Universal Consent | Crossover Health

Crossover Health Medical Group

New Patient Registration

Please read this Agreement carefully: It is a legally binding contract. By accepting it, you are electronically signing and agreeing to be bound by this New Patient Registration for yourself, if you are the patient, or on behalf of your child, if he or she is the patient, in which case, you acknowledge that you are the parent or legal guardian, and each of the demarcated documents contained herein including: the Notice of Privacy Practices, General Consent and Patient Rights and Responsibilities. If you do not wish to be bound by this Agreement, you may not receive any services provided by Crossover Health Medical Group.

Notice Of Privacy Practices (Effective Date: October 2019)

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.

As required by the privacy regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA):

A. Our commitment to your privacy:

Our practice is dedicated to maintaining the privacy of your individually identifiable health information (also called protected health information, or PHI). In conducting our business, we will receive information and 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 in our practice concerning your PHI. 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 realize that these laws are complicated, but we must provide you with the following important information:

How we may use and disclose your PHI
Your privacy rights in your PHI
Our obligations concerning the use and disclosure of your PHI

The terms of this notice apply to all records containing your PHI that are created or retained by our practice. We reserve the right to revise or amend this Notice of Privacy Practices (the “Notice”). Any revision or amendment to the Notice will be effective for all of your records that our practice has created or maintained in the past, and for any of your records that we may create or maintain in the future. Our practice will post a copy of our current Notice in our clinics in a visible location at all times and on our website, and you may request a copy of our most current Notice at any time. We are required to abide by the terms of the notice currently in effect A revised Notice may be obtained by forwarding a written request to Crossover Health Medical Group, 101 W. Avenida Vista Hermosa Ste. 120, San Clemente, CA 92672.

B. Your personal information:

We keep records of the medical care we provide you, and we may receive similar records from others. We use this information so that we, or other health care providers, can render quality medical care, obtain payment for services and enable us to meet our professional and legal responsibilities to operate our medical practice. We may store this information in a chart and in our computers. This information makes up your medical record. The medical record is our property; however, this notice explains how we use information about you and when we are allowed to share that information with others.

C. Our privacy practices:

We have a HIPAA and Health Information Technology for Economic and Clinical Health (“HITECH”) Act Policy in place to help ensure your PHI is protected. Crossover Health Medical Group not only uses traditional methods to deliver care but also cutting edge technology to help deliver quality care to our patients. It is our policy to maintain reasonable and feasible physical, electronic and process safeguards to restrict unauthorized access to and protect the availability and integrity of your health information. Our protective measures may include secured office facilities, locked file cabinets, managed computer network systems and password protected accounts. Access to health information is only granted on a “need-to-know” basis. Once the need is established the access is limited to the minimum necessary information to accomplish the intended purpose. Our staff are required to comply with the policies and procedures designed to protect the confidentiality of your health information. Any staff member who violates our privacy policy is subject to disciplinary action.

D. If you have questions about this Notice, please contact:

101 W. Avenida Vista Hermosa Ste. 120

San Clemente, CA 92672

E. We may use and disclose your PHI in the following ways:

The following categories describe the different ways in which we may use and disclose your PHI.

Treatment. Our practice may use your PHI to treat you. For example, we may ask you to have laboratory tests (such as blood or urine tests), and we may use the results to help us reach a diagnosis. We might use your PHI in order to write a prescription for you, or we might disclose your PHI to a pharmacy when we order a prescription for you. Many of the people who work for our practice – including, but not limited to, our doctors and nurses – may use or disclose your PHI in order to treat you or to assist others in your treatment. Additionally, we may also receive and disclose your PHI to other health care providers for purposes related to your treatment.
Payment. Our practice may use and disclose your PHI in order to bill and collect payment for the services and items you may receive from us. In addition, and by way of example of disclosures for payment purposes, we may disclose your PHI to other health care providers and entities to assist in their billing and collection efforts.
Health care operations. Our practice may use and disclose your PHI to operate our business. As examples of the ways in which we may use and disclose your information for our operations, our practice may use your PHI to evaluate the quality of care you received from us, or to conduct cost-management and business planning activities for our practice. We may disclose your PHI to other health care providers and entities to assist in their health care operations.
Appointment reminders. Our practice may use and disclose your PHI to contact you and remind you of an appointment.
Treatment options. Our practice may use and disclose your PHI to inform you of potential treatment alternatives or other health-related benefits and services that may be of interest to you.
Health-related benefits and services. Our practice may use and disclose your PHI to inform you of health-related benefits or services that may be of interest to you.
Release of information to family/friends. Our practice may release your PHI to a friend or family member that is involved in your care, or who assists in taking care of you. However, any such disclosure will be subject to legal requirements and our HIPAA and HITECH Policy.
Disclosures required by law. Our practice will use and disclose your PHI when we are required to do so by federal, state or local law.

F. Use and disclosure of your PHI in certain special circumstances:

The following categories describe unique scenarios in which we may use or disclose your identifiable health information:

