PRIVACY AND OTHER POLICIES

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Privacy Policy

Dignity Weight Center understands that your privacy is important to you. We are committed to protecting the privacy of your personally-identifiable information as you use this website. This Privacy Policy tells you how we protect and use information that we gather from you. By using this website, you consent to the terms described in the most recent version of this Privacy Policy. You should also read our Terms of Use to understand the general rules about your use of this website, and any additional terms that may apply when you access particular services or materials on certain areas of this website. “We,” “our” means Dignity Weight Center and its affiliates. “You,” “your,” visitor,” or “user” means the individual accessing this site.

PERSONAL AND NON-PERSONAL INFORMATION

Our Privacy Policy identifies how we treat your personal and non-personal information.

WHAT IS NON-PERSONAL INFORMATION AND HOW IS IT COLLECTED AND USED?

Non-personal information is information that cannot identify you. If you visit this website to read information, such as information about one of our services, we may collect certain non-personal information about you from your computer’s web browser. Because non-personal information cannot identify you or be tied to you in any way, there are no restrictions on the ways that we can use or share non-personal information. What is personal information and how is it collected? Personal information is information that identifies you as an individual, such as your name, mailing address, e-mail address, telephone number, and fax number. We may collect personal information from you in a variety of ways: • When you complete an application or other form • When you conduct a transaction with us, our affiliates, or others • When we collect information about in you in support of a transaction, such as credit card information • In some places on this website you have the opportunity to send us personal information about yourself, to elect to receive particular information, to learn more about or purchase access to one of our products or services, or to participate in an activity.

ARE COOKIES OR OTHER TECHNOLOGIES USED TO COLLECT PERSONAL INFORMATION?

Yes, we may use cookies and related technologies, such as web beacons, to collect information on our website. A cookie is a text file that is placed on your hard disk by a web page server. Cookies cannot be used to run programs or deliver viruses to your computer. Cookies are uniquely assigned to you, and can only be read by a web server in the domain that issued the cookie to you. One of the primary purposes of cookies is to provide a convenience feature to save you time. The purpose of a cookie is to tell the Web server that you have returned to a specific page. For example, if you register with us, a cookie helps Dignity Weight Center to recall your specific information on subsequent visits. This simplifies the process of recording your personal information, such as billing addresses, shipping addresses, and so on. When you return to the same Dignity Weight Center website, the information you previously provided can be retrieved, so you can easily use the features that you customized. A web beacon is a small graphic image that allows the party that set the web beacon to monitor and collect certain information about the viewer of the web page, web-based document or e-mail message, such as the type of browser requesting the web beacon, the IP address of the computer that the web beacon is sent to and the time the web beacon was viewed. Web beacons can be very small and invisible to the user, but, in general, any electronic image viewed as part of a web page or e-mail, including HTML based content, can act as a web beacon. We may use web beacons to count visitors to the web pages on the website or to monitor how our users navigate the website, and we may include web beacons in e-mail messages in order to count how many messages sent were actually opened, acted upon or forwarded.

Third party vendors also may use cookies on our website. For instance, we may contract with third parties who will use cookies on our website to track and analyze anonymous usage and volume statistical information from our visitors and members. Such information is shared externally only on an anonymous, aggregated basis. These third parties use persistent cookies to help us to improve the visitor experience, to manage our site content, and to track visitor behavior. We may also contract with a third party to send e-mail to our registered [users/members].

To help measure and improve the effectiveness of our e-mail communications, the third party sets cookies. All data collected by this third party on behalf of Dignity Weight Center is used solely by or on behalf of Dignity Weight Center and is shared externally only on an anonymous, aggregated basis. From time to time we may allow third parties to post advertisements on our website, and those third-party advertisements may include a cookie or web beacon served by the third party. This Privacy Policy does not cover the use of information collected from you by third party ad servers. We do not control cookies in such third party ads, and you should check the privacy policies of those advertisers and/or ad services to learn about their use of cookies and other technology before linking to an ad. We will not share your personal information with these companies, but these companies may use information about your visits to this and other web sites in order to provide advertisements on this site and other sites about goods and services that may be of interest to you, and they may share your personal information that you provide to them with others.

You have the ability to accept or decline cookies. Most web browsers automatically accept cookies, but you can usually modify your browser setting to decline cookies if you prefer. If you choose to decline cookies, you may not be able to fully experience the interactive features of the Dignity Weight Center websites you visit.

