PATIENT APPLICATION DISCLAIMER
BioXcellerator offers patients, doctors and scientists the opportunity to connect to licensed doctors who use adult stem cells as part of their clinical practice outside of the United States and Canada. Because stem cell therapy is not the standard of care in the US or Canada, the following important disclosures are made to everyone considering therapy:
To access the evaluation process, you must first agree that you have read and understand all of the statements above. I have read and understand all of the statements above:
MEDICAL SERVICES FACILITATION AGREEMENT
AND GENERAL RELEASE
Bioxcellerator, LLC in the United States is engaged in the business of medical tourism and medical services marketing. It provides access to excellent stem cell treatment care in Colombia. Its sole purpose is to facilitate or refer the patient to medical professionals that will help the Patient to make the decision on which route they will take for their medical treatment.
For the purpose of this notice and with regard to the Patient, the Patient acknowledges that Bioxcellerator acts only in the capacity of facilitator and/or coordinator. Bioxcellerator is not the Patient's treating physician or any other medical provider. Bioxcellerator does not perform any treatment or medical procedure. Patient acknowledges that she/he has conducted the necessary due diligence and has decided to seek treatment with no influence or pressure from Bioxcellerator.
1. Price. Patient will pay Bioxcellerator the amount indicated on the digital invoice for the services outlined in paragraph 3 below.
The total price quoted by Bioxcellerator is an estimate of the total cost of services but does not include unanticipated cost that are related or unrelated to the desired procedure, complications that are unrelated and/ or not detected prior to the procedure. These charges would be in addition to the total cost of the Package indicated in the initial price quotation.
Patient agrees to pay the full cost of the Package to Bioxcellerator and Bioxcellerator will pay the the third party providers directly. In all cases the full amount of the total price for the Package is due and payable prior to patient's departure to Colombia. The Package is subject to cancellation unless Patient pays in full a minimum of 14 days before the first scheduled treatment date. However in all cases, full payment must be made, and cleared the bank completely before any procedure can take place.
2. Non-Refundable Deposit. Unless otherwise agreed to in writing, upon execution of this agreement, Patient will pay Bioxcellerator in full or a non-refundable deposit of $1,500 USD.
3. Description of Services. For the amount identified in digital invoice and in paragraph 1 above, Bioxcellerator will facilitate the treatments or services described in invoice. treatments or services are subject to change based on medical team discression.
4. Dispute Resolution. Bioxcellerator will use its best efforts to assist Patient in resolving any issues related to the products or services delivered or rendered as a part of the Package or any of its components (treatment, hotel, travel, and any other accommodations as requested by the Patient). The Patient understands that Bioxcellerator offers no insurance, guarantee or warranty in any respect related to products or services delivered or rendered by third parties. Any disputes or claims against third party providers (i.e doctors, medical facility, airline, etc.) which cannot be resolved in good faith through the efforts of Bioxcellerator will need to be resolved between the Patient and that third party service provider(s).
5. Governing Law. This Agreement and its application and interpretation will be governed exclusively by its terms and by the laws of the Republic of Colombia.
6. Venue. The proper venue for any proceeding at law or in equity or under the provisions for any dispute between the parties will be Medellin, Colombia, and the parties hereby waive any right to object to the venue.
7. No Advice. Bioxcellerator offers no medical opinion or advice of any kind on any medical procedure. Information provided by Bioxcellerator is based on the best publicly available information and is not intended in any way to be used as a substitute for advice from the Patient's Physician.
8. Confidentiality. All Patient medical records received by Bioxcellerator will be held in the strictest confidence in secured electronic files.
9. Release. With the previous items in mind, Patient hereby accepts full responsibility for their own safety and expressly assumes all risks of harm, whether foreseen or unforeseen, and whether occurring while travelling, during pre/post-treatment care, during the desired procedure, at any time. Patient acknowledges that Bioxcellerator serves only as a facilitator and coordinator for the Package and that ultimately the extent, nature and scope of treatment received by Patient was the Patient's decision alone. Bioxcellerator will assist the patient in mitigating the risks associated with medical travel through third party contracts that the patient may want to enter into. Bioxcellerator uses its best efforts to provide a wide range of options for the Patient to consider and consult with their Physician. Bioxcellerator will disclose the details of the Clinic and the Physician providing the requested medical services to the Patient. All Medical services are provided by medical professionals who are not employees of Bioxcellerator, LLC.