Public health risks. Our practice may disclose your PHI to public health authorities that are authorized by law to collect information for the purpose of:
- Maintaining vital records, such as births and deaths;
- Reporting child abuse or neglect;
- Preventing or controlling disease, injury or disability;
- Notifying a person regarding potential exposure to a communicable disease;
- Notifying a person regarding a potential risk for spreading or contracting a disease or condition
- Reporting reactions to drugs or problems with products or devices;
- Notifying individuals if a product or device they may be using has been recalled;
- Notifying appropriate government agency(ies) and authority(ies) regarding the potential abuse or neglect of an adult patient (including domestic violence); however, we will only disclose this information if the patient agrees or we are required or authorized by law to disclose this information; or
- Notifying your employer under limited circumstances related primarily to workplace injury or illness or medical surveillance.
Health oversight activities. Our practice may disclose your PHI to a health oversight agency for activities authorized by law. Oversight activities can include, for example, investigations, inspections, audits, surveys, licensure and disciplinary actions; civil, administrative and criminal procedures or actions; or other activities necessary for the government to monitor government programs, compliance with civil rights laws and the health care system in general.
Lawsuits and similar proceedings. Our practice may use and disclose your PHI in response to a court or administrative order, if you are involved in a lawsuit or similar proceeding. We also may disclose your PHI in response to a discovery request, subpoena or other lawful process by another party involved in the dispute, but only if we have made an effort to inform you of the request or to obtain an order protecting the information the party has requested.
Law enforcement. We may release PHI if asked to do so by a law enforcement official:
- Regarding a crime victim in certain situations, if we are unable to obtain the person’s agreement;
- Concerning a death we believe has resulted from criminal conduct;
- Regarding criminal conduct at our offices;
- In response to a warrant, summons, court order, subpoena or similar legal process;
- To identify/locate a suspect, material witness, fugitive or missing person; or
- In an emergency, to report a crime (including the location or victim(s) of the crime, or the description, identity or location of the perpetrator).
Deceased patients. Our practice may release PHI to a medical examiner or coroner to identify a deceased individual or to identify the cause of death. If necessary, we also may release information in order for funeral directors to perform their jobs.
Organ and tissue donation. Our practice may release your PHI to organizations that handle organ, eye or tissue procurement or transplantation, including organ donation banks, as necessary to facilitate organ or tissue donation and transplantation if you are an organ donor.
Research. Our practice may use and disclose your PHI for research purposes in certain limited circumstances. We will obtain your written authorization to use your PHI for research purposes except when an Internal Review Board or Privacy Board has determined that the waiver of your authorization satisfies all of the following conditions:
- The use or disclosure involves no more than a minimal risk to your privacy based on the following: (a) an adequate plan to protect the identifiers from improper use and disclosure; (b) an adequate plan to destroy the identifiers at the earliest opportunity consistent with the research (unless there is a health or research justification for retaining the identifiers or such retention is otherwise required by law); and (c) adequate written assurances that the PHI will not be re-used or disclosed to any other person or entity (except as required by law) for authorized oversight of the research study, or for other research for which the use or disclosure would otherwise be permitted;
- The research could not practicably be conducted without the waiver; and
- The research could not practicably be conducted without access to and use of the PHI.
Serious threats to health or safety. Our practice may use and disclose your PHI when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. Under these circumstances, we will only make disclosures to a person or organization able to help prevent the threat.
Military. Our practice may disclose your PHI if you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate authorities.
National security. Our practice may disclose your PHI to federal officials for intelligence and national security activities authorized by law. We also may disclose your PHI to federal and national security activities authorized by law. We also may disclose your PHI to federal officials in order to protect the president, other officials or foreign heads of state, or to conduct investigations.
Inmates. Our practice may disclose your PHI to correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official. Disclosure for these purposes would be necessary: (a) for the institution to provide health care services to you, (b) for the safety and security of the institution, and/or (c) to protect your health and safety or the health and safety of other individuals.
Workers’ compensation. Our practice may release your PHI for workers’ compensation and similar programs.
Change of Ownership. In the event that our practice is sold or merged with another organization, your medical record will become the property of the new owner, although you will maintain the right to request that copies of your health information be transferred to another physician or medical group.
De-Identified Data. We may use or share your PHI once it has been “de-identified.” PHI is considered de-identified when it has been processed in such a way that it can no longer personally identify you.
Limited Data Sets. We may also use a “limited data set” that does not contain any information that can directly identify you. This limited data set may only be used for the purposes of research, public health matters or health care operations. For example, a limited data set may include your city, county and zip code, but not your name or street address.

G. Receiving PHI from providers, insurance entities and their business associates:

We want to make you aware that, just as Crossover Health Medical Group uses and discloses certain PHI in your treatment, our operations and management and certain payment practices, Crossover Health Medical Group receives PHI from other healthcare entities and their business associates including but not limited to: medical files, charts, laboratory testing results, imagining results, and insurance claims data. PHI that is received and maintained by Crossover Health Medical Group from outside entities is subject to the protections of relevant law and our HIPAA and HITECH policy.

H. Your written permission:

Except as described in this Notice, or as otherwise permitted by law, we must obtain your written permission – called an authorization – prior to using or sharing health information that identifies you as an individual. If you provide an authorization and then change your mind, you may revoke your authorization in writing at any time. Once an authorization has been revoked, we will no longer use or share your health information as outlined in the authorization form; however you should be aware that we won’t be able to retract a use or disclosure that was previously made in good faith based on what was then a valid authorization from you.

Except as specified above under the applicable state law of the practice location, we may not share your health information with your employer or benefit plan unless you provide us an authorization to do so.

I. Other Restrictions:

Under the applicable state law of the practice location, there may be additional laws regarding the use and disclosure of health information related to HIV status, communicable diseases, reproductive health, genetic test results, substance abuse, mental health and mental retardation. Generally, we will be bound by whatever law is more stringent and provides more protection for your privacy.

