Terms and condition

Dear Client:

By continuing to use our system, you agree to the following Payment terms and conditions, Consent to Treatment and Communicate, HIPAA Privacy Notice, Consent to Communicate with Others:

Payment Terms and Conditions

  • The charges shown is an estimate and it will be reserved on your card or bank account.  
  • Your actual charges may vary.
  • The actual charges depend on insurance policy reimbursements and/or your co-pay and/or deductibles.
  • Because of multiple players in charging, you may also see charges broken down and charged at different dates to reflect reimbursements and/or your deductibles and/or your co-pay.
  • In addition to these terms and conditions, all other terms and conditions listed in spineapple.com apply.
  • For any questions / concerns - please contact dearspineapple@spineapple.com or 313-467-2196.
  • If requested, you will be provided a detailed breakdown on the charges and its associated dates.

CONSENT TO TREATMENT and COMMUNICATE, HIPAA NOTICE of PRIVACY PRACTICES, TERMS and CONDITIONS, and CONSENT to COMMUNICATE with OTHERS.



 

GENERAL TERMS and CONDITIONS

Last revised date: June 01 2017.

Resourcience LLC, doing business as spineapple. (“Spineapple”, “spineapple”,“us” or “we”) provides users (“you” or “Users”) of the Spineapple Online application (“Application”) and website available at www.spineapple.com (collectively the “Site”) with a technology platform to schedule in-person on demand physical therapy appointments (each, a “Session”) by physical therapists (each, a “Physical Therapist”) offering their service via the Site. The services offered by Spineapple include the Site and any other features, content, products, or services offered from time to time by Spineapple in connection with the Site (collectively, the “Services”). These Spineapple Terms of Service (“Terms”) sets forth the legally binding terms for your use of the Site. By using the Site, you agree to be bound by these Terms. Sessions are currently only available in the state of Michigan.

BY ESTABLISHING AN ACCOUNT ON THE SITE AND/OR BY USING THE SITE, YOU ACKNOWLEDGE THAT YOU HAVE READ, UNDERSTAND, AND AGREE TO FOLLOW AND BE BOUND BY THESE TERMS. IF YOU DO NOT WISH TO BE BOUND BY THESE TERMS, YOU MAY NOT ACCESS OR USE THE SITE OR THE SERVICES. THE TERM “YOU” OR “USER” REFERS TO THE INDIVIDUAL OR LEGAL ENTITY, AS APPLICABLE, THAT ESTABLISHES AN ACCOUNT ON OR USES THE SITE.

These Terms may be revised or updated from time to time. Accordingly, you should check the Terms regularly for updates. You can determine when the Terms were last revised by referring to the “Last Revised” legend at the top of this page. Any changes in these Terms take effect upon posting and will only apply to use of the Site after that date.

Physical Therapist Terms of Service. If you are a Physical Therapist using this service to provide Sessions to Users, your use of the Site and Services is governed by separate terms of service available at: dearspineapple@spineapple.com.

1.                Eligibility.

By using the Site, you represent and warrant that you are eighteen years of age or older and your use of the Site does not violate any applicable law or regulation. If you are using this Site on behalf of someone else, you represent and warrant that you have the legal authority and/or necessary authorization to do so.

2.                User Account.

1.                Creating Your Account. Prior to receiving, and in order to receive a Session, you must create a User account (an “Account”) by registering through the Site, providing us with true, accurate, and complete information as requested on the registration forms and pages (your “Registration Information”), and accepting these Terms, and agreeing to, electronically or otherwise, the Authorization for the Use and Disclosure of Health Information (the “Authorization Form”). You will promptly update all Registration Information to keep it true, accurate, and complete. Should we suspect that any Registration Information you provide is not true, accurate, or complete, we have the right to suspend or terminate your use of the Site. When you register, we will ask you to provide a user name and password. You agree to keep your password confidential. You agree to notify us immediately of any unauthorized use of your user name or password or if you believe that your password is no longer confidential. You will be responsible for any activities that occur under your Account until you terminate your Account in accordance with these Terms. We reserve the right to require you to alter your user name and/or password if we believe that your Account is no longer secure. You will not: (a) create an Account for anyone other than yourself who you are not legally authorized to do so; (b) create or use more than one Account for the same person at any given time; (c) transfer your Account to anyone else; (d) permit anyone else to use your Account; or (e) use or access any other person’s Account.

