Assumption of Risk and Notice of Liability
By agreeing to this Assumption of Risk and Notice of Liability you are also agreeing to our standard terms of service for SkyMedicus' general site.
THIS IS A LEGAL DOCUMENT – READ CAREFULLY
I, the Patient, desire to voluntarily obtain medical services provided by the Healthcare Provider ("Provider") that I have selected. I warrant that I have read and understand every provision contained in this Agreement. By signing this Assumption of Risk and Release of Liability, I hereby agree to comply with the following conditions:
INFORMED CONSENT AND AGREEMENT
I specifically warrant that I have been sufficiently informed and have been given the opportunity to discuss this form and its contents with the undersigned Healthcare Provider, and to have my questions adequately answered. I have been asked to make a choice about my treatment, and I hereby consent to receive medical services with the Healthcare Provider as planned, prescribed and provided by the undersigned Healthcare Provider. I agree to follow my Healthcare Provider’s medical services treatment plan exactly as s/he plans, prescribes and provides it for me, and I understand that any questions, concerns or complaints I have regarding my treatment must be communicated to my doctor as soon as they arise.
I warrant that I am making the decision to obtain medical services from the Healthcare Provider solely based upon my own independent investigation and analysis, and discussions that I may have had with my own medical, dental and/or legal advisors in the United States of America ("U.S.") or elsewhere, including but not limited to information related to the medical services to be obtained from Healthcare Provider, medications, post-treatment care, fitness for travel and/or other activities. I am fully aware that the Healthcare Provider as a healthcare professional has the ultimate decision whether it is safe to proceed with the procedure you have reserved.
I hereby give my unqualified, informed, consent to the Healthcare Provider to perform a the procedure as agreed upon in the SkyMedicus Quote (the "Medical Services"). I certify that I have been provided with materials describing the Medical Services and that I have reviewed such materials. In addition, I certify that I have been given the opportunity to discuss the Medical Services, including the potential benefits, risks, expected outcomes, and medical alternatives to the Medical Services, with a physician employed by, contracted with, [or selected by] the Healthcare Provider. In addition, to the extent that during course of the Medical Services or related services provided to me by the Healthcare Provider, the need arises for emergency, or life saving treatment, I hereby consent to the performance of any other medical services and procedures deemed necessary by the medical staff of the Healthcare Provider, and consent to the payment of all costs associated with any and all other medical services and procedures.
I have not been given any promises or warranties regarding the outcome or results of the Medical Services. I have been given guidelines outlining results and expectations. I understand that my results may or will vary and depend on many factors and variables, and that my results may or may not fall within the guidelines and expectations discussed.
I specifically warrant that I have been given adequate time and information to allow myself to make a decision to undergo this Medical Services. I further warrant that I have been advised to, and have had the opportunity to seek and obtain independent medical advice from an appropriately qualified medical practitioner in relation to any medical services that the Healthcare Provider may provide to me.
At this time, I confirm that I voluntarily desire to undergo and proceed with the Medical Services.
ASSUMPTION OF RISK
I understand that undergoing any medical services procedure entails substantial risk, and possible complications. I hereby acknowledge that there are known and unknown risks and possible complications associated with the Medical Services.
I agree to follow the advice of my Healthcare Provider while under his/her care. I understand that I have the right to deviate from the recommended treatment plan and in doing so, I hereby accept and agree to be solely responsible for the risks and complications that may occur as a result deviating from the recommended treatment plan, and will not hold Healthcare Provider responsible in any way.
I swear and affirm that all information and medical records provided by me to the Healthcare Provider shall be true, accurate and complete to the best of my knowledge, and I understand that the medical personnel, including but not limited to physicians, nurses, and technicians (collectively the "Medical Personnel") will be relying upon the truth, accuracy and completeness of such information and medical records in exercising their own medical judgment. I hereby indemnify, defend and hold harmless the Healthcare Provider from and against any liability arising from any inaccuracy, incompleteness, or intentional omission of information and medical records supplied by me or my physician in the U.S. or otherwise.
CANCELLATION OF PROCEDURE AND REFUNDS
I agree that the Healthcare Provider has the right to cancel the Medical Services at any time and for any reason in the sole and absolute discretion of the Medical Professional. If the Medical Services is canceled, I understand that I will receive an accounting of costs incurred by the Healthcare Provider up until the date of cancellation, and thereafter, I will receive a refund of any unused, but paid, fees.
I agree that in the event I choose the cancel the surgery, I may for any reason. If I elect to cancel the Medical Services, I will be liable for any costs incurred by the Healthcare Provider up until the date of cancellation, and thereafter, I will receive a refund of any unused, but paid, fees.
You can cancel your appointment prior to 48 hours before the appointment date via the SkyMedicus website. Before you make any changes or cancellations, please check the rules and restrictions associated with the third party healthcare or product/service provider to determine whether you can receive a refund. The rules and restrictions are detailed at the bottom of your appointment confirmation e-mail you received from SkyMedicus.