HOW DOES DIGNITY WEIGHT CENTER USE PERSONAL INFORMATION?

Dignity Weight Center may keep and use personal information we collect from or about you to provide you with access to this web site or other products or services, to respond to your requests, to bill you for products/services you purchased, and to provide ongoing service and support, to contact you with information that might be of interest to you, including information about products and services of ours and of others, or ask for your opinion about our products or the products of others, for record keeping and analytical purposes and to research, develop and improve programs, products, services and content.

Personal information collected online may be combined with information you provide to us through other sources. We may also remove your personal identifiers (your name, email address, social security number, etc). In this case, you would no longer be identified as a single unique individual. Once we have de-identified information, it is non-personal information and we may treat it like other non-personal information. Finally, we may use your personal information to protect our rights or property, or to protect someone’s health, safety or welfare, and to comply with a law or regulation, court order or other legal process.

DOES DIGNITY WEIGHT CENTER SHARE PERSONAL INFORMATION WITH OTHERS?

We will not share your personal information collected from this web site with an unrelated third party without your permission, except as otherwise provided in this Privacy Policy. In the ordinary course of business, we may share some personal information with companies that we hire to perform services or functions on our behalf. In all cases in which we share your personal information with a third party for the purpose of providing a service to us, we will not authorize them to keep, disclose or use your information with others except for the purpose of providing the services we asked them to provide.

We will not sell, exchange or publish your personal information, except in conjunction with a corporate sale, merger, dissolution, or acquisition. For some sorts of transactions, in addition to our direct collection of information, our third party service vendors (such as credit card companies, clearinghouses and banks, and/or companies we hire to do marketing and marketing related tasks) who may provide such services as credit, insurance, marketing, and escrow services may collect personal information directly from you to assist you with your learning about or services, booking an appointment, or completing a transaction. We do not control how these third parties use such information, but we do ask them to disclose how they use your personal information before they collect it.

When given an appropriate court or related criminal justice order, we may be legally compelled to release your personal information in response to a court order, subpoena, search warrant, law or regulation. We may cooperate with law enforcement authorities in investigating and prosecuting web site visitors who violate our rules or engage in behavior, which is harmful to other visitors (or illegal). We may disclose your personal information to third parties if we feel that the disclosure is necessary to protect our rights or property, protect someone’s health, safety or welfare, or to comply with a law or regulation, court order or other legal process.

As discussed in the section on cookies and other technologies, from time to time we may allow a third party to serve advertisements on this web site. If you share information with the advertiser, including by clicking on their ads, this Privacy Policy does not control the advertisers use of your personal information, and you should check the privacy policies of those advertisers and/or ad services to learn about their use of cookies and other technology before linking to an ad. If you found our website and company by clicking on an ad online, and/or completing a form showing your interest in our services, the marketing company through which you found our ad would know of your interest in our services, and would know any information you voluntarily provide in any form you fill out. Please note, by expressing your interest in our services and providing your personal information (including your desire to join our clinic, or your status of having joined our clinic, or any other non-clinical or clinical information you provide when expressing your interest in our clinic via ads or landing page form), you agree to share the information you provide to Dignity Weight Center, its staff, and our associated marketing partners, who may follow up with you about your interest in receiving clinical care in the future. Cookies and related tracking technologies may analyze your use of the website and tailor your online experience, including by sharing information with third party marketing partners.

HOW IS PERSONAL INFORMATION USED FOR COMMUNICATIONS?

We may contact you periodically by e-mail, mail or telephone to provide information regarding programs, products, services and content that may be of interest to you. In addition, some of the features on this web site allow you to communicate with us using an online form. If your communication requests a response from us, we may send you a response via e-mail. The e-mail response or confirmation may include your personal information. We cannot guarantee that our e-mails to you will be secure from unauthorized interception.

HOW IS PERSONAL INFORMATION SECURED?

We have implemented generally accepted standards of technology and operational security in order to protect personally-identifiable information from loss, misuse, alteration, or destruction. Only authorized personnel and third party vendors have access to your personal information, and these employees and vendors are required to treat this information as confidential. Despite these precautions, we cannot guarantee that unauthorized persons will not obtain access to your personal information.

LINKS

This site contains links to other sites that provide information that we consider to be interesting. Dignity Weight Center is not responsible for the privacy practices or the content of such web sites.

