Terms and Conditions
TERMS CONDITIONS OF SERVICES, PAYMENT & CONSENT FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION.
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 NUMI Hydration LLC. 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 NUMI Hydration LLC AND ITS PERSONNEL ARE NOT PAID OR REIMBURSED FOR THE SERVICES AND HANGOVER MANAGEMENT PROGRAM OR SUPPLEMENTS, VITAMINS OR PHARMACEUTICALS OFFERED BY NUMI Hydration LLC 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.
NUMI Hydration LLC 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 NUMI Hydration LLC 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. NUMI Hydration LLC personnel will not screen for, diagnose, monitor or otherwise provide any care or treatment for such conditions NUMI Hydration LLC is relying upon the foregoing representations and warranties upon your entering into these Terms and Conditions and upon NUMI Hydration LLC acceptance of you for the provision of services.
I hereby give my consent for NUMI Hydration to use and disclose protected health information (PHI) about me to carry out treatment, payment and health care operations (TPO) (The Notice of Privacy Practices provided by NUMI Hydration LLC describes such uses and disclosures more completely.) I have the right to review the Notice of Privacy Practices prior to signing this consent. NUMI Hydration reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to NUMI Hydration. With this consent, NUMI Hydration may call my home or other alternative location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any calls pertaining to my clinical care, including laboratory test results, among others. With this consent, NUMI Hydration may mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements as long as they are marked “Personal and Confidential.” With this consent, NUMI Hydration may e-mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements. I have the right to request that NUMI Hydration restrict how it uses or discloses my PHI to carry out TPO. The practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.
I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, NUMI Hydration may decline to provide treatment to me.
By signing this form below, I am consenting to allow NUMI Hydration to use and disclose my PHI to carry out TPO.
INFORMED CONSENT, CLIENT REPRESENTATIONS/WARRANTIES & DISCLAIMER AGREEMENT
I understand that participating in intravenous (IV) hydration, vitamin/supplement administration, pharmaceutical administration, programs and services made available by NUMI Hydration LLC carries 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 NUMI Hydration LLC 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 NUMI Hydration Group, and I am not choosing to participate with any expectation that NUMI Hydration Group will screen for, diagnose, monitor or otherwise provide any care or treatment for such conditions.
I acknowledge and understand that NUMI Hydration LLC is relying upon the foregoing representations and warranties from me upon NUMI Hydration LLC's acceptance of me for participation in its NUMI Hydration’s IV hydration, programs and services.
I acknowledge and understand that NUMI Hydration Group is not responsible or liable for any complications that result from the use of any client provided or custom requested vitamins, injections, or medication.
RISKS INCLUDE THE FOLLOWING:
INJURY, BLEEDING, INFECTION, INFLAMMATION/SWELLING, BRUISING OR SCARRING RESULTING FROM IV INFILTRATION, EXTRACTION, EXTRAVASATION AND INJECTION, MISPLACEMENT OF IV LINES IN THE BODY, AIR EMBOLISM, FLUID OVERLOAD, MEDICATION ADVERSE INTERACTIONS, NERVE INJURIES, LIGHTHEADEDNESS OR FAINTING, PAIN OR BURNING DURING INJECTION
YOU EXPRESSLY REPRESENT AND WARRANT TO NUMI HYDRATION 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 NUMI Hydration 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.
I have read the above, do agree with these terms and consent to participate in the NUMI Hydration LLC's program.
HIPPA Privacy Policy
OUR LEGAL RESPONSIBILITIES
We are required by law to give you this notice. It provides you on how we may use and disclose protected health information about you and describes your rights and our obligations regarding the use and disclosure of that information. We shall maintain the privacy of protected health information and provide you with notice of our legal duties and privacy practices with respect to your protected health information.
We have the right to change these policies at any time. If we change our privacy policies, we will notify you of these changes immediately. This current policy is in effect unless stated otherwise. If the policy is changed, it will apply to all your current and past health information.
You may request a copy of our notice any time. You may contact NUMI Hydration LLC, at 4500 N 10th St suite 10 McAllen TX, 78504, (956) 477-4189 at any time to request a copy of this privacy policy.