J. Your rights regarding your PHI:

You have the following rights regarding the PHI that we maintain about you:

Confidential communications. You have the right to request that our practice communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than work. In order to request a type of confidential communication, you must make a written request to Crossover Health Medical Group, 101 W. Avenida Vista Hermosa Ste. 120, San Clemente, CA 92672 and inform us of the requested method of contact, or the location where you wish to be contacted. Our practice will accommodate reasonable requests. You do not need to give a reason for your request.
Requesting restrictions. You have the right to request a restriction in our use or disclosure of your PHI for treatment, payment or health care operations. Additionally, you have the right to request that we restrict our disclosure of your PHI to only certain individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies or when the information is necessary to treat you. In order to request a restriction in our use or disclosure of your PHI, you must make your request in writing to Crossover Health Medical Group, 101 W. Avenida Vista Hermosa Ste. 120, San Clemente, CA 92672.
Your request must describe in a clear and concise fashion:
- The information you wish restricted;
- Whether you are requesting to limit our practice’s use, disclosure or both; and/or
- To whom you want the limits to apply.
Inspection and copies. You have the right to inspect and obtain a copy of the PHI that may be used to make decisions about you, including patient medical records and billing records, but not including psychotherapy notes. You must submit your request in writing to Crossover Health Medical Group, 101 W. Avenida Vista Hermosa Ste. 120, San Clemente, CA 92672 in order to inspect and/or obtain a copy of your PHI. Our practice may charge a fee for the costs of copying, mailing, labor and supplies associated with your request. Our practice may deny your request to inspect and/or copy in certain limited circumstances; however, you may request a review of our denial. Another licensed health care professional chosen by us will conduct reviews.
Amendment. You may ask us to amend your health information if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by or for our practice. To request an amendment, your request must be made in writing and submitted to Crossover Health Medical Group, 101 W. Avenida Vista Hermosa Ste. 120, San Clemente, CA 92672.
You must provide us with a reason that supports your request for amendment. Our practice will deny your request if you fail to submit your request (and the reason supporting your request) in writing. Also, we may deny your request if you ask us to amend information that is in our opinion: (a) accurate and complete; (b) not part of the PHI kept by or for the practice; (c) not part of the PHI which you would be permitted to inspect and copy; or (d) not created by our practice, unless the individual or entity that created the information is not available to amend the information.
Accounting of disclosures. All of our patients have the right to request an “accounting of disclosures.” An “accounting of disclosures” is a list of certain non-routine disclosures our practice has made of your PHI for purposes not related to treatment, payment or operations. Use of your PHI as part of the routine patient care in our practice is not required to be documented – for example, the doctor sharing information with the nurse; or the billing department using your information to file your insurance claim. In order to obtain an accounting of disclosures, you must submit your request in writing to Crossover Health Medical Group, 101 W. Avenida Vista Hermosa Ste. 120, San Clemente, CA 92672.
All requests for an “accounting of disclosures” must state a time period, which may not be longer than six (6) years from the date of disclosure. The first list you request within a 12-month period is free of charge, but our practice may charge you for additional lists within the same 12-month period. Our practice will notify you of the costs involved with additional requests, and you may withdraw your request before you incur any costs.
Right to a paper copy of this notice. You are entitled to receive a paper copy of our Notice. You may ask us to give you a copy of this Notice at any time. To obtain a paper copy of this Notice, contact Crossover Health Medical Group at (949) 891-0328.
Right to file a complaint. If you believe your privacy rights have been violated, you may file a complaint with our practice or with the Secretary of the Department of Health and Human Services. To file a complaint with our practice, contact Crossover Health Medical Group, 101 W. Avenida Vista Hermosa Ste. 120, San Clemente, CA 92672. All complaints must be submitted in writing. You will not be penalized for filing a complaint.
Right to provide an authorization for other uses and disclosures. Our practice will obtain your written authorization for uses and disclosures that are not identified by this Notice or permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your PHI may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your PHI for the reasons described in the authorization. Please note: we are required to retain records of your care.

Again, if you have any questions regarding this Notice or our health information privacy policies, please contact Crossover Health Medical Group at (949) 891-0328.

I acknowledge that I have received the Notice of Privacy Practices for Crossover Health Medical Group, and have been provided an opportunity to review it. If you have any questions or would like a hard copy of this Notice, please ask for one at the front desk or contact Crossover Health Medical Group at (949) 891-0328.

GENERAL CONSENT

I hereby give my consent for Crossover Health Medical Group to receive, use and disclose Protected Health Information (“PHI”) about me, including but not limited to medical charts, records, laboratory results, imaging results, insurance claims data and information, to carry out treatment, payment and health care operation (“TPO”) as described in the Notice of Privacy Practices. I recognize the need for medical care; authorize the Crossover Health Medical Group to render such medical and ancillary care, tests, procedures, drugs and other services and supplies under the general and specific instruction of the Crossover Health Medical Group. Except for emergency or extraordinary circumstances, it is my understanding that additional consents will be obtained by my treating physician if more invasive services are to be performed or if additional consents or authorizations are required by law. I understand and am aware that the practice of medicine is not an exact science and acknowledge that no guarantee has been made to me as to the result of treatment or examination. I understand that it is my right to consent, or to refuse consent, to any proposed procedure or therapeutic course.

I understand that Crossover Health Medical Group uses advanced technology to deliver quality care, and I consent to the use of this technology. If you have any questions regarding the technology used by Crossover Health Medical Group, please contact Crossover Health Medical Group at (949) 891-0328.

Also, with this consent Crossover Health Medical Group 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.
Mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards, patient statements, and any items pertaining to my clinical care, including laboratory test results, among others.
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, patient statements, and any items pertaining to my clinical care, including laboratory test results, among others.

CONSENT FOR ANCILLARY SERVICES

Please read this entire document prior to agreeing to it. It is important that you understand the information contained in this document. Please ask questions before you sign if there is anything that is unclear.

If receiving Physical Therapy Services

The nature of physical therapy. Physical therapy involves the use of many different types of physical evaluation and treatment. We use a variety of procedures and modalities that can be used to help us to try and improve your function. As with all forms of medical treatment, there are benefits and risks involved with physical therapy.

Analysis / Examination / Treatment. As a part of the analysis, examination, and treatment, you are consenting to the following possible procedures: therapeutic exercise, massage therapy, electrical stimulation, range of motion testing, orthopedic testing, muscle strength testing, postural analysis, testing, ultrasound, and heat/cold therapy.

The material risks inherent in physical therapy services. Therapeutic manipulation and exercises are an integral part of most physical therapy treatment plans. This manipulation and these exercises have inherent physical risks associated with them. If you have any questions regarding the type of exercise you are performing and any specific risks associated with your exercises or the manipulations, your therapist will be glad to answer them.