2.                Account Use Restrictions. The Site is for the personal use of Users only and Users may not use them in connection with any commercial endeavors. You represent and warrant that you will use the Site solely for your own personal benefit or the benefit of someone you are legally authorized to act for and that you will not resell or distribute the Site. You will not use any information obtained from the Site in order to harass, abuse, or harm another person, or in order to contact, advertise to, solicit, or sell to any User without that User’s prior explicit consent. You will not: (i) interfere with, disrupt, or create an undue burden on the Site or the networks or services connected to the Site; (ii) introduce software or automated agents to the Site so as to produce multiple Accounts, generate automated messages, or to strip or mine data from the Site; (iii) reverse engineer the Site or assist another in the same; or (iv) engage in any fraudulent, illegal, or unauthorized use of the Site. You will not attempt to impersonate another User or person, including, without limitation, any employee of Spineapple. At all times, you will use the Site in a manner consistent with any and all applicable laws and regulations.

3.                Ordering Services. Prior to receiving a Session, you must agree to the Authorization Form, and each time you order a Session you must provide payment for the Session as described in these Terms. To order a Session, you must be at least 18 years of age. On a first visit, a Physical Therapist will be selected for you based on his/her proximity and/or availability to you. You will receive confirmation by e-mail, push notification, or text message indicating that your order has been placed and the Physical Therapist has accepted the Session order. On subsequent visits you may select a Physical Therapist previously seen or request a new Physical Therapist. All follow-up visits with a Physical Therapist must be scheduled via the Site.

4.                Compliance with Terms. Spineapple will determine User’s compliance with these Terms in our sole discretion and our decision shall be final and binding. Any violation of the these Terms may result in restrictions on User’s access to and use of all or part of the Site and may be referred to law enforcement authorities. We may cancel, suspend or block your use of the Site and/or registration at any time, without cause. We may terminate and/or suspend your registration immediately, if there has been a violation of these Terms and such other policies and terms posted on the Site. Your right to use the Site will end once your registration is terminated, and any data you have stored on the Site may be unavailable later, unless we are required to retain it by law. You may terminate your registration at any time. We recommend that you transfer any information stored on the Site prior to terminating registration. We are not responsible or liable for any records or information that is made unavailable to you as a result of your termination of registration. YOU AGREE THAT WE WILL NOT BE LIABLE TO YOU OR ANY OTHER PARTY FOR ANY TERMINATION OF YOUR ACCESS TO THE SITE.

3.                Term. 

These Terms shall remain in full force and effect while you use the Site or have an Account. You may delete your Account at any time, for any reason by updating the information in your profile. Spineapple may terminate your Account for any reason, effective upon sending notice to you at the then-current e-mail address in your Registration Information.

4.                Fees and Payment.

1.                Payment Terms. At the time you order any Session, you will be required to give us a valid credit card number, issued by an issuer accepted by us, together with any other payment information we request. Your credit card issuer terms govern your use of your designated payment method, and you must refer to those terms and not these Terms to determine your rights and liabilities as a cardholder. You agree that no additional notice or consent is required before Spineapple invoices the designated payment method for all amounts due and payable. You agree to pay all such fees and charges incurred in connection with your use of the Site in accordance with the fees, charges, and billing terms in effect at the time a fee or charge is due and payable. You agree to provide Spineapple with complete and accurate billing and contact information. If the contact information you have provided is false or fraudulent, Spineapple may terminate your access to the Site in addition to any other legal remedies. Spineapple reserves the right, at any time, to change its prices and billing methods for Sessions and other products and services sold, either immediately upon posting on the Site, or by e-mail delivery to you.

2.                Distinct Fees. You acknowledge that the fees and charges incurred in connection with your use of the Site and your order of any Session include, even if billed collectively, two distinct fees: 1) Professional Physical or Occupational therapy services  and 2) materials used or provided during the session. Spineapple may identify to you the respective portions of your payment for fees and charges upon request.

5.                Order acceptance policy.

Your receipt of an electronic order confirmation merely confirms our receipt of your order and does not signify Spineapple’s acceptance of your order. Your order will be deemed accepted when your assigned Physical Therapist provides you with your Session. In the event that your assigned Physical Therapist cannot provide you with a Session for any reason, Spineapple reserves the right at any time after receipt of your order to decline your order. In the event that Spineapple declines your order, Spineapple will return your payment using the same payment method designated by you on your order.

