Terms + Conditions
TERMS AND CONDITIONS OF SERVICES & PAYMENT
By signing below, you are agreeing to the following Terms and Conditions of our engagement. You must return a signed copy of this document to JMB Medical Group prior to receiving services. The services recipient is referred to herein as “client” or “you”. These terms to which you agree are referred to as “Terms and Conditions” or “Agreement”.
Insurance Not Accepted; Client’s Responsibility for Payment.
CLIENT UNDERSTANDS AND ACKNOWLEDGES THAT JMB Medical Group AND ITS PERSONNEL ARE NOT PAID OR REIMBURSED FOR THE SERVICES AND HANGOVER MANAGEMENT PROGRAM OR SUPPLEMENTS, VITAMINS OR PHARMACEUTICALS OFFERED BY JMB Medical Group BY MANAGED CARE PLANS, MEDICARE, MEDICAID, OR OTHER THIRD PARTY PAYOR PROGRAMS INCLUDING YOUR HEALTH INSURANCE CARRIER, AND DO NOT ACCEPT INSURANCE FOR SUCH SERVICES.
Clients will be BILLED DIRECTLY and shall be personally responsible for payment, regardless of whether clients are reimbursed by their insurance company, managed care plan or other third party payer.
***SPECIAL NOTICE AND ACKNOWLEDGEMENTS***
JMB Medical Group does NOT diagnose or treat any illness, disease or health condition.
Upon entering into these Terms and Conditions, you expressly represent and warrant that you are not engaging JMB Medical Group or its personnel with the expectation that it or they will diagnose or otherwise provide treatment for any illness, disease or condition of any nature. JMB Medical Group personnel will not screen for, diagnose, monitor or otherwise provide any care or treatment for such conditions. JMB Medical Group is relying upon the foregoing representations and warranties upon your entering into these Terms and Conditions and upon JMB Medical Group’s acceptance of you for the provision of services.
This Agreement shall be governed by the laws of the State of New York, without regard to its conflicts of law rules. The parties hereby agree that any and all proceedings related to or arising out of this Agreement shall be maintained in the courts in New York County, which court shall have exclusive jurisdiction for such purpose, and by execution and delivery of this Agreement, each party waives to the fullest extent permitted by law any objection which it may now or hereafter have to the venue of such courts, and further waives any claim that any such action or proceeding brought in any such court has been brought in an inconvenient forum. The parties hereby acknowledge personal jurisdiction for the foregoing purpose. No delay or failure to exercise any remedy or right occurring upon any default shall be construed as a waiver of such remedy or right, or an acquiescence in such default, nor shall it affect any subsequent default of the same or a different nature. The provisions of this Agreement shall be severable, and if any provisions shall be prohibited by law, or invalid, or unenforceable in whole or in part for any reason, the remaining provisions shall remain in full force and effect. No party hereto shall be considered to be the drafter of this Agreement or any paragraph or term hereof and no presumption shall apply to any party as the “drafter.”
CLIENT REPRESENTATIONS / WARRANTIES & DISCLAIMER AGREEMENT:
Informed Consent / Participants Risks:
I ACKNOWLEDGE AND AGREE THAT THE SOLE RISK OF INJURY OR HARM RESULTING IN ANY MANNER FROM MY CHOOSING TO PARTICIPATE IN SUCH REGIMEN, PROGRAMS AND SERVICES RESTS ENTIRELY WITH ME TO THE EXTENT THAT I DO NOT DISCLOSE MY HEALTH CONDITIONS, MEDICATIONS OR DRUG USE IN ADVANCE.
I expressly represent and warrant to JMB Medical Group that I have never been diagnosed with nor treated for any diseases, illnesses or conditions which may result in increased risk when I participate in regimens, programs or services made available by JMB Medical Group, and I am not choosing to participate with any expectation that JMB Medical Group will screen for, diagnose, monitor or otherwise provide any care or treatment for such conditions.
I acknowledge and understand that JMB Medical Group is relying upon the foregoing representations and warranties from me upon JMB Medical Group’s acceptance of me for participation in its Nutri-drip IV hydration, programs and services.
RISKS INCLUDE THE FOLLOWING:
INJURY, BLEEDING, INFECTION, INFLAMMATION/SWELLING, BRUISING OR SCARRING RESULTING FROM IV INFILTRATION, EXTRACTION AND EXTRAVASATION
MISPLACEMENT OF IV LINES IN THE BODY
MEDICATION ADVERSE INTERACTIONS
LIGHTHEADEDNESS OR FAINTING
YOU EXPRESSLY REPRESENT AND WARRANT TO [SHORT NAME] THAT YOU ARE NOT A USER OF ILLEGAL DRUGS AND/OR CONTROLLED SUBSTANCES AND ARE NOT UNDER THE INFLUENCE OF SAME OR RECOVERING FROM USE OF SAME AT THE TIME OF THE PROVISION OF SERVICES TO YOU.
IN THE EVENT OF AN EMERGENCY, CALL 911 OR PROCEED TO THE NEAREST EMERGENCY ROOM.
ACKNOWLEDGMENT: I confirm that I have read this form and fully understand its contents. I acknowledge that no guarantees or assurances have been made to me concerning the results intended from the sessions and programs offered by JMB Medical Group. I understand the nature of the sessions and programs and that participating in them carries risks. I have been given an opportunity to ask questions, and all of my questions have been answered fully and to my satisfaction. I agree to my assumption of all risks associated with my participation.
Patient Authorization for Use and Disclosure of Protected Health Information
This authorization permits NutriDrip to use and/or disclose the following individually identifiable health information about me include, but are not limited to:
Date(s) of services, type of services, origin of information, age, gender, vital signs
The information will be used or disclosed for the following purpose:
Obtaining research data to reflect our growth, sales, and types of services requested by our client population.
The purpose is provided so that I can make an informed decision whether to allow release of the information. This authorization will expire one (1) year from date of service.
The Practice will not receive payment or other remuneration from a third party in exchange for using or disclosing the PHI.
I do not have to sign this authorization in order to receive treatment from NutriDrip. In fact, I have the right to refuse to sign this authorization. When my information is used or disclosed pursuant to this authorization, it may be subject to redisclosure by the recipient and may no longer be protected by the federal HIPAA Privacy Rule. I have the right to revoke this authorization in writing except to the extent that the practice has acted in reliance upon this authorization.