If receiving Chiropractic Services

The nature of the chiropractic adjustment. The primary treatment used by the Crossover Chiropractor is spinal manipulative therapy. The Crossover Chiropractor may use his or her hands or a mechanical instrument upon your body in such a way as to move your joints. That may cause an audible “pop” or “click,” much as you have experienced when you “crack” your knuckles. You may feel a sense of movement.

Analysis / Examination / Treatment. As a part of the analysis, examination, and treatment, you are consenting to the following possible procedures: spinal manipulative therapy; palpation; vital signs; range of motion testing; orthopedic testing; basic neurological testing; muscle strength testing; postural analysis; testing; ultrasound; hot/cold therapy; EMS; and radiographic studies.

The material risks inherent in chiropractic adjustment. As with any health care procedure, there are certain complications which may arise during chiropractic manipulation and therapy. These complications include but are not limited to: fractures, disc injuries, dislocations, muscle strain, cervical myelopathy, costovertebral strains and separations, and burns. Some types of manipulation of the neck have been associated with injuries to the arteries in the neck leading to or contributing to serious complications including stroke. Some patients will feel some stiffness and soreness following the first few days of treatment. The Crossover Chiropractor will make every reasonable effort during the examination to screen for contraindications to care; however, if you have a condition that would otherwise not come to our attention, it is your responsibility to inform us.

The probability of those risks occurring. Fractures are rare occurrences and generally result from some underlying weakness of the bone which will be checked for during the taking of your history and during examination and X-ray. Stroke has been the subject of tremendous disagreement. The incidences of stroke are exceedingly rare and are estimated to occur between one in one million and one in five million cervical adjustments. The other complications are also generally described as rare.

The potential benefits of chiropractic adjustment. The vast majority of chiropractic patients tend to achieve improvement in their physical conditions with chiropractic care. Improvement can be measured in many different ways, including reduction in pain, increased range of motion, less stiffness, increased athletic performance, and other ways. It must be remembered that different people get different results; different people have different pre- existing conditions, and are of different ages and occupations (with different types of physical stress). Your situation is unique, and no guarantees are given. You will have to determine what results you get for yourself.

The availability and nature of other treatment options. Other treatment options for your condition may include: rest, acupuncture, physical therapy, medical care, medications (both over the counter and prescribed), hospitalization, surgery, and others.

If you chose to use one of the above noted “other treatment” options, you should be aware that there are risks and benefits of such options and you may wish to discuss these with your primary medical physician.

The risks and dangers attendant to remaining untreated. Remaining untreated may allow the formation of adhesions and reduce mobility which may set up a pain reaction further reducing mobility. Over time this process may complicate treatment making it more difficult and less effective the longer it is postponed.

If receiving Acupuncture Services

Analysis / Examination / Treatment. As a part of the analysis, examination, and treatment, you are consenting to the following possible procedures: acupuncture; Tui-Na (Chinese massage); moxibustion; Chinese herbal medicine; cupping; scraping techniques (i.e., Gua Sha); nutritional and lifestyle counseling; and electrical stimulation.

You understand that herbs may need to be prepared and the teas consumed according to the instructions provided orally and in writing. The herbs may have an unpleasant smell or taste. You will immediately notify us of any unanticipated or unpleasant effects associated with the consumption of the herbs.

The material risks inherent in acupuncture. You have been informed that acupuncture is a generally safe method of treatment, but that it may have some side effects, including bruising, numbness, swelling, or tingling near the needling sites that may last a few days, and dizziness or fainting. Bruising is a common side effect of cupping and Gua Sha/scraping. Unusual risks of acupuncture include spontaneous miscarriage, nerve damage and organ puncture, including lung puncture (pneumothorax). Although Crossover Acupuncturists use sterile disposable needles and maintain a clean and safe environment, infection is another possible risk. Burns and/or scarring are a potential risk of moxibustion and cupping. You understand that while this document describes the major risks of treatment, other side effects and risks may occur. The herbs and nutritional supplements (which are from plant, animal and mineral sources) that have been recommended are traditionally considered safe in the practice of Chinese Medicine, although some may be toxic in large doses. You understand that some herbs may be inappropriate during pregnancy. Some possible side effects of taking herbs are nausea, gas, stomach ache, vomiting, headache, diarrhea, rashes, hives, and tingling of the tongue. You will notify the clinical member of Crossover who is caring for you if you are or become pregnant, or are actively trying to conceive.

If receiving Massage Therapy Services

The nature of massage therapy. Massage therapy involves the rubbing and kneading of muscles and joints of the body. During your session, your body will be draped at all times for comfort, security and warmth. Massage therapy is for the purpose of stress reduction, pain reduction, relief from muscle tension, and increasing circulation.

Analysis / Examination / Treatment. As a part of the analysis, examination, and treatment, you are consenting to the following possible procedures: massage therapy procedures and techniques and heat/cold therapy.

The material risks inherent in massage therapy services. You have been informed that massage therapy is safe, but that it may have some side effects, particularly with deep tissue massage, the influx of toxins such as lactic acid from your muscles can cause nausea, vomiting or soreness. These side effects are rare and should subside relatively quickly. However, Crossover’s Massage Therapist does not diagnose illness or disease, or any other disorder. Massage therapy is not a substitute for medical examinations or medical care, and it is recommended that you are concurrently working with your primary physician for any condition you may have.

The probability of those risks occurring. Since the physical responses to a specific treatment can vary widely from person to person, it is not always possible to accurately predict your response to a certain treatment. We are not able to guarantee precisely what your reaction to a particular treatment might be, nor can we guarantee that our treatment will help the condition for which you are seeking treatment. There is also a risk that your treatment may cause pain or injury, or may aggravate previously existing conditions. Because massage should not be performed under certain medical conditions, you must inform your massage therapist of all your known physical conditions, medical conditions, and medications and keep the massage therapist updated of any changes. If you experience any pain or discomfort during the session, you will immediately inform the massage therapist of any discomfort, so the application of pressure or strokes may be adjusted accordingly to fit your level of comfort.