6.                Order cancellation policy. 

After booking a Session, a hold will be placed for the Session fee on your chosen payment option. Your payment option will not be charged for the Session fee until 1 hour prior your scheduled Session is set to begin. You may cancel your Session without charge up to 1 hour prior to the scheduled Session time. If you cancel your Session within 1 hour prior to the scheduled Session time, you will be owe and be charged cancellation fees totaling $50. This amount is comprised of an administrative cancellation fee which will be retained by Spineapple and a professional cancellation fee which will be retained by the Physical Therapist that was scheduled to provide the Session.

7.                Spineapple Content.

The Site contains Content owned and/or developed by or on behalf of Spineapple and its licensors (“Spineapple Content”). Spineapple and its licensors own and retain all proprietary rights in the Spineapple Content and the Site. You shall not reproduce, distribute, publicly perform (including by means of digital audio transmission), publicly display, create derivative works of, and otherwise use the Spineapple Content. Spineapple hereby grants you a limited, revocable, non-sublicenseable license to reproduce and publicly display the Spineapple Content (excluding any software code) solely for your personal use in connection with viewing the Site and using the Services.

8.                User Guidelines.

Spineapple reserves the right (but is not obligated) to investigate and to take appropriate legal action in its sole discretion for any violation of this provision or these Terms or any conduct that is offensive, illegal, or violates the rights of, harms, or threatens the safety of, other Users or third parties, including removing such content from the Site, notifying the appropriate authorities, barring violators from accessing the Site, and terminating the Accounts of such violators. Without limiting the foregoing, you agree that you will not post any Prohibited Content. “Prohibited Content” includes Content that: (i) is offensive or promotes racism, bigotry, hatred or physical harm of any kind against any group or individual; (ii) bullies, harasses, or advocates stalking, bullying, or harassment, of another person; (iii) involves the transmission of “junk mail,” “chain letters,” unsolicited mass mailing, or “spamming,”; (iv) is false or misleading or promotes, endorses or furthers illegal activities or conduct that is abusive, threatening, obscene, defamatory or libelous; (v) promotes, reproduces, performs or distributes an illegal or unauthorized copy of another person’s work that is protected by copyright or trade secret law; (vi) is involved in the exploitation of persons under the age of 13 in a sexual or violent manner, or solicits personal information from anyone under 13; (vii) provides instructional information about illegal activities such as making or buying illegal weapons, violating someone’s privacy, or providing or creating computer viruses and other harmful code; (viii) solicits passwords or personally identifying information for commercial or unlawful purposes from other Users; (ix) except as expressly approved by Spineapple, involves commercial activities and/or promotions such as contests, sweepstakes, barter, advertising, or pyramid schemes; (x) contains viruses, Trojan horses, worms, time bombs, cancelbots, corrupted files, or similar software; (xi) violates any applicable law, including, but not limited to export laws; or (xii) otherwise violates these Terms or creates liability for Spineapple.

9.                Copyright Policy.

Upon prompt notification to Spineapple by a copyright owner or a copyright owner’s legal agent, it is Spineapple’s policy to terminate the Account of any User who repeatedly infringes third party copyright rights. Without limiting the foregoing, if you believe that your work has been copied and posted on the Site in a way that constitutes copyright infringement, please provide our Copyright Agent (using the contact information listed below) with the following information: (i) an electronic or physical signature of the person authorized to act on behalf of the owner of the copyright interest; (ii) a description of the copyrighted work that you claim has been infringed; (iii) a description of the location on the Service of the material that you claim is infringing; (iv) your address, telephone number, and email address; (v) a written statement by you that you have a good faith belief that the disputed use is not authorized by the copyright owner, its agent, or the law; (vi) a statement by you, made under penalty of perjury, that the above information in your notice is accurate and that you are the copyright owner or authorized to act on the copyright owner’s behalf. Contact information for Spineapple’s Copyright Agent for notice of claims of copyright infringement is as follows:

Resourcience LLC,DBA: Spineapple. Attn: Copyright Agent. Resourcience LLC. 1514 Charter Oak Dr, Rochester Hills, Mi, 48309.

10.             Third Parties and Other Users and Physical Therapists.

1.                Third Party Content. Content from other persons (including any Users and Physical Therapists), advertisers, and other third parties may be made available to you through the Site. Because Spineapple does not control such Content, you agree that Spineapple is not responsible for any such Content, including advertising and information about third party products or services. Because Spineapple does not have control over such Content, Spineapple makes no guarantees about the accuracy, currency, suitability, or quality of such Content, and Spineapple assumes no responsibility for unintended, objectionable, inaccurate, misleading, or unlawful Content made available by other persons (including any Users), advertisers, and third parties.