PUBLIC DISCUSSIONS

This site may provide public discussions on various business valuation topics. Please note that any information you post in these discussions will become public, so please do not post sensitive information in the public discussions. Whenever you publicly disclose information online, that information could be collected and used by others. We are not responsible for any action or policies of any third parties who collect information that users disclose in any such forums on the web site. Dignity Weight Center does not agree or disagree with anything posted on the discussion board. Also remember that you must comply with our other published policies regarding postings on our public forums.

HOW CAN A USER ACCESS, CHANGE, AND/OR DELETE PERSONAL INFORMATION?

You may access, correct, update, and/or delete any personally-identifiable information that you submit to the web site or to us by any other means/methods. You may also unsubscribe from mailing lists or any registrations on the web site or other third party marketing services. To do so, please either follow instructions on the page of the email or web site on which you have provided such information or subscribed or registered or contact us at info@dignityweightcenter.com. 

CHILDREN’S PRIVACY

Dignity Weight Center  will not intentionally collect any personal information (such as a child’s name or email address) from children under the age of 13. If you think that we have collected personal information from a child under the age of 13, please contact us.

CHANGES

Dignity Weight Center  reserves the right to modify this statement at any time. Any changes to this Privacy Policy will be listed in this section, and if such changes are material, a notice will be included on the homepage of the web site for a period of time. If you have any questions about privacy at any websites operated by Dignity Weight Center  or about our website practices, please contact us at: info@dignityweightcenter.com. 

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HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.
We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice, at any time. The new notice will be effective for all protected health information that we maintain at that time. Upon your request, we will provide you with any revised Notice of Privacy Practices. You may request a revised version by accessing our website, or calling the office and requesting that a revised copy be sent to you in the mail or asking for one at the time of your next appointment.

1. Uses and Disclosures of Protected Health Information

Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office who are involved in your care and treatment for the purpose of providing health care services to you. Your protected health information may also be used and disclosed to pay your health care bills and to support the operation of your physician’s practice.
Following are examples of the types of uses and disclosures of your protected health information that your physician’s office is permitted to make. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by our office.

Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with another provider. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. We will also disclose protected health information to other physicians who may be treating you. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you. In addition, we may disclose your protected health information from time-to-time to another physician or health care provider (e.g., a specialist or laboratory) who, at the request of your physician, becomes involved in your care by providing assistance with your health care diagnosis or treatment to your physician.

Payment: Your protected health information will be used and disclosed, as needed, to obtain payment for your health care services provided by us or by another provider. This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services we recommend for you such as: making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.

Health Care Operations: We may use or disclose, as needed, your protected health information in order to support the business activities of your physician’s practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, fundraising activities, and conducting or arranging for other business activities.

We will share your protected health information with third party “business associates” that perform various activities (for example, billing or transcription services) for our practice. Whenever an arrangement between our office and a business associate involves the use or disclosure of your protected health information, we will have a written contract that contains terms that will protect the privacy of your protected health information.

We may use or disclose your protected health information, as necessary, to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you. You may contact our Privacy Officer to request that these materials not be sent to you.

Other Permitted and Required Uses and Disclosures That May Be Made Without Your Authorization or Opportunity to Agree or Object.

We may use or disclose your protected health information in the following situations without your authorization or providing you the opportunity to agree or object. These situations include:

Required By Law: We may use or disclose your protected health information to the extent that the use or disclosure is required by law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, if required by law, of any such uses or disclosures.

Public Health: We may disclose your protected health information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. For example, a disclosure may be made for the purpose of preventing or controlling disease, injury or disability.

Communicable Diseases: We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.

Health Oversight: We may disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws.

Abuse or Neglect: We may disclose your protected health information to a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, we may disclose your protected health information if we believe that you have been a victim of abuse, neglect or domestic violence to the governmental entity or agency authorized to receive such information. In this case, the disclosure will be made consistent with the requirements of applicable
federal and state laws.

Food and Drug Administration: We may disclose your protected health information to a person or company required by the Food and Drug Administration for the purpose of quality, safety, or effectiveness of FDA-regulated products or activities including, to report adverse events, product defects or problems, biologic product deviations, to track products; to enable product recalls; to make repairs or replacements, or to conduct post marketing surveillance, as required.

Legal Proceedings: We may disclose protected health information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), or in certain conditions in response to a subpoena, discovery request or other lawful process.