You have the right to ask your massage therapist what type of massage he or she is planning to perform based on your history, diagnosis, and symptoms. You may also discuss with your massage therapist what the potential risks and benefits of a specific massage or treatment might be. You have the right to request and require that any procedure or technique be modified, changed or stopped. You also have the right to have any part of your body not massaged (please let the therapist know). You have the right to decline any portion of your treatment at any time or during your treatment session.

If receiving Health Coaching Services

Analysis / Examination / Treatment. As a part of the analysis, examination, and treatment, you are consenting to the following possible procedures: consultation and guidance about health factors within your own control such as your diet, nutrition, lifestyle, and nutritional evaluation or testing.

The material risks inherent in nutritional counseling. You have been informed that nutritional counseling is safe. However, you understand that the Crossover Dietitian/Health Coach is a Health Coach or Registered Dietitian not a medical physician and does not dispense medical advice, nor will the Crossover Health Coach/Dietitian diagnose or treat any medical condition but will provide nutrition and lifestyle support and education for an already diagnosed condition. The Crossover Health Coach/Dietitian may provide education to enhance knowledge of health through the use of whole foods, lifestyle education on the benefits of movement, sleep and stress management and emotional awareness. While nutrition and lifestyle coaching can be an important complement to medical care, you understand these services are not a substitute for medical care.

Methods of nutrition and lifestyle evaluation or testing made available to you are not intended to diagnose disease. Rather, these assessment tests are intended as a guide to developing an appropriate health-supportive program for you, and to monitor your progress in achieving goals.

Understand that the Crossover Health Coach/Dietitian will keep notes as a record of your work together. These notes document the topics that you talk about, interventions used, and treatment plans or any other considerations that may be helpful to your work with your health coach/dietitian. Records will be stored in a secure location.

Medical records, personal information and history divulged in session to the Crossover Health Coach/Dietitian will be kept strictly confidential unless you consent to sharing your medical and nutritional information by way of a signed release.

The probability of those risks or benefits occurring. Since the health factors are within your own control, the probability of the desired outcomes can vary widely from person to person, it is not always possible to accurately predict your response to a certain nutrition or lifestyle program. We are not able to guarantee precisely what your results might be, nor can we guarantee that our consultation and evaluation will help the condition for which you are seeking treatment.

If receiving Behavioral Health Counseling and Therapy Services

The nature of couples counseling, family counseling and psychotherapy. Therapy works best when you are an active partner in the process, so please know that Crossover Therapists/Counselors welcome your feedback or questions about our work at any time.

The material beneﬁts inherent in therapy. Participating in therapy may result in beneﬁts including, but not limited to: reduced stress and anxiety; a decrease in negative thoughts and self-sabotaging behaviors; improved interpersonal relationships; increased comfort in social, work, and family settings; increased capacity for intimacy; increased self-conﬁdence and ability to experience life more fully; and deeper self-awareness and self- acceptance. Such beneﬁts may require substantial effort on your part, including active participation in the therapeutic process, honesty, and a willingness to change feelings, thoughts and behaviors as needed. There is no guarantee that therapy will yield any or all of the beneﬁts listed above.

The material risks inherent in therapy. Participating in therapy may involve discomfort, including discussing difﬁcult feelings and experiences, and may evoke strong emotions, including anger, sadness, and fear. During the therapeutic process, many clients ﬁnd that they may feel worse before they feel better. This is generally a normal course of events. Personal growth and change may be easy and swift at times while slow or frustrating at other times. You may also at times feel conﬂicted about attending sessions. If this is the case, we urge you to bring up your concerns so that we can address them. The process of therapy may sometimes result in unanticipated outcomes, such as changes in personal or career relationships and goals. Please be aware that any decisions about your relationships, personal life, or work life are your responsibility.

Conﬁdentiality. Therapy is designed to be a safe place for you to talk about any personal issues you choose to explore. The information disclosed by you is generally conﬁdential and will not be released to any third party outside of the Crossover Health Center without written authorization from you, except where required or permitted by law. This means that we will not divulge anything you tell us to anyone except in either of the following conditions:

You give us your permission to talk to another provider, pursuant to the Crossover Notices of Privacy Practices, such as a health-care professional who is providing you treatment.
You tell us something that your counselor is legally required to reveal to others.
Professional consultation is an important component of a healthy psychotherapy practice. As such, your therapist regularly participates in clinical, ethical, and legal consultation with appropriate professionals. During such consultations, your therapist will not reveal any of your personally identifying information.

Your therapist may take notes during a session, and will also produce other notes and records regarding treatment. These notes constitute clinical and business records, which by law, your therapist is required to maintain. Your therapist will not alter his/her normal record keeping process at the request of any patient. Any request of a copy of your records must be made in writing and done pursuant to the Crossover Notice of Privacy Practices. Your therapist may also reserve the right to refuse to produce a copy of the record under certain circumstances. As with all your medical records, your behavioral health records are securely stored and separate from your employment records. Patient conﬁdentiality includes a ﬁrewall between Crossover Health and your employer. As part of our integrated approach to whole person health and wellness, all providers within the health center have access to the electronic medical record, and will consult across disciplines to deliver the best possible care. This will occur exclusively on a need to know basis for the purpose of continuity and coordination of care.

If you are seeing us for couples therapy or family therapy, we consider your relationship or the family unit to be the patient. During the course of our work, we may see one individual or multiple individuals for one or more sessions or for part of a session.