Please note that some healthcare procedures are fully non-refundable from the time the appointment is made. Additionally, many Healthcare Providers will generally charge a fee if cancellation occurs within 48 to 24 hours of the scheduled appointment. Rules vary by country and Healthcare Provider, so it is important to check the rules associated with your appointment. You must request a refund directly with the third party health care provider. They will issue a refund in accordance with their policies within 48 hours of the request via the same payment method you used to book the appointment.
The deposit paid to SkyMedicus, Inc. for your healthcare appointment is non-refundable. However, SkyMedicus, Inc. will issue you a credit which you may apply to another healthcare procedure.
By paying the deposit to secure your healthcare appointment, you understand that you are purchasing SkyMedicus Credits. SkyMedicus Credits are used to secure healthcare appointments or purchase goods from the SkyMedicus Healthcare Marketplace. Should you need to cancel your purchase or appointment prior to the scheduled date of arrival, you can request that the SkyMedicus Credits be returned to your account for use elsewhere in the SkyMedicus Healthcare Marketplace.
SkyMedicus Credits can be used anywhere inside the SkyMedicus Healthcare Marketplace to secure goods or services. All Sales are Final at the time SkyMedicus Credits are purchased.
ROLE OF SKYMEDICUS
I understand and acknowledge that SkyMedicus is NOT a Healthcare Provider. SkyMedicus, Inc. (“SkyMedicus”) is a health information services company also offering electronic medical records management.
SkyMedicus promotes transparency in healthcare pricing and unbiased health information services with an aim to offer consumers more choices on how they govern their healthcare. SkyMedicus does not refer patients to any HealthCare Provider and does not charge any Healthcare Provider to be listed on the SkyMedicus Healthcare Marketplace at (“SkyMedicus.com”). I hereby agree to hold the Provider free from any and all liability associated with any advice, recommendations, and/or services provided by any medical tourism agency.
AGREEMENT TO ARBITRATE
It is understood that any dispute that arises from services rendered by the Healthcare Provider, will be determined by submission to arbitration by law in which the services were rendered, before resorting to a lawsuit or any other court process.
It is also understood that any dispute that does not relate to medical malpractice, including a dispute as to whether or not a dispute is subject to arbitration, will also be determined by submission to binding arbitration in accordance with law in the Country of which services were rendered.
A demand for arbitration must be communicated in writing to all parties. Each party shall come to an agreement as to the date and time of arbitration within sixty (60) days of the demand for arbitration. Each party will equally split the fees associated with arbitration. Additionally, each party will be responsible for their respective attorneys’ fees.
VENUE AND GOVERNING LAW
In the event any dispute arises between me and the Healthcare Provider, then with respect to any litigation arising from such dispute, I (a) consent to submit to the exclusive personal jurisdiction of the courts of ordinary jurisdiction in the City and Country of which services are rendered regardless if their local is not within the United States (b) agree not to attempt to deny or defeat such personal jurisdiction by motion or other request for leave from any such courts, (c) agree not to bring any action relating to such dispute in any court other than a court of ordinary jurisdiction sitting in the City and Country of which services were rendered, (d) agree to submit any complaint in writing within thirty (30) days of becoming aware of any medical complication. I hereby agree that any dispute arising out of the Healthcare Services shall be governed and construed in accordance with the laws of the Country in which services were rendered.
Having read this form in its entirety, my signature below acknowledges that I agree with and understand all of the statements contained and set forth within this document. I am aware of the risks of the Medical Services, and fully understand and accept these risks.
I further warrant that I desire to voluntarily obtain medical services provided by the Healthcare Provider ("Provider") in their remote offices that may not be within the United States. I warrant that I have read and understand every provision contained in this Agreement.
This notice describes how your medical information may be used and disclosed and how you can get access to this information. Please review it carefully.
This notice of privacy practices describes how the healthcare provider, its medical staff members and employees may disclose your protected health information (PHI) for purposes of treatment, payment and health care operations, and for other purposes that are permitted or required by law.
I. OUR RESPONSIBILITIES:
The provider takes the privacy of your health information seriously. We are required by law to maintain the privacy of your health information and provide you with this Notice and Privacy Practices. We will abide by the terms of this Notice of Privacy Practices.
We reserve the right to change this Notice of Privacy Practices and to make any new Notice of Privacy Practices effective for all protected health information that we maintain.
II. WHAT IS “PROTECTED HEALTH INFORMATION” (PHI)?
Protected health information (PHI) is demographic and individually identifiable health information that will or may identify the patient and relates to the patient’s past, present or future physical or mental health or condition and related health care services.
III. WHAT DOES “HEALTH CARE OPERATIONS” INCLUDE?
Health care operations include activities such as communications among health care providers, conducting quality assessment and improvement activities; evaluating the qualifications, competence, and performance of health care professionals; training future health care professionals; contracting with insurance companies: conducting medical review and auditing services; compiling and analyzing information in anticipation of or for use in legal proceedings; and general administrative and business functions.
IV. HOW IS MEDICAL INFORMATION USED?
The provider uses medical records as a way of recording health information, planning care and treatment as a tool for routine health care operations. Your insurance company may request information such as procedure and diagnosis information that we are required to submit in order to bill for treatment we provide to the patient.