HOW WE MAY USE OR DISCLOSE YOUR PROTECTED HEALTH INFORMATION
The following examples describe ways that we may use your protected health information for your treatment, payments, healthcare operations etc. but please be advised that not every use or disclosure in a particular category will be listed.
Treatment: We may use and disclose your protected health information to provide you treatment. This includes disclosing your protected health information to other medical providers, trainees, therapists, medical staff, and office staff that are involved in your health care.
For example, your medical provider might need to consult with another provider to coordinate your care. Also, the office staff may need to use and disclose your protected health information to other individuals outside of our office such as the pharmacy when a prescription is called in.
Payment: Your protected health information may also be used to obtain payment from an insurance company or another third part. This may include providing an insurance company your protected health information for a pre-authorization for a medication we prescribed.
Health Care Operations: We may use or disclose your protected health information in order to operate this medical practice. These activities include training students, reviewing cases with employees, utilizing your information to improve the quality of care, and contacting you be telephone, email, or text to remind you of your appointments.
If we have to share your protected health information to third party “business associates” such as a billing service, if so, we will have a written contract that contains terms that will protect the privacy of your protected health information.
We may also use and disclose your protected health information for marketing activities. For example, we might send you a thank you card in the mail with a coupon for specialized services or products.
We may also send you information about products or services that might be of interest to you. You can contact us at any point to stop receiving this information.
We will not use or disclose your protected health information for any purpose other than those identified in this policy without your specific, written Authorization. You may give us written authorization to use your protected health information or to disclose it to anyone for any purpose. You can revoke this authorization at any time but will not affect the protected health information that was shared while the authorization was in effect.
Appointment reminders: We may contact you as a reminder that you have an appointment for your initial visit, follow up visit, or lab work via text, phone or email.
Others Involved in Your Health Care: We may disclose protected health information about you to your family members or friends if we obtain your verbal agreement to do so, or if we give you an opportunity to object to such a disclosure and you do not raise an objection. For example, we may assume that if your spouse or friend is present during your evaluation, that we can disclose protected professional information to this person. 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 if there is an urgent or emergent need.
Research; We will not use or disclose your health information for research purposes unless you give us authorization to do so.
Organ Donation: If you are an organ donor, we may release protected health information to organizations that handle organ procurement or organ, eye or tissue transplantation if it is necessary to facilitate this process.
Public Health Risks: We may disclose your protected health information, if necessary, in order to prevent or control disease, report adverse events from medications or products, prevent injury, disability or death. This information may be disclosed to healthcare systems, government agencies, or public health authorities. We may have to disclose your protected health information to the Food and Drug Administration to report adverse events, defects, problems, enable recalls etc. if required by FDA regulation.
Health Oversight Activities: We may disclose protected health information to health oversight agencies for audits, investigations, inspections or licensing purposes. These disclosures might be necessary for state and federal agencies to monitor healthcare systems and compliance with civil law.
Required by Law: We will disclose protected health information about you when required to do so by federal, state and/or local law.
Workman’s compensation: We may disclose your protected health information to workman’s comp or similar programs.
Lawsuits: We may disclose your protected health information in response to a court action, administrative action or a subpoena.
Law Enforcement: We may release protected health information to a law enforcement official in response to a court order, subpoena, warrant, subject to all applicable legal requirements.
YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION
Access to medical records: You have the right to access and receive copies of your protected health information that we use to make decisions about your care. You must submit a written request to obtain your protected health information to the individual listed at the end of this privacy policy. We reserve the right to charge you a fee for the time it takes to obtain and copy the protected health information and provide it to you.
Amendment: If you believe the protected health information, we have about you is incorrect or incomplete, you may ask us to amend the information You will need to submit a written request on why you feel the health information should be amended. We may deny your request to amend if you did not send a written request or give a reason on why it should be amended. If we deny your request, we will provide you a written explanation. We may deny your request if we believe the protected health information is accurate and complete.