Law Enforcement: We may also disclose protected health information, so long as applicable legal requirements are met, for law enforcement purposes. These law enforcement purposes include (1) legal processes and otherwise required by law, (2) limited information requests for identification and location purposes, (3) pertaining to victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) in the event that a crime occurs on the premises of our practice, and (6) medical emergency (not on our practice’s premises) and it is likely that a crime has occurred.

Coroners, Funeral Directors, and Organ Donation: We may disclose protected health information to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose protected health information to a funeral director, as authorized by law, in order to permit the funeral director to carry out their duties. We may disclose such information in reasonable anticipation of death. Protected health information may be used and disclosed for cadaveric organ, eye or tissue donation purposes.

Criminal Activity: Consistent with applicable federal and state laws, we may disclose your protected health information, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. We may also disclose protected health information if it is necessary for law enforcement authorities to identify or apprehend an individual.

Military Activity and National Security: When the appropriate conditions apply, we may use or disclose protected health information of individuals who are Armed Forces personnel (1) for activities deemed necessary by appropriate military command authorities; (2) for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits, or (3) to foreign military authority if you are a member of that foreign military services. We may also disclose your protected health information to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally authorized.

Workers’ Compensation: We may disclose your protected health information as authorized to comply with workers’ compensation laws and other similar legally-established programs.

Inmates: We may use or disclose your protected health information if you are an inmate of a correctional facility and your physician created or received your protected health information in the course of providing care to you.

Uses and Disclosures of Protected Health Information Based upon Your Written Authorization:
Other uses and disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law as described below. You may revoke this authorization in writing at any time. If you revoke your authorization, we will no longer use or disclose your protected health information for the reasons covered by your written authorization. Please understand that we are unable to take back any disclosures already made with your authorization.

Other Permitted and Required Uses and Disclosures That Require Providing You the Opportunity to Agree or Object:
We may use and disclose your protected health information in the following instances. You have the opportunity to agree or object to the use or disclosure of all or part of your protected health information. If you are not present or able to agree or object to the use or disclosure of the protected health information, then your physician may, using professional judgment, determine whether the disclosure is in your best interest.

Facility Directories: Unless you object, we will use and disclose in our facility directory your name, the location at which you are receiving care, your general condition (such as fair or stable), and your religious affiliation. All of this information, except religious affiliation, will be disclosed to people that ask for you by name. Your religious affiliation will be only given to a member of the clergy, such as a priest or rabbi.

Others Involved in Your Health Care or Payment for your Care: Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your protected health information that directly relates to that person’s involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose protected health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition or death. Finally, we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care.

2. Your Rights

Following is a statement of your rights with respect to your protected health information and a brief description of how you may exercise these rights.
You have the right to inspect and copy your protected health information. This means you may inspect and obtain a copy of protected health information about you for so long as we maintain the protected health information. You may obtain your medical record that contains medical and billing records and any other records that your physician and the practice uses for making decisions about you. As permitted by federal or state law, we may charge you a reasonable copy fee for a copy of your records.
Under federal law, however, you may not inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding; and laboratory results that are subject to law that prohibits access to protected health information. Depending on the circumstances, a decision to deny access may be reviewable. In some circumstances, you may have a right to have this decision reviewed. Please contact our Privacy Officer if you have questions about access to your medical record.
You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or health care operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.
Your physician is not required to agree to a restriction that you may request. If your physician does agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment. With this in mind, please discuss any restriction you wish to request with your physician.
You have the right to request to receive confidential communications from us by alternative means or at an alternative location. We will accommodate reasonable requests. We may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not request an explanation from you as to the basis for the request. Please make this request in writing to our Privacy Officer.
You may have the right to have your physician amend your protected health information. This means you may request an amendment of protected health information about you in a designated record set for so long as we maintain this information. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Please contact our Privacy Officer if you have questions about amending your medical record.
You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. This right applies to disclosures for purposes other than treatment, payment or health care operations as described in this Notice of Privacy Practices. It excludes disclosures we may have made to you if you authorized us to make the disclosure, for a facility directory, to family members or friends involved in your care, or for notification purposes, for national security or intelligence, to law enforcement (as provided in the privacy rule) or correctional facilities, as part of a limited data set disclosure. You have the right to receive specific information regarding these disclosures that occur after April 14, 2003. The right to receive this information
is subject to certain exceptions, restrictions and limitations.
You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice electronically.

3. Complaints
You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our Privacy Officer of your complaint. We will not retaliate against you for filing a complaint.
You may contact your doctor if you have any other questions about privacy practices.

