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Alive & Well Healthcare Membership | St. George, Utah
Concierge Monthly Medical Service
Participation Enrollment Form
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Participation Enrollment Form
Please only fill this form out after you have signed up for a plan.
Information Provided is strictly confidential and will become part of your medical record.
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Address Line 2
District of Columbia
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Phone # (main contact # for your account)
How did you hear about Alive & Well?
This Phone # is a:
Home Land Line
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What Type of Membership did you Purchase?
Couple (me + 1)
Family (me + #)
Please List Other Family Members (if applicable). All members listed must live under the primary member's roof.
Date of Birth
please use the plus button at the right to add more lines.
Alive & Well provides medical and wellness services by licensed professionals. The vision of Alive & Well is to provide instant access to quality health care and consultation for employees and families. It is important that you understand your rights and responsibilities when receiving health and wellness services. This document will provide you with an informed consent to receive treatment, information on confidentiality and HIPAA laws and ways to contact your provider team. We look forward to working with you and your family!
Confidentiality & HIPAA
Confidentiality is an important element of the process. Your identity and ongoing work will be kept strictly confidential. We will only release information about our work with your written permission, or if required by court order. We also abide by the Health Insurance Portability & Accountability Act of 1996 (HIPAA) which protects the privacy of medical records (See Notice of HIPAA Privacy Practices Form). Your provider may disclose instant access to quality health care and consultation for your employees and their families for the following reasons: A. Information in the following situations: (1) where uses and disclosures are required by law; (2) where uses and disclosures concern victims of abuse, neglect, or domestic violence; (3) where uses and disclosures are for health and oversight activities (4) where uses and disclosures are for judicial and administrative proceedings; (5) where uses and disclosures are for law enforcement purposes; (6) where uses and disclosures are for research purposes; (7) where uses and disclosures are to avert a serious threat to health or safety; (8) where uses and disclosures are required under Workers’ Compensation. Under Utah law, a provider is required to report the following: (a) abuse or neglect of minors; (b) abuse, neglect, or exploitation of elderly or disabled persons; (c) abuse, neglect, and illegal, unprofessional, or unethical conduct in an in-patient mental health facility, a chemical dependency treatment facility or a hospital providing comprehensive medical rehabilitation services; (d) sexual exploitation by a provider; (e) certain release and exchange of information concerning the treatment of a sex offender. In addition, a provider must report sexual misconduct as follows: the provider has reasonable cause to suspect that a client has been the victim of a sexual exploitation, sexual contact, or therapeutic deception by another licensee or a mental health services provider during therapy or any other course of treatment, or if a client alleges sexual exploitation, sexual contact, or therapeutic deception by another licensee or mental health services provider (during therapy or any other course of treatment). Finally, our providers will warn others if he or she reasonably believes that you may inflict harm on yourself or others.
Summary Notice of HIPAA Privacy Practices
The Health Insurance Portability & Accountability Act of 1996 (HIPAA) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential. This Act gives you, the Patient, significant rights to understand and control how your health information is used. HIPAA provides penalties for covered entities that misuse personal health information. We have prepared this "Summary Notice of HIPAA Privacy Practices" to explain how we are required to maintain the privacy of your health information and how we may use and disclose your health information. A Notice of HIPAA Privacy Practices containing a more complete description of the uses and disclosures of your health information is available to you upon request. We may use and disclose your medical records for each of the following purposes: treatment, payment, and health care operations: ● TREATMENT means providing, coordinating, or managing health care and related services by one or more health care providers. ● PAYMENT means such activities as obtaining payment or reimbursement for services, billing or collection activities and utilization review. ● HEALTH CARE OPERATIONS include managing your Electronic Medical Record to facilitate diagnostic medical consultations with participating physicians, as well as conducting quality assessment and improvement activities, auditing functions, cost-management analysis and customer service. We may also create and distribute de-identified health information by removing all references to individually identifiable information. We may contact you to provide information about our services or other health-related services that may be of interest to you. Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization. You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to Alive & Well. 1. You have the right to ask for restrictions on the ways we use and disclose your health information for treatment, payment and health care operations. You may also request that we limit our disclosures to persons assisting your care. We will consider your request, but are not required to accept it. 2. You have the right to request that you receive communications containing your protected health information from us by alternative means or at alternative locations. For example, you may ask that we only contact you at home or by mail. 3. Except under certain circumstances, you have the right to inspect and copy medical, billing and other records used to make decisions about you. If you ask for copies of this information, we may charge you a nominal fee for copying and mailing. 4. If you believe that information in your records is incorrect or incomplete, you have the right to ask us to correct the existing information or add missing information. Under certain circumstances, we may deny your request, such as when the information is accurate and complete. 5. You have a right to receive a list of certain instances when we have used or disclosed your medical information. If you ask for this information from us more than once every twelve months, we may charge you a fee. You will be assigned a provider team that will provide medical and wellness services. All licensed professionals carry a current license under Utah law. You have a right to request a copy of that license. You have a right to make a complaint to the professional licensing board of that given license. Each provider also has a professional biography and resume that can be provided when requested. We would hope you would discuss any concerns you may have with us. We want to provide excellent treatment to you and your family. You have the right to refuse any services that are offered or quit services at any time. The following services may be offered to you as an Alive & Well participant: ● Acute Medical Care ● Medical Evaluations & Assessments ● Medical Referrals ● Telemedicine ● Wellness Assessments & Coaching ● Fitness Assessments & Consultation ● Medical Prescriptions ● Nutrition Assessments & Consultation ● Wellness Competitions ● Health & Wellness educational presentations Informed Consent I acknowledge that I have received, read, understood, and consent to the following documents: (1) Confidentiality & HIPAA Policies; and, (2) Professional Qualifications Statement; (3) Professional Services Statement; and (4) this Client Consent (collectively as the “Documents”). I further acknowledge that I seek and consent to Alive & Well medical and wellness services as described. I agree to comply with all of the policies and procedures of the Alive & Well program. This consent is given for 12 months from the date signed and may be renewed at any time. This consent does not cover the treatment of providers or affiliates outside of the Alive & Well provider team.
I have read and agree to the above document. The Information provided is accurate to the best of my knowledge. All family members listed live with me.
Digital Signature - Please Enter Full Name
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