Disclosures, Consent & Important Safety Information

Here are all of our Mandatory Disclosures & the Important Safety Information Affiliated with the products we use in our practice.

Quick Note 

On the left you will find the disclosures for all heath and safety information that is affiliated with some of the products we use in our practice. Please take a moment to view the important health and safety information. 

These are just a few of the products we offer and of course we will go over all of the products we offer and find the best solution for you! Our website is meant to operate as an informational hub but all information and content here is strickly for informational purposes only and is not intended to replace the advice of any other medical professional. 

I voluntarily authorize the rendering of services by 5 Star Medical Inc. providers and employees. I acknowledge that no guarantees are made as to the effect of such examination, recommendation, or treatment on my condition or the condition of the person for whom I am duly authorized to make decisions. I acknowledge the right to refuse medical and surgical procedures. I understand all services are elective and non refundable. All services must be paid in advance or on day of service. Services provided are not billed to medical insurance. Please call 5 Star Medical Inc. for questions. Staff of 5 Star Medical Inc. may not be available at all times. Please leave a message, email, or text. All emergencies should be directed to the nearest emergency room or specialty practice. Emergency treatment for complications should be reported to 5 Star Medical Inc. but please do not delay evaluation or treatment if intervention is necessary. Any complications must be treated at patient expense.
By law, 5 Star Medical Inc. is required to provide you with our Notice of Privacy Practices. This notice describes how your medical records may be used and disclosed by our staff. It also tells how you may obtain access to this information. 5 Star Medical Inc. wants to insure you that your medical and protected health information is secured. As a patient, you are entitled to the following rights:
The right to inspect and copy your information.
The right to request corrections to your information.
The right to request that your information be restricted.
The right to request confidential communications
The right to a report of disclosures of your information
The right to a paper copy of this Notice
I hereby acknowledge and understand that I have received a copy of this practice’s NOTICE OF PRIVACY PRACTICES. I understand that if in any case I have questions or concerns regarding my privacy practice rights, I may contact the 5 Star Medical Inc. I further understand that the practice will make available to me updates to this NOTICE OF PRIVACY PRACTICES if in any case, should it be changed, amended, or modified in any way.
Cancellations without 24 hour notice will result in a fee. Late appointment arrivals of more than 10 minutes or more may require the appointment to be rescheduled to assure your safety and best results for treatment. To avoid an automatic charge to your account or credit card on file, please cancel or reschedule at least 24 hours before your appointment either by phone, email, or online scheduling. We send a 48 hour auto email reminder for your appointment followed by a text message at least one business day prior. Please understand that when you don’t show for your appointment, staff still must be paid.
Fee $25 for 1st missed/no show appointment or cancellation less than 24 hours. Fee $69 for 2nd and each subsequent appointment.
Signature of this liability waiver indicates acknowledgement of the above and responsibility for payment of all services rendered on the signer’s behalf and of signer’s dependents.
I consent to photographs and/or video being taken to record baseline state, evaluate treatment result, for medical education, training, professional publications and/or sales purposes. No photographs revealing my identity will be used without my written consent. If my identity is not revealed, these photographs may be used and displayed publicly without my permission.
I understand that these procedure are cosmetic and that payment is my responsibility. I further agree, in the event of non-payment, to bear the cost of collection, and/or court costs and reasonable legal fees, should they be required. Should additional procedures be necessary payment for materials and labor is expected at time of service. There are no free touch ups or refunds for treatments rendered. Outside consultants or procedures stemming from these procedures are not the responsibility of 5 Star Medical Inc. or providers. I understand and agree that all services rendered will be charged directly to me, and I am personally responsible for payment. I further agree, in the event of non-payment, to bear the cost of collection, and/or court costs and reasonable legal fees, should they be required.

HIPAA

Your Information. Your Rights. Our Responsibilities.

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Your Rights

You have the right to: 

  • Get a copy of your paper or electronic medical record
  • Correct your paper or electronic medical record
  • Request confidential communication
  • Ask us to limit the information we share
  • Get a list of those with whom we’ve shared your information
  • Get a copy of this privacy notice
  • Choose someone to act for you
  • File a complaint if you believe your privacy rights have been violated

Your Choices

You have some choices in the way that we use and share information as we: 

  • Tell family and friends about your condition
  • Provide disaster relief
  • Include you in a hospital directory
  • Provide mental health care
  • Market our services and sell your information
  • Raise funds

Our Uses and Disclosures

We may use and share your information as we: 

  • Treat you
  • Run our organization
  • Bill for your services
  • Help with public health and safety issues
  • Do research
  • Comply with the law
  • Respond to organ and tissue donation requests
  • Work with a medical examiner or funeral director
  • Address workers’ compensation, law enforcement, and other government requests
  • Respond to lawsuits and legal actions

Your Rights

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

Get an electronic or paper copy of your medical record 

  • You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this. 
  • We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

Ask us to correct your medical record

  • You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
  • We may say “no” to your request, but we’ll tell you why in writing within 60 days.

Request confidential communications

  • You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. 
  • We will say “yes” to all reasonable requests.

Ask us to limit what we use or share

  • You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.
  • If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.

Get a list of those with whom we’ve shared information

  • You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
  • We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of this privacy notice

You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

Choose someone to act for you

  • If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
  • We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated

  • You can complain if you feel we have violated your rights by contacting us using the information on page 1.
  • You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.
  • We will not retaliate against you for filing a complaint.

Your Choices

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us to:

  • Share information with your family, close friends, or others involved in your care
  • Share information in a disaster relief situation
  • Include your information in a hospital directory

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases we never share your information unless you give us written permission:

  • Marketing purposes
  • Sale of your information
  • Most sharing of psychotherapy notes

In the case of fundraising:

  • We may contact you for fundraising efforts, but you can tell us not to contact you again.

Our Uses and Disclosures

How do we typically use or share your health information? 

We typically use or share your health information in the following ways.

Treat you

We can use your health information and share it with other professionals who are treating you.

Example: A doctor treating you for an injury asks another doctor about your overall health condition.

Run our organization

We can use and share your health information to run our practice, improve your care, and contact you when necessary.

Example: We use health information about you to manage your treatment and services. 

Bill for your services

We can use and share your health information to bill and get payment from health plans or other entities. 

Example: We give information about you to your health insurance plan so it will pay for your services

How else can we use or share your health information? 

We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

Help with public health and safety issues

We can share health information about you for certain situations such as: 

  • Preventing disease
  • Helping with product recalls
  • Reporting adverse reactions to medications
  • Reporting suspected abuse, neglect, or domestic violence
  • Preventing or reducing a serious threat to anyone’s health or safety

Do research

We can use or share your information for health research.

Comply with the law

We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.

Respond to organ and tissue donation requests

We can share health information about you with organ procurement organizations.

Work with a medical examiner or funeral director

We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

Address workers’ compensation, law enforcement, and other government requests

We can use or share health information about you:

  • For workers’ compensation claims
  • For law enforcement purposes or with a law enforcement official
  • With health oversight agencies for activities authorized by law
  • For special government functions such as military, national security, and presidential protective services

Respond to lawsuits and legal actions

We can share health information about you in response to a court or administrative order, or in response to a subpoena.

Our Responsibilities

  • We are required by law to maintain the privacy and security of your protected health information. 
  • We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
  • We must follow the duties and privacy practices described in this notice and give you a copy of it. 
  • We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind. 

For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

Changes to the Terms of this Notice

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.

Please contact us with any questions or concerns you may have. We look forward to speaking with you soon!