TELEMEDICINE POLICIES

Regarding video-conferencing/telemedicine/online sessions, you understand and agree with the following:
-I understand that telemedicine is the delivery of medical and psychiatric (or psychotherapeutic) services using interactive audio and visual (video) electronic systems where the provider and the patient are not in the same physical location. The interactive electronic systems incorporate network and software security protocols to protect patient information and safeguard the data exchanged.
-Telemedicine provides convenience and increased accessibility to medical and psychiatric care for individuals who are unable to be treated face to face due to temporary circumstances such as being away at college or an extended stay away from home or having a physical limitation preventing travel to our office
-As with any medical procedure, there may be potential risks associated with the use of
telemedicine. These risks include, but may not be limited to:
 Therapy conducted online is technical in nature and problems may occasionally occur
with internet connectivity. Difficulties with hardware, software, equipment, and/or
services supplied by a 3rd party may result in service interruptions. Any problems
with internet availability or connectivity are outside the control of the clinician and the
clinician makes no guarantee that such services will be available or work as expected.
If something occurs to prevent or disrupt any scheduled appointment due to technical
complications and the session cannot be completed via online video conferencing, the
clinician will call the patient back at the phone number provided on the intake/onboarding forms.
 Information transmitted may not be sufficient (e.g., poor resolution of video) to allow
for appropriate medical decision making by the clinician.
 The provider may not be able to provide treatment to the patient using interactive
electronic equipment nor provide for or arrange for emergency care that the patient
may require, in cases of connection failure.
 Delays in medical evaluation and treatment may occur due to deficiencies or failures
of the equipment.
 Although highly unlikely, security protocols can fail, causing a breach of privacy of
confidential medical information.
-A lack of access to all the information that might be available in a face to face visit but not in a telemedicine session may result in errors in medical judgment.
-I understand that the laws that protect the privacy and confidentiality of medical information also apply to telemedicine.  I understand that the technology used by the provider is encrypted to prevent the unauthorized access to my private medical information.  I have the right to withhold or withdraw my consent to the use of telemedicine during the course of my care at any time. I understand that my withdrawal of consent will not affect any future care or treatment.  I understand that the provider has the right to withhold or withdraw his or her consent for the use of telemedicine during the course of my care at any time.  I understand that all the rules and regulations which apply to the practice of medicine in the state of my residence also apply to telemedicine.  I understand that the provider will not record any of our telemedicine sessions without written consent.  I understand that the provider will not allow any other individuals outside of the clinical team to listen to, view or record my telemedicine session without my express permission (verbal or written).
- I agree to take full responsibility for the security of any communications or treatment information involved with my own computer and with my own physical location.  I understand that I am solely responsible for maintaining the strict confidentiality of my login information and I will not allow another person to use my login information to access the telemedicine services. I also understand that I am responsible for using this technology in a secure and private location so that others cannot hear my conversation.  I understand that the company that the clinic has chosen to conduct the online appointment is an independent company specializing in HIPAA compliant telemedicine. My clinician has no responsibility for that company’s operations or security of my protected health information.  I will not record any telemedicine sessions without written consent from the provider. I will inform the provider if any other person can hear or see any part of our session before the session begins.  I understand that I, not the provider, am responsible for providing and configuring any electronic equipment used on my computer which is used for telemedicine. I understand that it is my responsibility to ensure the proper functioning of all electronic equipment before my session begins and I agree to revert to a telephone voice session utilizing the indicated backup telephone number provided (the clinic number, or alternative provided) should a video connection not function properly. If I am experiencing any technical difficulties, my clinician encourages me to call/contact the company chosen for online appointments for technical support if your clinician cannot help you.
-I have read and understand that all of the clinic policies of the clinic apply to all telemedicine as well as all in-person visits.
-I consent to paying fees that are the same in process and amounts as an in-office visit for the type and length of service provided, as per my contract with my insurance company.  
-I understand that a telemedicine appointment is scheduled the same as an in-office appointment would be, and should I not be available for the appointment or cancel it less than 24 hours in advance, there will be a $25 charge for a missed appointment for the time my practitioner has reserved for the scheduled appointment.
-Confidentiality norms still apply for tele-health services, and nobody will record the session without the permission from the patient.  
-There are potential benefits and risks of video-conferencing (e.g. limits to patient confidentiality) that differ from in-person sessions.  
-You agree to use the video-conferencing platform selected for our virtual sessions.  
-You need to use a computer webcam or tablet or smartphone during the session.  
-It is important to be in a quiet, private space that is free of distractions (including cell phone or other devices) during the session.  
-It is important to use a secure internet connection rather than public/free Wi-Fi.  
-It is important to be on time.
-If you need to cancel or change your tele-appointment, you must notify the clinician in advance by phone or email.  
-We need a back-up plan (e.g., phone number where you can be reached) to restart the session or to reschedule it, in the event of technical problems.  
-We need a safety plan that includes at least one emergency contact (filled out in your onboarding forms), in the event of a crisis situation.  
-If you are not an 18+ year old adult, we need the permission of your parent or legal guardian (and their contact information) for you to participate in telemedicine sessions.  
-As your clinician, we may determine that due to certain circumstances, telemedicine is no longer appropriate and that we should resume our sessions in-person or care should be directed in alternative ways.
-I have read and understand the information provided in this document regarding telemedicine. I have discussed this information with my provider to my satisfaction and needs and all my questions have been answered to my satisfaction. I hereby give my informed consent for the use of telemedicine in my medical care and authorize the provider to use telemedicine in the course of my diagnosis and treatment.


