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Terms & Conditions and Consent for Treatment

Professional Health Awareness Corporation


HealthAzure, Inc. and/or WeLuvUs (dba) Integrative Apothecary and associates are required, by law, to maintain the privacy and confidentiality of your protected health information and to provide our patients with notice of our legal duties and privacy practices with respect to your protected health information.

Disclosure of Your Health Care Information


We may disclose your health care information to other healthcare professionals within our practice for the purpose of treatment, payment or healthcare operations.

“On occasion, it may be necessary to seek consultation regarding your condition from other health care providers associated within the WeLuvUs Integrative Apothecary Group.”

“It is our policy to provide a substitute health care provider, authorized by WeLuvUs to provide assessment and/or treatment to our patients, without advanced notice, in the event of your primary health care provider’s absence due to vacation, sickness, or other emergency situation.”


We may disclose your health information to your insurance provider for the purpose of payment or health care operations.

“If you pay for your health care services personally, we will, as a courtesy, provide an itemized billing for your insurance carrier on the purpose of reimbursement to you. The billing statement contains medical information, including diagnosis, date of injury or condition, and codes which describe the health care services received. Payment for health care services are rendered upfront..”

Workers’ Compensation

We may disclose your health information as necessary to comply with State Workers’ Compensation Laws.


We may disclose your health information to notify or assist in notifying a family member, or another person responsible for your care about your medical condition or in the event of an emergency or of your death.

Public Health

As required by law, we may disclose your health information to public health authorities for purposes related to: preventing or controlling disease, injury or disability, reporting child abuse or neglect, reporting domestic violence, reporting to the Food and Drug Administration problems with products and reactions to medications, and reporting disease or infection exposure.

Judicial and Administrative Proceedings

We may disclose your health information in the course of any administrative or judicial proceeding.

Law Enforcement

We may disclose your health information to a law enforcement official for purposes such as identifying or locating a suspect, fugitive, material witness or missing person, complying with a court order or subpoena, and other law enforcement purposes.

Deceased Persons

We may disclose your health information to coroners or medical examiners.

Organ Donation

We may disclose your health information to organizations involved in procuring, banking, or transplanting organs and tissues if you are a donor.


We may disclose your health information without the personal identifying information to researchers conducting research that has been approved by an Institutional Review Board.

Public Safety

It may be necessary to disclose your health information to appropriate persons in order to prevent or lessen a serious and imminent threat to the health or safety of a particular person or to the general public.

Specialized Government Agencies

We may disclose your health information for military, national security, prisoner and government benefits purposes.


We may contact you for marketing purposes or fundraising purposes, as described below.


“As a courtesy to our patients, it is our policy to call your home on the evening prior to your scheduled appointment to remind you of your appointment time. If you are not at home, we leave a reminder message on your answering machine or with the person answering the phone. No personal health information will be disclosed during this recording or message other than the date and time of your scheduled appointment along with a request to call our office if you need to cancel or reschedule your appointment.”

“It is our practice to participate in charitable events to raise awareness, food donations, gifts, money, etc. During these times, we may send you a letter, post card, invitation or call your home to invite you to participate in the charitable activity. We will provide you with information about the type of activity, the dates and times, and request your participation in such an event. It is not our policy to disclose any personal health information about your condition for the purpose of WeLuvUs sponsored fund-raising events.”

Change of Ownership

In the event that WeLuvUs is sold or merged with another organization, your health information/record will become the property of the new owner.

Your Health Information Rights

•  You have the right to request restrictions on certain uses and disclosures of your health information. Please be advised, however, that WeLuvUs is not required to agree to the restriction that you requested.

•  You have the right to have your health information received or communicated through an alternative method or sent to an alternative location other than the usual method of communication or delivery, upon your request.

•  You have the right to inspect and copy your health information.

•  You have a right to request WeLuvUs Integrative Apothecary to amend your protected health information. Please be advised, however, that WeLuvUs Integrative Apothecary is not required to agree to amend your protected health information. If your request to amend your health information has been denied, you will be provided with an explanation of our denial reason(s) and information about how you can disagree with the denial.

•  You have the right to receive an accounting of disclosures of your protected health information made by WeLuvUs Integrative Apothecary.

•  You have the right to a paper copy of this Notice of Privacy Practices at any time upon request.

Changes to this Notice of Privacy Practices

WeLuvUs reserves the right to amend this Notice of Privacy Practices at any time in the future, and will make the new provisions effective for all information that it maintains. Until such amendment is made, WeLuvUs (dba) and/or providers are required by law to comply with this Notice.

WeLuvUs is required by law to maintain the privacy of your health information and to provide you with notice of its legal duties and privacy practices with respect to your health information.