These sessions should be seen as part of the work that we are doing with the couple or family, unless otherwise indicated. However, please know that anything we discuss when your partner or other family members are not present may be disclosed to them if, in the best judgment of your therapist, doing so is necessary to effectively help your relationship or family unit. This “no secrets” policy is intended to allow your therapist to continue to treat the patient (the couple or family unit) by preventing, to the extent possible, a conﬂict of interest to arise where an individual’s interests may not be consistent with the interests of the unit being treated. For instance, information learned in the course of an individual session may be relevant or even essential to the proper treatment of the couple or the family. Other than that, your therapist will not disclose conﬁdential information about your treatment to anyone else unless all persons who participated in the treatment provide written authorization to release such information.

Psychotherapist-patient privilege. The information disclosed by you, as well as any records created, is subject to the psychotherapist-patient privilege. The psychotherapist-patient privilege results from the special relationship between a therapist and a patient in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient privilege. Typically, the patient is the holder of the psychotherapist-patient privilege. If your therapist receives a subpoena for records, deposition testimony, or testimony in a court of law, your therapist will assert the psychotherapist-patient privilege on your behalf until instructed, in writing, to do otherwise by you or your representative. You should be aware that you might be waiving the psychotherapist-patient privilege if you make your mental or emotional state an issue in a legal proceeding. You should address any concerns you might have regarding the psychotherapist-patient privilege with your attorney.

Patient litigation. Your therapist will not voluntarily participate in any litigation, or custody dispute in which you and another individual, or entity, are parties. Your therapist has a policy of not communicating with your attorney and will generally not write or sign letters, reports, declarations, or afﬁdavits to be used in your legal matter. Your therapist will generally not provide records or testimony unless compelled to do so. Should your therapist be subpoenaed, or ordered by a court of law, to appear as a witness in an action involving you, you agree to reimburse Crossover for any time spent for preparation, travel, or other time in which your therapist has made him/herself available for such an appearance at present customary rates.

Completion of therapy. The length of your therapy depends on the speciﬁcs of your situation and the progress achieved. As the completion of your goals is approaching, your therapist will discuss with you a plan for ending therapy. If during therapy you come to feel that the issues for which you are seeking therapy are not being satisfactorily addressed and you wish to see another therapist, referrals to other therapists will be given to you to assist in a smooth transition if you desire. If it becomes clear that you are not beneﬁtting from the therapy, your therapist is ethically bound to stop treating you and will provide you with referrals to other sources for therapy.

You have the right to ask your counselor what type of treatment he or she is planning based on your history, diagnosis, symptoms and testing results. You may also discuss with your therapist/counselor what the potential risks and beneﬁts of a speciﬁc treatment might be. You have the right to decline any portion of your treatment at any time or during your treatment session.

Your therapist reserves the right to terminate therapy at his/her discretion. Reasons for termination include, but are not limited to, failure to comply with treatment recommendations, conﬂicts of interest, and failure to participate in therapy, your needs are outside of your therapist’s scope of competence or practice, or you are not making adequate progress in therapy. You have the right to terminate therapy at your discretion. Should you choose to end your therapy, one ﬁnal visit is generally recommended to facilitate a positive termination experience and give an opportunity to reﬂect on the work that has been done. Your therapist will also attempt to ensure a smooth transition to another therapist by offering referrals to you as appropriate to your needs at the point of termination.

In addition, you agree that you do not expect the clinical staff to be able to anticipate and explain all possible risks and complications of treatment, and you wish to rely on the clinical staff to exercise judgment during the course of treatment, which the clinical staff thinks at the time, based upon the facts then known, is in your best interest. You understand that results are not guaranteed.

Scope of Services. Testing, forensic or court ordered counseling, education or learning disabilities, and custody evaluations are not covered as part of the services provided in the health center. Licensure. Your therapist/counselor is licensed as a mental health professional, and will provide you with licensure information at your request.

Emergency and After Hours. Circumstances may arise when immediate assistance is required. Your therapist’s ofﬁce is equipped with a conﬁdential voice mail system that allows you to leave a message at any time. Your therapist will make every effort to return calls within 24 hours (or by the next business day), but cannot guarantee the calls will be returned immediately. Crossover is unable to provide 24-hour crisis service. In the event that you are feeling unsafe or require immediate medical or psychiatric assistance, you should call 911, or go to the nearest emergency room.

If receiving Optometric Services

The nature of the optometric services. Optometric services can involve eye examinations for health and vision problems, pupillary dilation, and vision testing for prescription glasses or contact lens. A variety of tests and procedures can be used to help the clinical staff determine patient eye health and vision correction needs.

Analysis / Examination / Treatment. As a part of the analysis, examination, and treatment, you are consenting to the following possible procedures: pupillary dilation; vision testing; retinal photography, glaucoma screening and eye examination.

The material risks inherent in optometric services. The majority of examinations and procedures are pain-free and relatively easy. Objects such as lens and medical equipment may come in close contact with the eyes during certain examinations. Pupillary dilation is pain-free, relatively easy, with minimal after effects. Evaluation of the retina/fundus without pupillary dilation may allow for sight and/or life threatening disease, hemorrhages, tumors, etc., to go undetected. Most patients suffer no loss of distance vision from the dilation drops, however, some experience a mild decrease. Near vision (arm length and closer) will be blurred 2-4 hours afterwards. Bright lights and sunshine may be bothersome and a slight headache may occur. We will supply a pair of sunglasses if you did not bring your sun wear with you. Special precaution is recommended for driving, operation of heavy equipment, and in few cases, even walking.

The probability of those risks occurring. Less than 1 in 40,000 patients suffer serious side effects from dilating drops. The symptoms are usually eye pain, intense headache and possible nausea and may not start immediately. If after leaving the office, you experience eye pain, cloudy or steamy vision or severe headache, call us immediately.

You have the right to ask your optometrist what type of treatment he or she is planning based on your history, diagnosis, symptoms and testing results. You may also discuss with your optometrist what the potential risks and benefits of a specific treatment might be. You have the right to decline any portion of your treatment at any time or during your treatment session.