UNDERSTANDING OF OFFICE POLICIES

*I will ask my clinician any questions that I may have about my treatment at Dignity Weight Center (Dignity Weight Center is our DBA, the formal name is Center for Brain Health PLLC).

*I understand that Dignity Weight Center is my provider primarily for helping to optimize weight loss and related nutrition/eating/physical activity/sleep cognitions, emotions, and behaviors.

*I understand that my care at Dignity Weight Center is supposed to be for a short term period and not indefinite, with patients working with Dignity Weight Center on average for 6-9 months, though some for shorter durations and others for longer durations; there is no set time i have to be in the clinic.

*I understand that I may discontinue treatment at any time.

*I understand that my care at Dignity Wight Center includes medical as well as psychosocial integrated care and approaches.

*I understand that during my time working with Dignity Weight Center, it is recommended that I also have regular sessions with the outside clinician who regularly follows my care and physical and mental health, i.e. my primary care clinician, therapist, psychiatrist, etc.).

*I understand that Dignity Weight Center's program is not supposed to replace my other clinicians who care for my physical health (i.e., primary care clinician, endocrinologist, cardiologist, therapist, psychiatrist, neurologist, etc.), but rather is supposed to complement and supplement them, and be utilized in parallel with those other clinicians.

*I understand that all health recommendations and suggestions that are provided by Dignity Weight Center are entirely optional, and suggested for my benefit and that it is up to me to undertake interventions I want to try, and that all interventions have potential risks and benefits that will be explained to me.

*Specifically, I understand that in regards to any suggested medical or psychosocial interventions or treatment recommendations that Dignity Weight Center makes, it is my responsibility to ask any questions I have to clarify the suggestion or recommendation, and also to consider whether I would like to implement it in my health journey in light of my values, preferences, knowledge, and health goals, and what my other clinicians may also be saying or suggesting or recommending to me.  Suggestions made by Dignity Weight Center do not automatically supersede recommendations made by my other clinicians (primary care clinician, therapist, psychiatrist, neurologist, etc.), and the reverse is also true (Suggestions made by my other clinicians do not automatically supersede recommendations made by Dignity Weight Center).

*I understand that Dignity Weight Center explains and reviews medical options and interventions with patients, runs laboratory testing, metabolic rate testing, a DEXA scan, and can advise on medical and psychosocial issues, side effects, efficacy, interventions, etc. and what may be optimal treatment options for them, however, Dignity Weight Center, because medications tend to need to be life long, and Dignity Weight Center tends to see people for about 9 months only,  will not be prescribing medications to me, refilling medications for me, or performing procedures or surgery on me.  All surgery or medication management will be the responsibility of my regular/other/longitudinal clinicians (primary care clinician, surgeon, psychiatrist, therapist, etc.), and Dignity Weight Center, if indicated, can write a letter to your other clinicians on your behalf with our expert surgical or medication recommendations.

*Dignity Weight Center will do everything they can to communicate clearly about any interventions or recommendations they make, however I understand that I am the one who is primarily responsible for communicating - as is needed - any suggestions or recommendations that Dignity Weight Center gives me to my other clinicians (i.e. my primary care clinician, outpatient therapist, psychiatrist, endocrinologist, etc.).

