1. In seeking care from Fresh Aesthetics, I hereby consent to receive medical treatment and care from Fresh Aesthetics and its authorized medical staff. This consent includes, but is not limited to, diagnostic procedures, medical treatments, and any other healthcare services deemed necessary by my healthcare provider. I understand that the practice of medicine is not an exact science and that no guarantees have been made to me regarding the outcome of any procedures or treatments.
2. Release of Liability. In consideration of the medical services provided to me, I hereby release and discharge Fresh Aesthetics, its officers, employees, and agents from any and all claims, demands, or causes of action that I may have now or in the future, arising out of\or in connection with the medical treatment and care provided to me. This release of liability does not apply to acts of gross negligence or willful misconduct.
3. HIPAA Compliance and Authorization for Use and Disclosure of Protected Health Information. I acknowledge that Fresh Aesthetics is required by law to maintain the privacy of my protected health information (PHI) in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and its implementing regulations. I understand that my PHI may be used and disclosed for purposes of treatment, payment, and healthcare operations as permitted by HIPAA.
3.1 Authorization for Use and Disclosure. I authorize Fresh Aesthetics to use and disclose my PHI for the basis of planning my care and treatment and a means of communication among the many health professionals who contribute to my care.
I understand that I have the right to revoke this authorization in writing at any time, except to the extent that Fresh Aesthetics has already taken action in reliance on this authorization.
3.2 Patient Rights. I understand that I have the right to request restrictions on certain uses and disclosures of my PHI, the right to receive confidential communications, the right to inspect and copy my PHI, and the right to request an amendment to my PHI. I acknowledge that I have received a copy of Fresh Aesthetics Privacy Practices, which provides a more detailed description of my rights and the uses and disclosures of my PHI.
4. Acknowledgment and Signature. I acknowledge that I have read and understand the terms of this Consent to Medical Treatment, Release of Liability, and HIPAA Compliance Agreement. I agree to the terms and conditions set forth herein.