10. Attorneys' Fees. In case of any action or proceeding to compel compliance with, or for a breach of, any of the terms and conditions of this Agreement, the prevailing party will be entitled to recover from the losing party all costs of the action or proceeding, including, but not limited to, reasonable attorneys' fees.
MEDICAL DISCLAIMER Information is provided for education and information purposes only, and is not intended to be a substitute for a health care provider about the services offered. Bioxcellerator, LLC is in the business of facilitating travel for medical purposes. Any information provided should not be considered complete, nor should it be relied on to suggest a course of treatment for a particular individual. It should not be used in place of a visit, call, consultation or the advice of your physician of other qualified health care provider. Bioxcellerator, LLC does not recommend any specific test, products, or procedures of a medical nature. Reliance on any information provided by Bioxcellerator, LLC is solely at your own risk. Bioxcellerator, LLC assumes no liability or responsibility for damage or injury to persons or property arising from any use of any product, information, or instruction offered or provided to you by the medical professionals that implement them. You access this service at your own risk. Bioxcellerator, LLC is not responsible or liable for medical procedures, advice, opinions and services provided by others.
HIPAA EMAIL CONSENT
VERY IMPORTANT! PLEASE READ!
• HIPAA stands for the Health Insurance Portability and Accountability Act
• HIPAA was passed by the U.S. government in 1996 in order to establish privacy and security protections for health information
• Most popular email services (ex. Hotmail®, Gmail®, Yahoo®) do not utilize encrypted email
• When we send you an email, or you send us an email, the information that is sent is not encrypted. This means a third party may be able to access the information and read it since it is transmitted over the Internet. In addition, once the email is received by you, someone may be able to access your email account and read it.
• Email is a very popular and convenient way to communicate for a lot of people, so in their latest modification
to the HIPAA act, the federal government provided guidance on email and HIPAA
• The information is available in a pdf (page 5634) on the U.S. Department of Health and Human Services website ‐ https://www.govinfo.gov/content/pkg/FR-2013-01-25/pdf/2013-01073.pdf
• The guidelines state that if a patient has been made aware of the risks of unencrypted email, and that same patient provides consent to send and receive health information via email, then a health entity may send that patient personal medical information via unencrypted
NOTICE OF PRIVACY PRACTICES, PLANNING, POLICIES AND CONSENT
Effective Date: October 1, 2015
If you have any questions about this notice, please contact our privacy officer at:
Phoenix, AZ 85018
1. Summary of Rights and Obligations Concerning Health Information. Bioxcellerator Clinic and Laboratory in Medellin Colombia (“Bioxcellerator”) is committed to preserving the privacy and confidentiality of your health information, which is required both by federal and state law. We are required by law to provide you with this notice of our legal duties, your rights, and our privacy practices, with respect to using and disclosing your health information that is created or retained by Bioxcellerator. Each time you visit us, we make a record of your visit. Typically, this record contains your symptoms, examination and test results, our assessment of your condition, a record of your treatment interventions, and a plan for future care or treatment. We have an ethical and legal obligation to protect the privacy of your health information, and we will only use or disclose this information in limited circumstances. In general, we may use and disclose your health information to:
We may also use or disclose your health information where you have authorized us to do so.
Although your health record belongs to Bioxcellerator, the information in your record belongs to you.
You have the right to:
We are required to:
Should our information practices change, a revised Notice of Privacy Practices will be available upon request. If there is a material change, a revised Notice of Privacy Practices will be distributed to the extent required by law. We will not use or disclose your health information without your authorization, except as described in our most current Notice of Privacy Practices. In the following pages, we explain our privacy practices and your rights to your health information in more detail.