*I understand that for any treatments or interventions that are not discussed by my clinician at Dignity Weight Center, I have a responsibility to continue to follow the recommendations of my other clinicians in regards to those treatments, and overall, I understand that, as is relevant and needed for me, engaging in regular therapy with my regular therapist, if I have one, and taking my medications and doing other interventions as prescribed will likely help in my overall clinical outcomes.

*During my course of care at Dignity Weight Center, I will continue my regularly scheduled appointment(s) with my other clinicians (primary care clinician, surgical follow up, psychiatrist, etc.) as they will continue to follow me and prescribe any of my ongoing medications, surgery, and therapy, if needed.


INSURANCE AND PAYMENT POLICIES

*Dignity Weight Center will work with my insurance company to submit claims and clinical information as appropriate for my insurance company to pay for my clinically indicated treatment.

*I understand that Dignity Weight Center cannot guarantee that my insurance company will cover my care at Dignity Weight Center, but Dignity Weight Center will do the best they can to advocate on your behalf for coverage if needed.

*I am responsible for paying any co-payments, co-insurances, and/or deductibles that are a part of my medical insurance plan contract that I have selected and contracted.  The amount of these co-payments, co-insurances, and/or deductibles will be communicated to me by Dignity Weight Center or affiliates after communication with my insurance company.

*I give my consent for Dignity Weight Center to communicate with my health insurance company for the purposes of my care in this clinic

*The benefits information supplied by Dignity Weight Center is a summary of my health plan benefits. The details listed included in the summary are subject to change at any time by my insurance company or if I change my insurance plan coverage. I will consult with my healthcare insurance provider for detailed information pertaining to my individual healthcare coverage and if my plan benefits change, this is my responsibility to communicate to Dignity Weight Center.

*If my insurance does not cover my treatment for whatever reason, I am free to decline treatment.

*I understand that when my insurance claims have processed or before then if benefits information is known, I will receive an electronic and/or paper statement of my out of pocket fees due (i.e., for co-payment, deductible, co-insurance, etc.), and I can pay this directly online using the link provided in email and/or text, or by sending in a check by paper mail.

*I agree to allow Dignity Weight Center and affiliate billing companies (i.e. Denise Leal of E-Medibill) to email and/or text me electronic statements of any amounts due for my account.

*Since treatment at Dignity Weight Center requires many sessions over time, as an optional payment option, I will am free to provide my credit card information online and have it stored in a secure manner, and agree to have my card charged on the same day of an appointment for any copayments or deductibles or co-insurances that are due, based on the specific contract I have with my insurance company.

*If I need to miss a treatment session, I will do my best to contact Dignity Weight Center at least 24 hours ahead of time so that they can accommodate other patients who may be waiting for open appointment slots.

*If I miss an appointment and don't cancel it at least 24 hrs before my appointment time, I will be charged a $25 late cancellation/No Show fee.

*I will do my best to come to appointments 5 minutes in advance so that my treatment can start on time.

*I understand that if I show up to my appointment 10 or more minutes late, the clinician has the right to cancel/reschedule the appointment since there wouldn’t be time to do the session that day.

*I understand that the treatments proposed are most likely to work if I attend all prescribed treatment sessions as scheduled.

*I understand that all medical care is probabilistic and there is no guarantee that any intervention suggested will definitively result in the desired health goal I aspire toward and am seeking help for at Dignity Weight Center

*I can terminate treatment at any time and for any reason, however I understand that this would most likely negatively impact my chance for effective treatment.

OPTIONAL SERVICES

*We offer optional remote weight monitoring in our clinic. This is because our patients have asked for it, daily self-monitoring is one of the best predictors of long term sustainable weight loss, and because it is clinically helpful to see the trajectory of weights between sessions, and the overall trend.  We work with TrueBlueMD who is the scale company.  After your initial visit with us they contact you to ask if you are interested in this service.  You are welcome to decline it or enroll.  You will only be contacted if your insurance covers the service, and this will be checked in advance.  The scale will be shipped to you and the weight data is automatically transmitted to your clinician.

*Metabolic rate testing and DEXA scans are entirely optional services and not required.  These are not covered by insurance.  

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CONTACT INFORMATION

Lady Isleta, PTRP
Office Manager
Dignity Weight Center
lady@dignityweightcenter.com
www.dignityweightcenter.com
617-855-7288 (phone)  
844-733-6150 (fax)

Omar Sultan Haque, M.D., Ph.D.
Founder and Medical Director
Dignity Weight Center
info@dignityweightcenter.com