2.                Responsibility. Your interactions with other persons (including any Users and Physical Therapists) or third parties using the Site, and any other terms, conditions, warranties or representations associated with such dealings, are solely between you and the other person or third party. You agree that Spineapple will not be responsible for any loss or damage incurred as the result of any such dealings or with respect to any other User’s use or disclosure of your personally identifiable information.

3.                Third-Party Links. The provision of links to other Sites or locations is for your convenience and does not signify our endorsement of such other Sites or locations or their contents. Links to other Sites or locations may also be posted by other persons. Spineapple has no control over, does not review, and cannot be responsible for, these outside Sites or their content. Please be aware that our Privacy Policy does not apply to these outside Sites.

11.             No Warranty.

TO THE EXTENT LEGALLY PERMITTED UNDER THE APPLICABLE LAWS, (A) THE SITE IS PROVIDED “AS-IS” AND AS AVAILABLE, (B) SPINEAPPLE EXPRESSLY DISCLAIMS ANY WARRANTIES AND CONDITIONS OF ANY KIND, WHETHER EXPRESS OR IMPLIED OR STATUTORY, INCLUDING, BUT NOT LIMITED TO, THE WARRANTIES OR CONDITIONS OF MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, TITLE, QUIET ENJOYMENT, ACCURACY, OR NON-INFRINGEMENT. SOME JURISDICTIONS DO NOT ALLOW THE EXCLUSION OF IMPLIED WARRANTIES OR LIMITATIONS ON HOW LONG AN IMPLIED WARRANTY MAY LAST, SO THE ABOVE LIMITATIONS MAY NOT APPLY TO YOU.

12.             Limitation on Liability.

TO THE EXTENT LEGALLY PERMITTED UNDER APPLICABLE LAW, SPINEAPPLE SHALL NOT BE LIABLE TO YOU OR ANY THIRD PARTY FOR ANY INDIRECT, CONSEQUENTIAL, EXEMPLARY, INCIDENTAL, SPECIAL OR PUNITIVE DAMAGES, INCLUDING ANY LOST PROFIT DAMAGES ARISING FROM YOUR USE OF THE SITE, EVEN IF SPINEAPPLE HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH DAMAGES. NOTWITHSTANDING ANYTHING TO THE CONTRARY CONTAINED HEREIN, SPINEAPPLE’S LIABILITY TO YOU FOR ANY DAMAGES ARISING FROM OR RELATED TO ANY CAUSE OF ACTION WHATSOEVER, REGARDLESS OF THE FORM OF THE ACTION, SHALL BE LIMITED TO THE GREATER OF ONE HUNDRED U.S. DOLLARS ($100), OR THE AMOUNTS YOU PAID TO SPINEAPPLE IN THE SIX (6) MONTHS PRIOR TO THE ACCRUAL OF THE CLAIM. NOTHING IN THESE TERMS SHALL LIMIT OR EXCLUDE SPINEAPPLE’S LIABILITY FOR GROSS NEGLIGENCE OR INTENTIONAL MISCONDUCT OF SPINEAPPLE OR EMPLOYEES, OR FOR DEATH OR PERSONAL INJURY. SOME JURISDICTIONS DO NOT ALLOW THE EXCLUSION OR LIMITATION OF LIABILITY, SO THE ABOVE LIMITATION OR EXCLUSION MAY NOT APPLY TO YOU.

13.             Release.

You hereby release Spineapple, its officers, employees, agents, and successors from claims, demands any and all losses, damages, rights, claims, and actions of any kind including, without limitation, personal injuries, death, and property damage, that is either directly or indirectly related to or arises from any interaction with any other User and/or with any Physical Therapist.

If you are a California resident, you waive California Civil Code §1542, which says: “A general release does not extend to claims which the creditor does not know or suspect to exist in his favor at the time of executing the release, which if known by him must have materially affected his settlement with the debtor.”

14.             Indemnity.

You agree to defend, indemnify, and hold Spineapple, its subsidiaries, affiliates, officers, agents, and other partners and employees, harmless from any loss, liability, claim, or demand, including reasonable attorney’s fees, made by any third party due to or arising out of your use of the Site in violation of these Terms and/or arising from your breach of any provision of these Terms.