If receiving Virtual Services

Crossover provides virtual services, meaning you may not always see your provider in-person but rather will interact and receive care via certain available technologies included in the Crossover Health Virtual technology (“XOV”), as described below.

If you choose to receive virtual services via XOV, you should be aware of certain important information:

The information obtained via XOV may be used for diagnosis, therapy, follow-up and/or education, and may include any of the following care delivery methods:

Live 2-way audio and video technology
Store-and-forward technology
Medical images
Patient medical records
Output data from medical devices and sound and video files

XOV will incorporate network and software security protocols designed to protect the confidentiality of patient identification and imaging data and will include measures designed to safeguard the data and to protect its integrity against intentional or unintentional corruption.

Responsibility for patient care should remain with your local primary care clinician, if you have one, as should your patient medical records. However, if you choose to receive virtual care via XOV, you will receive such care as permitted in your state, and Crossover will maintain medical records and will provide them to your primary care provided as requested or required.

Prior to care being delivered via XOV, your Care Team Provider/s will ensure that the services and care delivery method/s are appropriate for management of your healthcare. Accordingly, all services may not be available virtually.

Below are the benefits and risks associated with virtual care:

Expected Benefits:

Improved access to medical care by enabling a patient to remain in his/her local healthcare site (e.g. home) while the physician consults and obtains test results at distant/other sites; Efficient medical evaluation and management; and Obtaining expertise of a specialist that may be difficult to obtain in person.

Possible Risks:

As with any medical procedure, there are potential risks associated with the use of virtual care via XOV. These risks include, but may not be limited to:

In rare cases, information transmitted regarding your physical condition may not be sufficient (e.g., poor resolution of images) to allow for appropriate health care decision making by the healthcare provider, thus necessitating a face-to-face meeting with the patient, or at least a rescheduled video consult; Delays in evaluation or treatment could occur due to failures of the telehealth equipment. If this happens, you may be contacted by phone or other means of communication by the healthcare provider; In rare cases, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors; and Although the electronic systems we use will incorporate network and software security protocols to protect the privacy and security of health information, in rare instances, security protocols could fail, causing a breach of privacy of your personal health information.

By signing this overall document below, you acknowledge that you understand and agree with the following:

I understand that the laws that protect privacy and the confidentiality of medical information also apply to virtual care and XOV, and that no information obtained in the use of XOV, which identifies me, will be disclosed to researchers or other entities without my written consent or as outlined in the Notice of Privacy Practices. I have access to all of my personal medical information pertaining to virtual care via XOV in accordance with applicable laws and regulations.

I understand that I have the right to withhold or withdraw my consent to the use of XOV in the course of my care at any time, without affecting my right to future care or treatment.

I understand the alternatives to receiving virtual care via XOV as they have been explained to me, and I choose to proceed with a virtual care consultation at this time. I understand that in choosing to participate in an XOV consultation some parts of the exam involving physical tests may be conducted by individuals at my location, or at a testing facility, at the direction of a consulting healthcare provider.

I understand that XOV may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas, including out of state.

I understand that I may expect the anticipated benefits from the use of XOV in my care, but that no results can be guaranteed or assured. I may need to see an appropriately trained healthcare profession in person after my virtual care visit via XOV should the need arise.

I understand that my healthcare information may be shared with other individuals for scheduling, treatment, payment, billing and healthcare operations purposes. Others may also be present during the consultation other than my healthcare provider and consulting healthcare provider in order to operate XOV. These individuals will all maintain confidentiality of the information obtained. I further understand that I will be informed of an individual’s presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history/physical examination that are personally sensitive to me; (2) ask non-medical personnel to leave during the examination; and/or (3) terminate the consultation at any time.

I have read and understand the information provided above regarding use of virtual care via XOV, and all of my questions have been answered to my satisfaction. I have also read this document carefully, and understand the risks and benefits of virtual care via XOV and have had my questions regarding the care methods and technologies explained. By signing this patient registration, including this specific informed consent for virtual services via the Crossover Platform below, I hereby state that I have read, understood, consent to receive virtual care via XOV.

DO NOT SIGN UNTIL YOU HAVE READ AND UNDERSTAND THE ABOVE.

You have the right to ask your Provider what type of treatment he or she is planning based on your history, diagnosis, symptoms and testing results. You may also discuss with your Provider what the potential risks and benefits of a specific treatment might be. You have the right to decline any portion of your treatment at any time or during your treatment session.

I have read or have had read to me the above explanation of the proposed ancillary services treatment. I have discussed it with my Crossover Provider and have had my questions answered to my satisfaction. By signing below I state that I have weighed the risks involved in undergoing treatment and have decided that it is in my best interest to undergo the treatment recommended. Having been informed of the risks, I hereby give my consent to treatment. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment.

PATIENT RIGHTS AND RESPONSIBILITIES

As a partner in my health care, I have the following rights:

The right to be treated with respect, consideration, and dignity.
The right to appropriate privacy while receiving care from Crossover Health Medical Group.
The right to be provided, to the degree known, information concerning diagnosis, evaluation, treatment, and prognosis. When it is medically inadvisable to provide such information to me, the information will be provided to a person designated by me or to a legally authorized person.
The right to be provided an opportunity to participate in decisions involving my health care, except when such participation is contraindicated for medical reasons.
The right to change providers if other qualified providers are available.
The right to file a complaint or provide feedback regarding my care. To file a complaint with our practice, contact Crossover Health Medical Group, 101 W. Avenida Vista Hermosa Ste. 120, San Clemente, CA 92672. All complaints must be submitted in writing. You will not be penalized for filing a complaint. It is your right.
The right to consent to or to refuse any treatment or procedure or refuse to participate in research.
When the need arises, a reasonable attempt will be made for health care professionals and other staff to communicate in the language or manner primarily used by me.
The right to the following information:
- Services available from Crossover Health Medical Group.
- Provisions for after-hours and emergency care.
- Fees for services.
- Payment policies.
- Advance directives, as required by state or federal law and regulations.
- The credentials of my health care provider.
- The existence of malpractice insurance.
As a partner in my health care, I have the following responsibilities:
- I will provide accurate health information to my health care provider about any conditions that I may have and any medications, including over-the-counter products and dietary supplements I am taking, and any allergies or sensitivities that I may have.
- I will schedule routine physical exams and other health maintenance exams recommended to me by my health care provider (pap smear, mammogram, bone density, colonoscopy, routine blood tests, immunizations, etc.). I put myself at risk for not detecting other medical diseases if I only see my health care provider for immediate problems. I will make appointments with my health care provider to discuss routine health screenings.
- I will follow treatment plans recommended to me by my health care provider, including completing testing, making an appointment with a specialist, and taking my medications. I will participate in my treatment plan and be sure to clearly comprehend any treatment plan. I will ask questions when I do not understand. I understand that not following my treatment plans may put my health at risk.
- I will keep my appointments and reschedule any missed appointments. I understand that my health care provider schedules these appointments to follow up on my response to treatment and to monitor my medical conditions. During these appointments, my health care provider may order tests, refer me to a specialist, change my medications, and diagnose a medical problem. If I do not follow up, I may put my health at risk and may have medical conditions go undetected.
- I understand that the goal of Crossover Health Medical Group is to provide me with test results in a timely fashion. If I do not hear from Crossover Health Medical Group, I will call the office for test results. I understand that not hearing from the office about a particular test does not necessarily mean that the test result is normal.
- I will inform my health care provider if my medical condition changes, does not improve, or worsens. This will allow my health care provider to re-evaluate my condition and make changes in treatment. If I do not inform my health care provider, I may put my health at risk.
- I will take charge of my health and try to make positive choices for my health including not smoking, not using illegal drugs, eating a healthy diet, and getting appropriate exercise.
- I will take responsibility to understand the services provided by Crossover Health Medical Group and its limitations, and will ask Crossover Health Medical Group if I have any questions.
- I will provide a responsible adult to transport me home from the Wellness Center and who will remain with me for twenty-four (24) hours, if required by my healthcare provider.
- I will accept personal financial responsibility for any charges not covered by my insurance. I will ask questions if I have any regarding coverage of services.
- I will be respectful of all the health care professionals and staff, as well as other patients.
MISCELLANEOUS PROVISIONS
- Indemnity. You agree to indemnify, defend and hold harmless Crossover Health Medical Group and their respective affiliates from and against all losses, liability, expenses, damages and costs, including reasonable attorney’s fees, arising out of or related to any breach of this agreement, any negligent or wrongful action or omission by you related to your use of services through Crossover Health Medical Group, or any negligent or wrongful use of the Crossover Health Medical Group services (including, without limitation, infringement of third party intellectual property rights or negligent or wrongful conduct).
- Severability. The provisions of this Agreement are severable, and in the event any provision hereof is determined to be invalid or unenforceable, such invalidity or unenforceability shall not affect the validity or enforceability of the remaining provisions, but such provision shall be reformed, if reasonably possible, only to the extent necessary to make it enforceable.
- Entire Agreement. This Agreement, together with any Crossover Health Medical Group rules or policies referred to herein, represents the complete agreement between you and Crossover Health concerning the subject matter hereof, and it replaces all prior oral or written communications concerning such subject matter. Crossover Health Medical Group may modify this Agreement as permitted by law.
- Assignment. You may not assign, transfer or delegate this Agreement or any part of it without Crossover Health Medical Group’s prior written consent. Crossover Health Medical Group may freely transfer, assign or delegate all or any part of this Agreement, and any rights and duties hereunder. The Agreement will be binding upon and inure to the benefit of the heirs, successors and permitted assignees of the parties.
- Waiver. Failure to exercise or delay in exercising any right hereunder, or failure to insist upon or enforce strict performance of any provision of this Agreement, shall not be considered waiver thereof, which can only be made by signed writing. No single waiver shall be considered a continuing or permanent waiver.
- Governing Law. This Agreement shall be governed by and construed in accordance with the laws of the state where the services are provided without giving effect to any choice of law rules or principles. Any cause of action or claim you may have with respect to Crossover Health Medical Group must be commenced within one (1) year after it arises, except to the extent such limitation is not enforceable. To the fullest extent permitted by law, each party to this Agreement waives its or his or her right to a jury trial with respect to any dispute or other controversy arising from hereunder.

For California residents:

NOTICE TO CONSUMERS

Medical doctors are licensed and regulated by the Medical Board of California.

(800) 633-2322
www.mbc.ca.gov

For Texas residents:

NOTICE CONCERNING COMPLAINTS

Complaints about physicians, as well as other licensees and registrants of the Texas Medical Board, including physician assistants, acupuncturists, and surgical assistants may be reported for investigation at the following address:

Texas Medical Board
Attention: Investigations
333 Guadalupe, Tower 3, Suite 610
P.O. Box 2018, MC-263
Austin, Texas 78768-2018

Assistance in filing a complaint is available by calling the following telephone number: 1-800-201-9353. For more information please visit our website at www.tmb.state.tx.us

For Washington residents:

Complaints about physicians, as well as other licensees and registrants of the Washington Medical Board, including physician assistants, acupuncturists, and surgical assistants may be reported for investigation at the following address:

Washington State Department of Health
Phone: (360) 236-4700 www.doh.wa.gov

For New York residents:

Complaints about physicians, as well as other licensees and registrants of the New York Medical Board, including physician assistants, acupuncturists, and surgical assistants may be reported for investigation at the following address:

New York State Education Department
Phone: (518) 474-3852 http://www.nysed.gov