerning the results and outcomes of the treatment rendered by the registered dietitians at Everlong. 

Nutritional evaluation or testing provided in counseling is not intended for the diagnosis of disease. Rather, these assessment tests are intended as a guide in developing an appropriate health-supportive program for you and to monitor your progress in achieving your goals.

You agree to hold Everlong harmless for claims or damages in connection with our work together. This is a contract between yourself and Everlong, and you understand that it is also a release of potential liability. 

Consent for Telehealth Consultation

You understand that your health and wellness provider, Everlong, wishes you to have a telehealth consultation.

This means that through an interactive video connection, you will be able to consult with the above-named provider about your health and wellness concerns. Your provider has explained to you how telehealth will be used to do such a consultation and how else we will use telehealth to connect while working together, using the Healthie telehealth platform.

You understand there are potential risks with this technology:

• The video connection may not work, or it may stop working during the consultation.

• The video picture or information transmitted may not be clear enough to be useful for the consultation.

The benefits of a telehealth consultation are:

• You do not need to travel to the consult location.

• You have access to a specialist through this consultation.

Consent to Use Zoom for Telehealth

Zoom is the technology service we will use to conduct telehealth video conferencing for telehealth appointments. It is simple to use, and there are no passwords required to log in. By signing this document, you acknowledge that:

• Zoom is NOT an Emergency Service, and in the event of an emergency, you will use a phone to call 911.

• Zoom facilitates videoconferencing and is not responsible for the delivery of any healthcare, medical advice, or care. You do not assume that your provider has access to any or all of the technical information in Zoom or that such information is current, accurate, or up-to-date. You will not rely on your health care provider to have any of this information in Zoom. To maintain confidentiality, you will not share your telehealth appointment link with anyone unauthorized to attend the appointment.

By acknowledging this “CONSENT TO TREAT, WAIVER, AND RELEASE,” agreement, you certify that you have read this entire document, understand the risks and benefits of the telehealth consultation, and have had your questions regarding the procedure explained, and you hereby consent to participate in telehealth sessions under the conditions described in this document.

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