If you have questions about any part of this notice or if you want more information about your privacy rights, please contact the office by calling 415-375-8010. If not available, you may make an appointment for a personal conference in person or by telephone within 2 working days.


Complaints about your Privacy rights, or how WeLuvUs (dba) has handled your health information should be directed to Healthazure, Inc by calling this office at 415-375-8010. If is not available, you may make an appointment for a personal conference in person or by telephone within 2 working days. If you are not satisfied with the manner in which this office handles your complaint, you may submit a formal complaint to:
DHHS, Office of Civil Rights
200 Independence Avenue, S.W. Room 509F
HHH Building Washington, DC 20201

Consent For Treatment

1. CONSENT FOR TREATMENT: I hereby agree to the performance of such examinations, procedures and/or treatment as in the opinion of the attending health care professional, and/or licensed health care contractee or employee is/are deemed necessary on the patient named above. If the patient is a minor, I hereby certify that I am either the parent or legal guardian of the above named and hereby grant consent for treatment and request for services as aforementioned. I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures, including various modes of physical therapy and diagnostic x-rays, and any supportive therapies on me (or on the patient named below, for whom I am legally responsible) by the doctor of chiropractic indicated below and/or other licensed doctors of chiropractic and support staff who now or in the future treat me while employed by, working or associated with or serving as back-up for the doctor of chiropractic named below, including those working at the clinic or office listed below or any other office or clinic, whether Signatories to this form or not. I have had an opportunity to discuss with the doctor of chiropractic named below and/or with other office or clinic personnel the nature and purpose of chiropractic adjustments and procedures. I understand that results are not guaranteed. I understand and am informed that, as in the practice of medicine and like all other health modalities, results are not guaranteed, and there is no promise of cure. I further understand and am informed that, as in the practice of medicine, in the practice of chiropractic there are somerisks to treatment, including, but not limited to, fractures, disc injuries, strokes, dislocations and sprains. I do not expect the doctor to be able to anticipate and explain all risks and complications, and I wish to rely on the doctor to exercise judgment during the course of the procedure which the doctor feels at the time, based upon the facts then known, is in my best interests. I further understand that there are treatment options available for my condition other than chiropractic procedures. These treatment options include, but not limited to, self-administered, over-the-counter analgesics and rest; medical care with prescription drugs such as anti-inflammatories, muscle relaxants and painkillers; physical therapy; steroid injections; bracing; and surgery. I understand and have been informed that I have the right to a second opinion and to secure other opinions if I have concerns as to the nature of my symptoms and treatment options.

2. RELEASE OF INFORMATION: To the extent necessary to determine liability for payment and to obtain reimbursement, the health care professional may disclose portions of the patient’s record, to any person or corporation which is or may be liable, for all or any portion of the health care professional’s charge, including but not limited to insurance companies, health care service plans or workers’ compensation carries. I hereby state and agree that a photocopy and/or fax of this document will be as valid and binding on all parties involved as the original copy for this document.

3. INSURANCE ASSIGMENT: I do hereby assign irrevocable direct payment to the health care professional, and any contractees, the health care benefits due for the total charges or payment equal to the reimbursement rate, as may be appropriate, for any services rendered. I understand that I am financially responsible to the health care professionals and any other contractee, for services not covered by this assignment. I hereby instruct and direct any obligated company or individual to pay by check made out and mailed directly to the above noted provider.

4. FINANCIAL AGREEMENT: I agree, whether I am signing as agent or as patient, that in consideration of the services to be rendered to the patient, I individually obligate myself to pay the account of the health care professional in accordance with the regular rates and terms of the health care professionals. I understand that the health care professional shall have the right at any time to refuse to admit me or to provide health care or treatment for me. The health care professional, as a courtesy to the patient, agrees to extend credit by awaiting payment from the insurance company, provided any deductible and co-payment are paid on a weekly basis, for no longer than 60 days from the date of services at which time the account is due and payable. If the patient should discontinue treatment against the recommendations of the health care professional, then the entire balance is due and payable immediately. Should the account be referred to an attorney for collection or to a collection agency, the undersigned shall pay actual attorney’s fee and collection expenses. All delinquent accounts shall be charged a one and one-half percent interest charge per month or at the legal rate. The health care professional reserves the right to charge for a missed appointment fee if there is not at least a 24 hours cancellation notice prior to the appointment (office policy is approximately three-fourths of the average visit fee for no-show). There will be a $15.00 charge for returned checks. I further agree that the above mentioned health care provider be given irrevocable Power of Attorney to endorse/sign my name on any checks for payment of my health care professional’s bills. The health care professional can assume no responsibility for guaranteeing covered charges as billed. Should an overpayment be made, a refund check will be sent to the authorized party that is the overpayment. The health care professional reserves the right to have billing services performed by a contractual billing service.

