Notice of Privacy Practice ~ Consent for Treatment

As required by the privacy regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).This notice describes how health information about you may be used and disclosed and how you can get access to your individually identifiable health information.

Last Diet Ever, is dedicated to maintaining the privacy of your individually identifiable health information.  In conducting our business, we will create records regarding you and the treatment and services we provide to you.  We are required by law to maintain the confidentiality of health information that identifies you.  We also are required by law to provide you with this notice of our legal duties and the privacy practices that we maintain.  By federal and state law, we must follow the terms of the Notice of Privacy Practices that we have in effect at the time.

We may use and disclose your protected health information in the following ways: TREATMENT: We may use your information to treat you.  For example, we may ask you to have laboratory tests drawn, and we may use the results to help us reach a diagnosis. We may disclose your information to our pharmacy when we order your prescription for you.  Our doctors and staff may use or disclose your information in order to treat you or assist in your care.  If given authorization by you, we may disclose your information to other health care providers for purposes related to your treatment.  If given authorization by you, we may disclose your information to your spouse, children, parents or other family members who may assist in your care. HEALTH CARE OPERATIONS: We may use and disclose your information to operate our business.  DISCLOSURES REQUIRED BY LAW: We will use and disclose your information when we are required to do so by federal, state or local law. SPECIAL CIRCUMSTANCES: We may disclose your information to public health authorities that are authorized by law to collect information for the purpose of: Public Health Risks, Health Oversight Activities, Lawsuits, Law Enforcement, Serious Threats to Health or Safety.

You have the following rights regarding the individually identifiable health information we maintain about you: CONFIDENTIAL COMMUNICATIONS: You have the right to request that we communicate with you about your health and related issues in a particular manner or at a certain location.  REQUESTING RESTRICTIONS: You have the right to request a restriction in our use or disclosure of your information. Your request must be made in writing.  We are not required to agree to your request, however, if we do agree, we are bound by our agreement except when required by law, in emergencies or when the information is necessary to treat you.  INSPECTION OF COPIES: You have the right to inspect and obtain a copy of your information that we have on file.  We may charge a fee for the costs of copying and mailing associated with your request, which must be in writing. AMENDMENT: You may ask us to amend your health information if you believe it is incorrect or incomplete.  This must be made in writing.  RIGHT TO A PAPER COPY OF THIS NOTICE:            You are entitled to receive a paper copy of our Notice of Privacy Practices (upon request).

By signing below, I agree to the following:  I give permission to leave a PHONE MESSAGE with another person,  or on an answering machine, and/or voicemail at my home or cellular phone.  I give permission to send an E-MAIL:  I give permission to MAIL correspondence to my home address.

Patient Responsibility Statement/Agreement

I agree to the following:

1. I will contact my local emergency room or dial 911 if any adverse or allergic reaction occurs so that I will receive treatment immediately.
2. If I am taking medications for high blood pressure, I agree to measure my blood pressure at least daily or more frequently if so directed by the LDE physician. I will notify my personal physician if my blood pressure increases or decreases by more than 10 points.
3. If I am taking medication for diabetes, I agree to monitor my blood glucose at least daily or more frequently if so directed by the LDE physician. If my blood sugar falls below 70 or I experience symptoms of low blood sugar, I will notify my personal physician in a timely manner to adjust my medication appropriately.
4. Last Diet Ever Medical Weight Loss Clinic, is not responsible for any falsified medical information, and will not be held liable. Further treatment may be discontinued without refund.
5. I agree to the Last Diet Ever Clinic privacy policies, and understand my medical information is confidential for clinic use only. Last Diet Ever may contact my family physician if necessary for continued care.  All Last Diet Ever employees maintain strict confidentiality, and all employees adhere to HIPAA regulations.
6. I agree to immediately notify Last Diet Ever of any new medical conditions that arise during the course of my weight loss program.
7. I agree to report my weight loss via phone/e-mail every week to the Last Diet Ever office.
8. I agree to keep all scheduled follow up appointments as applicable to the program. I understand that Last Diet Ever reserves the right to discontinue treatment if I fail to comply with the program requirements.

hCG Program

Requirements  for the program:

• Must follow the diet EXACTLY as advised (with absolutely no cheating!);
• Must drink enough water;
• Has no underlying medical problems that would interfere with weight loss (sleep apnea, undertreated hypothyroidism, certain food allergies);
• Is not taking medications that may interfere;
• Not doing excessively high levels of exercise;

You are also required to report your weight loss weekly or Last Diet Ever reserves the right to discontinue treatment.