A. Treatment. We may use and disclose your protected health information to provide, coordinate and manage your medical care. That may include consulting with other health care providers about your health care or referring you to another health care provider for treatment including physicians, nurses, and other health care providers involved in your care. For example, we will release your protected health information to a specialist to whom you have been referred to ensure that the specialist has the necessary information he or she needs to diagnose and/or treat you.
B. Payment. We may provide health information to another health care provider, such as a laboratory company to assist in their billing and collection efforts.
C. Health Care Operations. We may use and disclose your health information to assist in the operation of our practice. For example, members of our staff may use information in your health record to assess the care and outcomes in your case and others like it as part of a continuous effort to improve the quality and effectiveness of the healthcare and services we provide. We may use and disclose your health information to conduct cost-management and business planning activities for our practice. We may also provide such information to other health care entities for their health care operations. For example, we may provide information to your health insurer for its quality review purposes.
D. Students. Students/interns work in our facility from time to time to meet their educational requirements or to get health care experience. These students may observe or participate in your treatment or use your health information to assist in their training. You have the right to refuse to be examined, observed, or treated by any student or intern. If you do not want a student or intern to observe or participate in your care, please notify your provider.
E. Business Associates. Bioxcellerator sometimes contracts with third-party business associates for services. Examples include answering services, transcriptionists, billing services, consultants, and legal counsel. We may disclose your health information to our business associates so that they can perform the job we have asked them to do. To protect your health information, however, we require our business associates to appropriately safeguard your information.
F. Appointment Reminders. We may use and disclose information in your medical record to contact you as a reminder that you have an appointment. We usually will send email reminders or call you at the home and/or the cell phone number provided the day before your appointment and leave a message for you on your answering machine or with an individual who responds to our telephone call. However, you may request that we call you only at a certain number or that we refrain from leaving messages and we will endeavor to accommodate all reasonable requests.
G. Treatment Options. We may use and disclose your health information in order to inform you of alternative treatments.
H. Release to Family/Friends. Our staff, using their professional judgment, may disclose to a family member, other relative, close personal friend or any other person you identify, your health information to the extent it is relevant to that person’s involvement in your care or payment related to your care. We will provide you with an opportunity to object to such a disclosure whenever we practicably can do so. We
may disclose the health information of minor children to their parents or guardians unless such disclosure is otherwise prohibited by law. Please let your provider know if you would not like us to release information to a family member or friend.
I. Health-Related Benefits and Services. We may use and disclose health information to tell you about health-related benefits or services that may be of interest to you. In face-to-face communications, such as appointments with your provider, we may tell you about other products and services that may be of interest you.
J. Newsletters and Other Communications. We may use your personal information in order to communicate to you via newsletters (including electronic newsletters), mailings, or other means regarding treatment options, health related information, disease management programs, wellness programs, or other community based initiatives or activities in which our practice is participating.
K. Disaster Relief. We may disclose your health information in disaster relief situations where disaster relief organizations seek your health information to coordinate your care, or notify family and friends of your location and condition. We will provide you with an opportunity to agree or object to such a disclosure whenever we practicably can do so.
L. Marketing. In most circumstances, we are required by law to receive your written authorization before we use or disclose your health information for marketing purposes. However, we may provide you with promotional gifts of nominal value. Under no circumstances will we sell our patient lists or your health information to a third party without your written authorization.
M. Public Health Activities. We may disclose medical information about you for public health activities. These activities generally include the following:
N. Food and Drug Administration (FDA). We may disclose to the FDA and other regulatory agencies of the federal and state government health information relating to adverse events with respect to drugs, food, supplements, products and product defects, or post-marketing monitoring information to enable product recalls, repairs, or replacement.
O. Research. We may disclose your health information to researchers when the information does not directly identify you as the source of the information or when a waiver has been issued by an institutional review board or a privacy board that has reviewed the research proposal and protocols for compliance with standards to ensure the privacy of your health information.
P. Workers Compensation. We may disclose your health information to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs established by law.