5. AUTHORIZATION: I hereby authorize the health care professional to verify that all information provided by the patient is correct. Furthermore, if deemed necessary, I authorize the health care professional to obtain a credit report on me. I hereby agree to provide additional information that the health care professional may require prompt, including any change of address.

6. ARBITRATION AGREEMENT: By signing this contract you are agreeing to have any issue of medical malpractice decided by neutral arbitration and you are giving up your right to a jury or court trial. See article 1 of this contract.

7. MEDICARE NON-COVERED SERVICES: The only chiropractic service that Medicare will pay for A2000 (manipulation of the spine) up to 12 visits per year. Other chiropractic services, such as exams, x-rays, physiotherapy, supplies, vitamin supplements, etc., are not covered by Medicare. Payment for these and other services are the patient’s responsibility.



Article1: Agreement to Arbitrate: It is understood that any dispute as to medical services rendered under this contract were unauthorized or were improperly, negligently or incompetently rendered, will be determined by submission to arbitration as provided by California law, and not by a lawsuit or resort to court process except as California provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration.


Article 2: All Claims Must be Arbitrated: It is intention of the parties that this agreement bind all parties whose claims may arise out of or relate to treatment or services provided by the health care provider including any heirs or past, present or future spouse(s) of the patient in relation to all claims, including loss of consortium. This agreement is also intended to bind any children of the patient whether born or unborn at the time of the occurrence giving rise to any claim. This agreement is intended to bind the patient and the health care provider and/or other licensed health care providers or preceptorship interns who now or in the future treat the patient while employed by, working or associated with or serving as back-up for the health care provider, including those working at the health care provider’s clinic or office or any other clinic or office, whether signatories to this form or not. All claims for monetary damages exceeding the jurisdictional limit of the small claims court against the health care provider, and/or the health care provider’s associates, association, corporation, partnership, employees, agents and estate, must be arbitrated including, without limitation, claims loss of consortium, wrongful death, emotional stress or punitive damages. Filling of any action in any court by the health care provider to collect any fee from the patient shall not waive the right to compel arbitration of any malpractice claim. However, following the assertion of any claim against the health care provider, any fee dispute, whether or not the subject of any existing court action, shall also be resolved by arbitration.


Article 3: Procedures and Applicable Law: A demand for arbitration must be communicated in writing to all parties. Each party shall select an arbitrator (party arbitrator) within thirty days and a third arbitrator (neutral arbitrator) shall be selected by the arbitrators appointed by the parties within thirty days thereafter. The neutral arbitrator shall then be the sole arbitrator and shall decide the arbitration. Each party to the arbitration shall pay such party’s pro rata share of the expenses and fees of the neutral arbitrator together with other expenses of the arbitration incurred by a party for such party’s own benefit. Either party shall have the absolute right to bifurcate the issues of liability and damage upon written request to the neutral arbitrator. The parties consent to the intervention and joinder in this arbitration of any person or entity that would otherwise be a proper additional party in a court action, and upon such intervention and joinder any existing court action against such additional person or entity shall be stayed pending arbitration. The parties agree that the provisions of the California Medical Injury Compensation Reform Act shall apply to disputes within this Arbitration Agreement including, but not limited to, sections establishing the right to introduce evidence of any amount payable as a benefit to the patient as allowed by law (Civil Code 3333.1), the limitation on recovery for non-economic losses (Civil Code 3333.2) and the right to have a judgment for future damages conformed to periodic payments (CCP 667.7). The parties further agree that the Commercial Arbitration Rules of the American Arbitration Association shall govern any arbitration conducted pursuant to this Arbitration Agreement.


Article 4: General Provisions: All claims based upon the same incident, transaction or related circumstances shall be arbitrated in one processing. A claim shall be waived and forever barred if (1) on the date notice thereof is received, the claim, if asserted in a civil action, would be barred by the applicable California statute of limitations, or (2) the claimant fails to pursue the arbitration claim in accordance with the procedures prescribed herein wit reasonable diligence.


Article 5: Revocation: This agreement may be revoked by written notice delivered to the health care provider within 30 days of signature and if not revoked will govern all professional services received by the patient.


Article 6: Retroactive Effect: If patient has an occurrence this agreement covers services rendered before the date it is signed (for example, emergency treatment) under justice for health. 

The undersigned certifies that he/she has read and understood the foregoing, is entitled to a copy of same upon request, and is the patient, or is duly authorized as the patient’s general agent to execute the above and accept its items. I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions about its content, and by signing I agree to the above-named procedures. 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.



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