15.             Electronic communications.

Communication between you and Spineapple will be affected through electronic means, including, without limitation, through the Site, e-mails, and/or SMS. For contractual purposes, you (a) consent to receive communications from Spineapple in an electronic form; and (b) agree that all terms and conditions, Terms, notices, disclosures, and other communications that Spineapple provides to you electronically satisfy any legal requirement that such communications would satisfy if it were in writing. The foregoing does not affect your statutory rights.

16.             Arbitration.

You agree that any claim, dispute, or controversy you may have against Spineapple arising out of, relating to, or connected in any way with these Terms, the Site or the Service, including any question regarding its existence, validity, or termination, as well as any challenge to the tribunal’s jurisdiction, shall be resolved by means of binding arbitration administered by the American Arbitration Association in accordance with its Commercial Arbitration Rules (except where those Rules conflict with provisions in these Terms, in which case these Terms shall govern). The arbitration hearing shall take place in Michigan, Michigan before a single arbitrator. The seat of the arbitration shall be Michigan. The arbitrator will, in rendering its decision, apply the substantive law of the State of Michigan, without giving effect to conflict of law provisions that may require the application of the laws of another jurisdiction. The decision and award rendered by the arbitrator will be final and non-appealable (except for an alleged act of corruption or fraud on the part of the arbitrator). The arbitrator shall be a practicing attorney or retired judge with at least fifteen years total working experience as such. Judgment on the award rendered by the arbitrator may be entered in any court having jurisdiction thereof.

Notwithstanding the foregoing, either party may immediately bring a proceeding seeking preliminary injunctive relief in a court having jurisdiction thereof which lies within the territorial boundaries of the state of Michigan.

The arbitrator shall issue a reasoned decision, which shall include findings of facts and conclusions of law.

The arbitrator shall require exchange by the parties of (i) the name and, if known, address and telephone number of each person likely to have knowledge of relevant information, identifying the subjects of the information, and (ii) non-privileged documents, including those in electronic form, that are relevant to the issues raised by any claim, defense or counterclaim or on which the producing party may rely in support of or in opposition to any claim, defense or counterclaim. The arbitrator shall limit such production based on considerations of unreasonable expense, duplication, and undue burden. These exchanges shall occur no later than a specified date within 60 days following the appointment of the arbitrator.

At the request of a party, the arbitrator may at his or her discretion order the deposition of witnesses. Depositions shall be limited to a maximum of three depositions per party. Each deposition shall be a maximum of four hours in duration unless the arbitrator otherwise determines. The arbitrator may allow such other discovery as he or she determines is reasonably necessary to a fair determination of the dispute; however, no party shall be directed to produce in excess of 5,000 pages of documents or produce more than five witnesses for depositions. In addition, notwithstanding the foregoing sentence, no interrogatories, requests for admission, or written depositions shall be allowed by the arbitrator, except that each party may serve five interrogatories within 90 days following the appointment of the arbitrator. These interrogatories may ask a party about their contentions and bases for their claims or defenses. Any dispute or objections regarding discovery or the relevance of evidence shall be determined by the arbitrator, and shall generally be in accordance with Michigan law. All discovery shall be completed within 120 days following the appointment of the arbitrator, unless the arbitrator otherwise determines.

No demand for arbitration may be made after the date when the institution of legal or equitable proceedings based on such claim or dispute would be barred by the applicable statute of limitation under the law of the state of Michigan or a shorter statute borrowed by Michigan under CPLR 202. Notwithstanding the foregoing, all claims shall be barred after two years from the occurrence of the event or events giving rise to the controversy, claim, dispute or breach.

You may bring claims against Spineapple in your individual capacity only, and not by way of any purported class, collective, or representative actions or arbitrations. Individual arbitrations may not be combined without the consent of all parties.

The arbitrator is not authorized to award punitive, special, exemplary, incidental or consequential damages, or other damages not measured by the prevailing party’s actual damages. An award of damages shall include pre-award interest at the rate of 4 percent from the time of the act or acts giving rise to the award. Each party shall bear its own costs, fees and expenses of arbitration.

The arbitration proceedings and arbitration award shall be maintained by the parties as strictly confidential, except as is otherwise required by court order or as is necessary to confirm, vacate or enforce the award and for disclosure in confidence to the parties’ respective attorneys, tax advisors and senior management and to family members of a party who is an individual.