B12 Program  (Optional)

B12  injections are recommended and should be received at regular 1 week intervals.

Supplements  (Optional)

1. I have been informed of the supplements available and understand their benefits.

Refunds:  Once you have met with our medical advisor, paid for your weight loss program, and the prescription hCG has been ordered from the pharmacy, there can be no refund, partial or otherwise.  Once prescription medication is dispensed, legally there can be no return.  All sales are final.

Cancellations:  Should you find for some unforeseen circumstance you wish to cancel your program and have met with our Medical Advisor, but the prescription has NOT been ordered, a partial refund of money can be issued (the total program cost minus $75).

Refunds and cancellations will be processed within 30 days of notification.

Any and all disputes must be filed in the Medina County Court System, Medina, Ohio.

Patient Agreement

I have chosen to participate in a Last Diet Ever Medical Weight Loss Clinic program.  I am aware that results may vary and are not guaranteed.

With prescription hCG, there are risks of possible side effects occurring such as fatigue, mild headaches, bruising or swelling at the injection site or allergic reaction, etc.

With prescription vitamin injections (B12) there are risks of possible side effects occurring such as an allergic reaction or sensitivity to any ingredients.

I agree that I have been counseled on a specific weight loss program for me with diet and nutritional supplementation, B12 injections, and prescription hCG injections to attain my targeted weight loss.  I must follow the program to achieve the desired results.  I have been counseled on self-injection (if applicable) and assume full responsibility for myself.  If applicable, I will also dispose of used syringes properly.  Patients who are found to have submitted fraudulent information will be terminated from the program.  Any medication is strictly for the use of the patient and is not to be transferred or distributed, modified or used by any other party.  The use of prescription hCG for weight loss has not been specifically approved by the FDA.  I understand that the use of prescription hCG for weight loss is an off-label usage by a physician and I have read and understand all disclosures provided by Last Diet Ever Medical Weight Loss Clinic.

Participation Waiver:  Last Diet Ever Medical Weight Loss Clinic and its staff, clinicians, and/or physicians are not responsible for treatment of any medical condition disclosed by any abnormal lab reports or myself.  I agree to seek medical treatment for any identified medical problems with my primary care provider of choice.  In all the disclosed risks, I will hold harmless: the physicians, nurses and all personnel of Last Diet Ever Medical Weight Loss Clinic for any adverse reactions or occurrences that my occur while participating in this program.

Disclaimer

Disclaimer: The U.S. Food and Drug Administration (FDA) has not approved Human Chorionic Gonadotropin (hCG) for use as a treatment for obesity or weight control. The use of hCG for weight loss is as an “off label” use, which means that it is considered safe when prescribed by and under the guidance of a licensed physician. HCG is FDA-approved to treat health conditions other than weight loss and has been in existence to do so for over 50 years.

Therefore, prescribing hCG in this manner is a legal and common practice by physicians in the United States.

FDA Statement:  I have been notified that since 1975, the FDA has required labeling and advertising of hCG to state:  “HCG has not been demonstrated to be an effective adjunctive therapy on the treatment of obesity.  There is no substantial evidence that it increases weight loss beyond that resulting from caloric restriction, that it causes a more attractive or ‘normal’ distribution of fat, or that it decreases the hunger and discomfort associated with calorie-restricted diets.”

Because an individual’s weight loss depends on a number of factors, Last Diet Ever DOES NOT guarantee any specific weight loss results.

I have read and understand the above acknowledgments.