Q. Law Enforcement. We may release your health information:
R. De-identified Information. We may use your health information to create "de-identified" information or we may disclose your information to a business associate so that the business associate can create de- identified information on our behalf. When we "de-identify" health information, we remove information that identifies you as the source of the information. Health information is considered "de-identified" only if there is no reasonable basis to believe that the health information could be used to identify you.
S. Personal Representative. If you have a personal representative, such as a legal guardian, we will treat that person as if that person is you with respect to disclosures of your health information. If you become deceased, we may disclose health information to an executor or administrator of your estate to the extent that person is acting as your personal representative.
T. Limited Data Set. We may use and disclose a limited data set that does not contain specific readily identifiable information about you for research, public health, and health care operations. We may not disseminate the limited data set unless we enter into a data use agreement with the recipient in which the recipient agrees to limit the use of that data set to the purposes for which it was provided, ensure the security of the data, and not identify the information or use it to contact any individual.
3. Authorization for Other Uses of Medical Information. Uses of medical information not covered by our most current Notice of Privacy Practices or the laws that apply to us will be made only with your written authorization. You should be aware that we are not responsible for any further disclosures made by the party you authorize us to release information to. If you provide us with authorization to use or disclose medical information about you, you may revoke that authorization, in writing, at any time. If you revoke your authorization, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. We are unable to take back any disclosures we have already made with your authorization, and we are required to retain our records of the care that we provided to you.
4. Your Health Information Rights. You have the following rights regarding medical information we gather about you:
A. Right to Obtain a Paper Copy of This Notice. You have the right to a paper copy of this Notice of Privacy Practices at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy.
B. Right to Inspect and Copy. You have the right to inspect and copy medical information that may be used to make decisions about your care. This includes medical and billing records.
To inspect and copy medical information, you must submit a written request to our privacy officer. We will supply you with a form for such a request. If you request a copy of your medical information, we may charge a reasonable fee for the costs of labor, postage, and supplies associated with your request. We may not charge you a fee if you require your medical information for a claim for benefits under the Social Security Act (such as claims for Social Security, Supplemental Security Income, and any other state or federal needs-based benefit program). If your medical information is maintained in an electronic health record, you also have the right to request that an electronic copy of your record be sent to you or to another individual or entity. We may charge you a reasonable cost based fee limited to the labor costs associated with transmitting the electronic health record.
C. Right to Amend. If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as we retain the information.
*To request an amendment, your request must be made in writing and submitted to our privacy officer. In addition, you must provide a reason that supports your request. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:
*If we deny your request for amendment, you may submit a statement of disagreement. We may reasonably limit the length of this statement. Your letter of disagreement will be included in your medical record, but we may also include a rebuttal statement.
D. Right to an Accounting of Disclosures. You have the right to request an accounting of disclosures of your health information made by us. In your accounting, we are not required to list certain disclosures, including:
o disclosures made for treatment, payment, and health care operations purposes or disclosures made incidental to treatment, payment, and health care operations. However, if the disclosures were made through an electronic health record, you have the right to request an accounting for such disclosures that were made during the previous 3 years;
*To request an accounting of disclosures, you must submit your request in writing to our privacy officer. Your request must state a time period which may not be longer than six years and may not include dates before October 1, 2015. Your request should indicate in what form you would like the accounting of disclosures (for example, on paper or electronically by e-mail). The first accounting of disclosures you request within any 12 month period will be free. For additional requests within the same period, we may charge you for the reasonable costs of providing the accounting of disclosures. We will notify you of the costs involved and you may choose to withdraw or modify your request at that time, before any costs are incurred. Under limited circumstances mandated by federal and state law, we may temporarily deny your request for an accounting of disclosures.