17.             Governing Law.

These Terms shall be governed by and interpreted by and under the laws of the State of Michigan, without giving effect to any conflict of laws principles that may provide the Site of the law of another jurisdiction. You and Spineapple agree to submit to the jurisdiction of, and agree that venue is proper in, the state courts located in Michigan, Michigan and the federal courts located in the Southern District of Michigan in such legal action or proceeding. Notwithstanding the foregoing, Spineapple may seek injunctive or other equitable relief to protect its intellectual property rights in any court of competent jurisdiction.

18.             Other.

These Terms constitutes the entire Terms between you and Spineapple regarding the use of the Site. If any provision of these Terms is, for any reason, found to be invalid or unenforceable, such provision will be changed and interpreted to accomplish the objectives to the greatest extent possible under any applicable law and the remaining provisions will continue in full force and effect. The failure of Spineapple to exercise or enforce any right or provision of these Terms shall not operate as a waiver of such right or provision. The section titles in these Terms are for convenience only and have no legal or contractual effect. Please contact us with any questions regarding these Terms at Spineapple, 1514 Charter Oak Drive, Rochester Hills, MI, 48309, or at dearspineapple@spineapple.com.

19.             Copyright/Trademark Information.

You acknowledge and agree that, as between Spineapple and you, all right, title, and interest in and to the Site and the Content, including without limitation any patents, copyrights, trademarks, trade secrets, inventions, know-how, and all other intellectual property rights are owned exclusively by Spineapple or its licensors and are protected by United States intellectual property laws and other applicable laws.

All content included in the Site, such as text, graphics, logos, icons, images, media, data, audio, animation, software and other information and materials, is the copyright and property of Spineapple or its content suppliers and protected by U.S. and international copyright laws. Permission is granted to electronically copy and print hard copy portions of the Site for the sole purpose of placing an order on the Site; using the Site as a resource; or using the Site for personal information. Any other use, including the reproduction, modification, distribution, transmission, republication, display or performance, of the Content of the Site, is strictly prohibited.

The trademarks, service marks, logos, slogans, trade names and trade dress used on the Site are proprietary to Spineapple. Unauthorized use of any trademark of Spineapple may be a violation of trademark laws. Any third party names or trademarks referenced in the Site do not constitute or imply affiliation, endorsement or recommendation by Spineapple or of Spineapple by the third parties.

CONSENT TO TREATMENT and COMMUNICATE

I, do hereby agree and give my consent for RESOURCIENCE LLC, doing business as SPINEAPPLE to furnish medical care and treatment that is considered necessary and proper in diagnosing or treating his/her physical and mental condition.   

CONSENT TO COMMUNICATE WITH OTHERS

I hereby authorize Spineapple, through its appropriate personnel, to communicate with my emergency contact, legal representations regarding services rendered, billing and payment for services rendered on my behalf.

AUTHORIZATION BENEFIT ASSIGNMENT - FINANCIAL RESPONSIBILITY- RELEASE OF INFORMATION

I authorize SPINEAPPLE to release to the insurance carrier any information needed for the payment of any claim. 

I authorize payment to SPINEAPPLE from my insurance carrier or third party payer. I agree to pay any applicable co-payments at the time of service and coinsurance and/or deductibles as agreed between Spineapple and me. 

I understand that my insurance benefits may not cover all charges and that I am responsible for those charges not covered by my health insurance or third party payer. 

I understand and agree that if I fail to make any of the payments for which I am responsible in a timely manner, I will be responsible for all costs of collecting monies owed, including court costs, collection agency fees, and attorney fees. The above may not apply for those patients that are considered Worker’s Compensation. However, be advised if you claim Worker’s Compensation benefits and are subsequently denied such benefits, you may be held responsible for the total amount of charges for services rendered to you. A photocopy of this authorization is to be considered as valid as the original.

 

By my click on "Agree", I authorize SPINEAPPLE, to release all information necessary, including medical records, to secure payment.

 

CONSENT TO COMMUNICATE WITH OTHERS

I hereby authorize Spineapple, through its appropriate personnel, to communicate with my emergency contact, legal representations regarding services rendered, billing and payment for services rendered on my behalf.

CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION: I have had full opportunity to read the SPINEAPPLE Notice of Privacy Practices. I understand that by signing this consent, I am giving my consent to SPINEAPPLE  to use and disclose my protected health information to carry out treatment, payment activities and health care operations. 

I understand the terms of this notice may change with time and SPINEAPPLE  will always post the current notice at the clinic, on the website and have copies available for distribution.