Accounting of Disclosures: You have the right to receive a list of instances in which we disclosed your personal health information unless the disclosure was used for treatment, payment, healthcare operations, was pursuant to a valid authorization and as otherwise provided in applicable federal and state laws and regulations. You must submit a written request to obtain this “accounting of disclosures” to the individual listed at the bottom of this policy. After your request has been approved, we will provide you the dates of the disclosure, the name of the individual or entity we disclosed the information to, a description of the information that was disclosed, the reason why it was disclosed, and any additional pertinent information. This information may not be longer than 20 years ago prior to the date the accounting is requested. We reserve the right to charge a reasonable fee for this process.
Restriction Requests: You have the right to request a restriction or limitation on the protected health information we use or disclose about you for treatment, payment, or healthcare operations. We shall accommodate your request except where the disclosure is required by law. We require this be a written request submitted to the individual at the end of this policy.
Confidential Communication: You have the right to request that we communicate with you about healthcare matters in a certain way and at a certain location. We must accommodate your request if it is reasonable and allows us to continue to collect payments and bill you.
Paper copy of this notice: You may request a hard copy of this practice policy if you reviewed and signed it via electronic means. To obtain this copy, contact the individual at the end of this privacy policy.
Complaints: If you believe your privacy rights have been violated, you may file a complaint with our office. You also file a complaint with the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request.
Name of Contact Person: Cassidy Chavez FNP
NUMI Hydration Members Agreement
Select Membership Offering:
Refresh: $45 to be billed monthly until canceled
○ Benefits: B-12 or Lipo+ shot , 1 Quick Drip, member pricing, birthday drip. Drips are not transferable.
Replenish: $95 to be billed monthly until canceled
○ Benefits include B-12 or Lipo+ shot, Wellness Drip, member pricing, 10% off NAD+ bundles, birthday drip.
Revitalize: $225 to be billed monthly until canceled
○ Benefits: 2 B-12 shot or Lipo+ shot, 1 Quench Drip, 2 Wellness Drips, member pricing, 10% off NAD+ bundles, birthday drip. Vitamin Drips can be shared with 4 individuals of member's choice- list provided by client. Member must be present for changes to client list.
Yearly: $250 to be billed ONCE and renewed only upon request
○ Benefits: member pricing, birthday drip
Rollover Clause: Wellness Drips are eligible for rollover; however, Hydration Drips are not. Any unused Hydration Drips within the month will be forfeited, along with any associated booster perks
Terms and Conditions:
Payment Responsibility: Clients are billed directly and are personally responsible for payment. NUMI
Hydration does not accept insurance for its services.
Non-Medical Services: NUMI Hydration does not diagnose or treat any illness, disease, or health
condition.
Consent for Use of Protected Health Information (PHI): Clients consent to NUMI Hydration using and
disclosing PHI for treatment, payment, and healthcare operations as described in the Notice of Privacy
Practices.
Informed Consent and Risk Acknowledgment: Participation in services involves risks, and clients
assume responsibility for these risks.
Privacy Policy: NUMI Hydration will maintain the privacy of PHI and may change its privacy policies as
required by law.
Communication: NUMI Hydration may contact clients for appointment reminders and may disclose PHI
to family members or friends with client's verbal agreement or as necessary.
Client Rights: Clients have rights regarding access to medical records, amendment requests, accounting of
disclosures, restriction requests, confidential communications, and receiving a hard copy of privacy policies
.
Complaints: Clients may file complaints regarding privacy rights violations with NUMI Hydration or the
U.S. Department of Health and Human Services.
Cancellation and Service Use Policy:
● Pre-Billing Usage: In the event that any drip services are utilized before the monthly billing cycle
and a subsequent cancellation attempt is made, the credit card on file will be charged for the full
cost of the drip services rendered, excluding any member discounts. This ensures fair
compensation for the services provided prior to the cancellation.
● Cancellation Before Service Use: If a cancellation occurs before any drip services are used
within a billing cycle, no additional fees will be applied, provided that the cancellation occurs after
the initial three-month membership period.
● Early Cancellation Fee: If membership is canceled before the completion of the first two months,
an early cancellation fee equivalent to two months membership fees will be charged to the credit
card on file. This policy is in place to ensure the sustainability and fairness of our membership
program.
● Yearly Cancellation: there will be no refunds issued for yearly memberships.