E. Right to Request Restrictions. You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment, or health care operations. If you paid out-of-pocket for a specific item or service, you have the right to request that medical information with respect to that item or service not be disclosed to a health plan for purposes of payment or health care operations, and we are required to honor that request. You also have the right to request a limit on the medical information we communicate about you to someone who is involved in your care or the payment for your care. Except as noted above, we are not required to agree to your request. If we do agree, we will comply with your request unless the restricted information is needed to provide you with emergency treatment. To request restrictions, you must make your request in writing to our privacy officer. In your request, you must tell us:
F. Right to Request Confidential Communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by e-mail. To request confidential communications, you must make your request in writing to your provider or our privacy officer. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
G. Right to Receive Notice of a Breach. We are required to notify you by first class mail or by e-mail (if you have indicated a preference to receive information by e-mail), of any breaches of Unsecured Protected Health Information as soon as possible, but in any event, no later than 60 days following the discovery of the breach. “Unsecured Protected Health Information” is information that is not secured through the use of a technology or methodology identified by the Secretary of the U.S. Department of Health and Human Services to render the Protected Health Information unusable, unreadable, and undecipherable to unauthorized users. The notice is required to include the following information:
If you believe your privacy rights have been violated, you may file a complaint with us. To file a complaint with us, contact our privacy officer at the address listed above. All complaints must be submitted in writing and should be submitted within 180 days of when you knew or should have known that the alleged violation occurred. See the Office for Civil Rights website, www.hhs.gov/ocr/hipaa/ for more information. You will not be penalized for filing a complaint.
6. Deposit and Payments
Until a payment is made, a potential patient has no financial commitment. Sharing medical records does not indicate you are a patient nor obligate you. Our consult with our medical team is a free consult. You will be given a full treatment plan and pricing before needing to decide on a deposit. To secure your potential treatment date and start your procedure planning, we require a non-refundable deposit. To lock in your dates, schedule and treatment options we will require payment in full. Our team can accept checks, credit cards, money wire or cash. We can electronically invoice and will provide an itemized receipt following any form of payment.
7. Account balances
We will require that patients are paid in full and have a zero-account balance before procedures are scheduled and performed. We recommend paying several months in advance to get started on recommended pretreatment vitamins, set a treatment date, schedule specialists, procedure rooms and make sure we have cells incubated for your treatment. Patients who have not paid in full can be rescheduled based on other paying patients in the queue for a stem cell procedure.
8. Refund Policy
Due to the large commitment of time needed and expense incurred to culture and incubate stem cells prior to the procedure, our treatments are non-refundable and cannot be canceled with or without notice. From date of the initial payment to BioXcellerator there is a 24 hour grace period to cancel for any reason and to receive a full refund less the non-refundable deposit of $1,500, any prescription, banking or shipping fees. Otherwise, all payments and fees are non-refundable and your treatment dates, cell cultures and therapy plan will be considered to be accepted by you immediately upon any payment. To request a refund, please do so in writing via email to firstname.lastname@example.org. We will return any balance eligible for refund via the same means it was paid. All payments received in a form of a credit card will be charged a 3.5% processing fee at time of refund.
9. Sharing of medical records
You agree to share medical information with our team for the purpose of creating a customized medical plan and therapy protocol. You also agree by signing the HIPPA form we have permission to share your information within our secure EMR (Electronic medical record) system with our doctors, nurse and admin staff. All information will be kept in house, never sold and only used for purposes of making medical decisions.
10. No Show Policy/ Cancellation /Scheduling
We understand that there are times when you must miss an appointment due to emergencies or obligations for work or family. However, when you do not call to cancel an appointment, you may be preventing another patient from getting much needed attention. We humbly request that you notify us prior to missing any scheduled appointments. Upon payment in full you may schedule your therapy up to 12 months in advance. Patients that are paid in full and have a zero balance may reschedule a planned therapy date with 30 days prior notice. If you have questions on our policies, please confirm with our team before making payments.
11. Currency Conversion
We accept multiple forms of payments. Payments made in the US will be charged in US dollars and those done in Colombia will be in COP (Colombian pesos) at the current daily exchange rate.
12. Governing Law. This Agreement and its application and interpretation will be governed exclusively by its terms and by the laws of the Republic of Colombia.
13. Venue. The proper venue for any proceeding at law or in equity or under the provisions for any dispute between the parties will be Medellin, Colombia, and the parties hereby waive any right to object to the venue.
I hereby acknowledge that Bioxcellerator has given me time to review the NOTICE OF PRIVACY PRACTICES, PLANNING, POLICIES AND CONSENT FORMS.