SIGNATURE for CONSENT By my click on agrees below I acknowledge that I have read, understand and agree to the terms and conditions contained in the CONSENT TO TREATMENT and COMMUNICATE,  the Authorization to release all information necessary to secure payment and the Consent For Use and Disclosure of Health Information. 

Notice of Privacy Practices

This notice describes how medical information about you may be used and disclosed and how you may have access to this information. If you have any questions about this Notice; please contact our Privacy Officer.

Contact information is listed at the end of this notice. This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services. We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice, at any time. The new notice will be effective for all protected health information that we maintain at that time. Upon your request, we will provide you with any revised Notice of Privacy Practices by calling the office and requesting that a revised copy be sent to you in the mail, via e-mail or asking for one at the time of your next appointment. Uses and Disclosures of Protected Health Information Based Upon Your Written Consent You will be asked by SPINEAPPLE to sign a consent form. Once you have consented to use and disclose your protected health information for treatment, payment and health care operations, SPINEAPPLE will use or disclose your protected health information as described in this notification. Your protected health information may be used and disclosed by your physical therapist, our staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you. Your protected health information may also be used and disclosed to pay your health care bills and to support the operation of SPINEAPPLE. Following are examples of the types of uses and disclosures of your protected health care information that SPINEAPPLE is permitted to make once you have signed our consent form. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by our office once you have provided consent. Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party that has already obtained your permission to have access to your protected health information. For example, we would disclose protected health information to physicians who may be treating you when we have the necessary permission from you to disclose your protected health information. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physical therapist has the necessary information to diagnose or treat you. In addition, we may disclose your protected health information from time-to-time to another physician or health care provider who, at the request of your physical therapist, becomes involved in your care by providing assistance with your health care diagnosis or treatment to your physician. Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services we recommend for you such as; making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities. Healthcare Operations: We may use or disclose, as-needed, your protected health information in order to support the business activities of SPINEAPPLE . These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, marketing and fundraising activities, and conducting or arranging for other business activities. For example, we may disclose your protected health information to medical school students or volunteers that see patients at our office. We may call you by first name only when in the waiting room when your physical therapist is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment, cancellation or absence from an appointment. We will share your protected health information with third party “business associates” that perform various activities (e.g., billing) for the practice. Whenever an arrangement between our office and a business associate involves the use of disclosure of your protected health information, we will have a written contract that contains terms that will protect the privacy of your protected health information. We may use or disclose your protected health information, as necessary, to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you. We may also use and disclose your protected health information for other marketing activities. For example, your name and address may be used to send you a newsletter about our practice and the services we offer. We may also send you information about products or services that we believe may be beneficial to you. You may contact our Privacy Officer to request that these materials not be sent to you. Uses and Disclosures of Protected Health Information Based upon Your Written Authorization Other uses and disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law as described below. You may revoke this authorization, at any time, in writing, except to the extent that your physical therapist or SPINEAPPLE has taken an action in reliance on the use or disclosure indicated in the authorization. Other Permitted & Required Uses and Disclosures That May Be Made With Your Consent, Authorization or Opportunity to Object We may use and disclose your protected health information in the following instances. You have the opportunity to agree or object to the use or disclosure of all or part of your protected health information. If you are not present or able to agree or object to the use or disclosure of the protected health information, then your physical therapist may, using professional judgment, determine whether the disclosure is in your best interest. In this case, only the protected health information that is relevant to your health care will be disclosed. Others Involved in Your Healthcare: Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your protected health information that directly relates to that person’s involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose protected health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care, your location, general condition or death. Finally, we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care. Emergencies: We may use or disclose your protected health information in an emergency treatment situation. If this happens, your physical therapist shall try to obtain your consent as soon as reasonably practicable after the delivery of treatment. If your physical therapist or another physical therapist in the practice is required by law to treat you and the physical therapist has attempted to obtain your consent but is unable to obtain your consent, he or she may still use or disclose your protected health information to treat you. Communication Barriers: We may use and disclose your protected health information if your physical therapist or another physical therapist in the practice attempts to obtain consent from you but is unable to do so due to substantial communication barriers and the physical therapist determines, using professional judgment, that you intend to consent to use or disclose under the circumstances. Other Permitted and Required Uses and Disclosures That May Be Made Without Your Consent, Authorization or Opportunity to Object We may use or disclose your protected health information in the following situations without your consent or authorization. These situations include: Required By Law: We may use or disclose your protected health information to the extent that the use or disclosure is required by law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, as required by law, of any such uses or disclosures. Public Health: We may disclose your protected health information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. The disclosure will be made for the purpose of controlling disease, injury or disability. We may also disclose your protected health information, if directed by the public health authority, to a foreign government agency that is collaborating with the public health authority. Communicable Diseases: We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition. Health Oversight: We may disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws. Abuse and Neglect: We may disclose your protected health information to a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, we may disclose your protected health information if we believe that you have been a victim of abuse, neglect or domestic violence to the government entity or agency authorized to receive such information. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws. Food and Drug Administration: We may disclose your protected health information to a person or company required by the Food and Drug Administration to report adverse events, product defects or problems, biologic product deviations, track products; to enable product recalls; to make repairs or replacements, or to conduct post marketing surveillance, as required. Legal Proceedings: We may disclose protected health information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), in certain conditions in response to a subpoena, discovery request or other lawful process. Law Enforcement: We may also disclose protected health information, so long as applicable legal requirements are met, for law enforcement purposes. These law enforcement purposes include (1) legal processes and otherwise required by law, (2) limited information requests for identification and location purposes, (3) pertaining to victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) in the event that a crime occurs on the premises of the practice, and (6) medical emergency (not on the Practice’s premises) and it is likely that a crime has occurred. Criminal Activity: Consistent with applicable federal and state laws, we may disclose your protected health information, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. We may also disclose protected health information if it is necessary for law enforcement authorities to identify or apprehend an individual. Military Activity and National Security: When the appropriate conditions apply, we may use or disclose protected health information of individuals who are Armed Forces personnel (1) for activities deemed necessary by appropriate military command authorities; (2) for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits, or (3) to foreign military authority if you are a member of that foreign military service. We may also disclose your protected health information to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally authorized. Workers’ Compensation: Your protected health information may be disclosed by us as authorized to comply with workers’ compensation laws and other similar legally established programs. Inmates: We may use or disclose your protected health information if you are an inmate of a correctional facility and your physical therapist created or received your protected health information in the course of providing care to you. YOUR RIGHTS Following is a statement of your rights with respect to your protected health information and a brief description of how you may exercise these rights. You have the right to inspect and copy your protected health information. This means you may inspect and obtain a copy of protected health information about you that is contained in a designated record set for as long as we maintain the protected health information. A “designated record set” contains medical and billing records and any other records that your physical therapist, referring physician and SPINEAPPLE uses for making decisions about you. Under federal law, however, you may not inspect or copy the following records; psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information. Depending on the circumstances, a decision to deny access may be reviewable. In some circumstances, you may have a right to have this decision reviewed. Please contact our Privacy Officer if you have any questions about access to your medical record. You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. SPINEAPPLE is not required to agree to a restriction that you may request. If your physical therapist believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. If SPINEAPPLE does agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment. With this in mind, please discuss any restriction you wish to request with your physical therapist and indicate this information on the SPINEAPPLE Consent For Use and Disclosure of Health Information form. You have the right to request to receive confidential communications from us by alternative means or at an alternative location. We will accommodate reasonable requests. We may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not request an explanation from you as to the basis for the request. Please make this request in writing to a front desk staff member. You may have the right to have SPINEAPPLE amend your protected health information. This means you may request an amendment of protected health information about you in a designated record set for as long as we maintain this information. In certain cases, we may deny your request for an amendment. If we deny your request for an amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Please contact our Privacy Officer to determine if you have any questions about amending your medical record. You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. This right applies to disclosures for purposes other than treatment, payment or healthcare operations as described in this Notice of Privacy Practices. It excludes disclosures we may have made to you, for a facility directory, to family members or friends involved in your care, or for notification purposes. You have the right to receive specific information regarding these disclosures that occurred after April 14, 2003. You may request a shorter timeframe. The right to receive this information is subject to certain exceptions, restrictions and limitations. You have the right to obtain a paper copy of this notice from us. If you received this notice on our website or via e-mail, you are still entitled to request a paper copy of this notice. Complaints You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our Privacy Officer of your complaint. All complaints shall be investigated without repercussion to you. We will not retaliate against you for filing a complaint. You may contact our Privacy Officer: 1514 charter oak drive, Rochester Hills, Mi, 48309. This notice was published and becomes effective on April 1, 2017. 

 

Regards,

Spineapple Team

 

 

 

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