V. EXAMPLES OF HOW MEDICAL INFORMATION MAY BE USED FOR TREATMENT, PAYMENT OR HEALTH OPERATIONS
• Medical information may be used to justify needed patient care services, (i.e. lab tests, prescriptions, treatment protocols).
• We will use medical information to establish a treatment plan.
• We may disclose protected health information to another provider for treatment (i.e. referring physicians, specialists and other providers working with the provider).
• We may submit claims to your insurance company containing medical information and we may contact their utilization review department to receive pre-certification (prior approval for treatment).
• We may use the emergency contact information you provided to contact you if the address of record is no longer accurate.
• We may contact you to remind you of the patient’s appointment by calling you or mailing a postcard.
• We may contact you to discuss treatment alternatives or other health related benefits that may be of interest.
VI. WHY DO I HAVE TO SIGN A CONSENT FORM?
When you, the patient or the parent or guardian of a patient, sign a consent form, you are giving the provider permission to use and disclose protected health information for the purposes of treatment, payment and health care operations. This permission does not include psychotherapy notes, alcoholism and drug abuse treatment records and other privileged categories of information which require a separate authorization. You will need to sign a separate authorization to have protected health information released for any reason other than treatment, payment or health care operations.
VII. WHAT ARE PSYCHOTHERAPY NOTES?
Psychotherapy notes are notes recorded (in any medium) by a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session that are separated from the rest of the patient’s medical record. Psychotherapy notes exclude medication prescription and monitoring, counseling session start and stop times, modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date.
VIII. WHY DO I HAVE TO SIGN A SEPARATE AUTHORIZATION FORM?
In order to release patient protected health information for any reason other than treatment, payment and health care operations, we must have an authorization signed by the patient or the parent or guardian of the patient that clearly explains how they wish the information to be used and disclosed.
IX. CAN I CHANGE MY MIND AND REVOKE AN AUTHORIZATION?
You may change your mind and revoke an authorization, except (1) to the extent that we have relied on the authorization up to that point, (2) the information is needed to maintain the integrity of the research study, or (3) if the authorization was obtained as a condition of obtaining insurance coverage. All requests to revoke an authorization should be in writing.
X. WHEN IS MY AUTHORIZATION / CONSENT NOT REQUIRED?
The law requires that some information may be disclosed without your authorization in the following circumstances:
• In case of an emergency
• When there are communication or language barriers
• When required by law
• When there are risks to public health
• To conduct health oversight activities
• To report suspected abuse or neglect
• To specified government regulatory agencies
• In connection with judicial or administrative proceedings
• For law enforcement purposes
• To coroners, funeral directors, and for organ donation
• In the event of a serious threat to health or safety
XI. YOUR PRIVACY RIGHTS
The 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.
1. You have the right to inspect and copy your health information.
This means you may inspect and obtain a copy of your PHI that is contained in a “designated record set” for so long as we maintain the PHI. A designated record set contains medical and billing records and any other record the provider uses in making decisions about you health care. You may not however, 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 certain PHI is subject to laws that prohibit access may be reviewable. In some circumstances, you may have the right to have this decision reviewed. Please contact our Clinic Administrator if you have questions about access to your medical record.
2. You have the right to request a restriction of your health information.
This means you may ask us to restrict or limit the medical information we use or disclose for the purposes of treatment, payment or health care operations. The provider is not required to agree to a restriction that you may request. We will notify you if we deny your request. If we do agree to the request restriction, we may not use or disclose your PHI in violation of that restriction unless it is needed to provide emergency treatment. You may request a restriction by contacting our Clinic Administrator.
3. You have the right to request to receive confidential communications by alternative means or at alternative locations.
We will accommodate reasonable requests. We may also condition this accommodation by asking you for an alternative address or other method of contact. We will not request an explanation from you as the basis for the requests must be made in writing to our Clinic Administrator.
4. You have the right to request amendments to your health information.
This means you may request an amendment of PHI about you in a designated record set for as long as we maintain this information. In certain cases, we may deny your request for an amendment. If we deny your request, you have the right to file a statement of disagreement with our Clinic Administrator and we may prepare a rebuttal to your statement and will provide you with a copy of this rebuttal. If you wish to amend your PHI, please contact our Clinic Administrator. Requests for amendment must be in writing.
5. You have the right to receive an accounting of disclosures of your health information.
You have the right to request an accounting of certain disclosures of your PHI made by the provider. This right applies to disclosures for purposes other than treatment, payment or health care operations as described in this Privacy Notice. We are also not required to account for disclosures that you requested, disclosures that you agreed by signing an authorization form, disclosures to family or friends involved in your care, or certain other disclosures we are permitted to make without your authorization. The request for an accounting must be made in writing to our Clinic Administrator. The request should specify the time period sought for the accounting. Accounting requests may not be made for periods of time in excess of six years.
6. You have the right to receive a paper copy of this Notice of Privacy Practices.
XII. WHAT IF I HAVE A QUESTION / COMPLAINT?
If you have questions regarding your privacy rights, please contact the healthcare provider before agreeing and proceeding with your checkout.