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Financial and Scheduling Agreement-Wellness Support Sessions

Payment:

You have the option to pay in full upon booking or to pay  a deposit of half the cost, and then pay the other half anytime before the start of your appointment.Your payment will be processed on Sunset Moth Wellness (SMW)'s online scheduler, Practice Better via the payment transaction software, Square. 

 

Paying in installments:

Practice Better automatically saves payment information when you choose to pay in installments (making a deposit upon booking instead of paying the full amount). If you do not want your payment information saved, you can go into your client portal to delete it. (You will receive an email invitation to set up your portal.) Once in your portal, click on “Invoices and Billing". Then click on the “Billing Information". There you will see your saved payment information. Click the three dots and you will see the option to delete this information. In the "invoice" tab you will see the invoice for your second installment, which will need to be paid before your appointment can begin. 

 

Canceling MORE than 24 hours before your session:

If you cancel a session more than 24 hours in advance, a refund request will be sent to SMW. Expect a refund on the payment card you used within 3-10 business days.

 

Canceling or Rescheduling LESS than 24 hours before your session:

If you cancel or reschedule a session less than 24 hours before the session begins or fail to show up,  you will be charged 50% of the total cost of the service. If you paid the entire cost, expect a 50% refund on the payment card you used within 3-10 business days.

If Sunset Moth Wellness cancels your appointment:

If Adrienne needs to cancel your appointment for any reason, you will be issued a full refund. Expect a refund on the payment card you used within 3-10 business days.

 

Trying to reschedule an appointment, but there are no future time slots available:

If you would like to reschedule but there are no future time slots available or time slots that would work with your schedule, please cancel your appointment and join the waitlist.  If you are owed a refund, expect it on the payment card you used within 3-10 business days.

 

FSA/HSA Accounts:

You may be eligible to use your FSA or HSA account for Services at Sunset Moth Wellness. Usually to qualify you will need a medical diagnosis and a recommendation from your doctor. I can always work with you and your doctor to submit the appropriate information.

Financial and Scheduling Agreement-Wellness Support Sessions

Financial and Scheduling Agreement-Group Movement Class Organizer

Payment:

The minimum amount owed is $90 for six or less participants. It costs $15 for every participant beyond six.  You can pay one total invoice or have participants pay separately. 

 

If you have chosen to pay one invoice, Sunset Moth Wellness will email you an invoice for your total amount due.  It is due at least 48 hours before the start of the class to secure your booking. If the invoice has not been paid on time, your class will be cancelled and your reservation time and date will no longer be available to you.

If you have chosen to have each participant pay separately, participants will pay for the class during the registration process. A minimum of $90 must be received per class at least 48 hours before the start of the class to secure your booking. If the minimum amount has not been paid on time, your class will be cancelled and your reservation time and date will no longer be available to you. You may request an invoice to pay the difference before the 48 hour mark. Expect any refunds within 3-10 business days.

 

Canceling or Rescheduling LESS than 48 hours before your class after you've paid:

If you cancel or reschedule your entire class less than 48 hours before the class begins there will be a $45 administrative fee. 


If you have paid by invoice, expect a refund less the fee on the payment card you used within 3-10 business days. 

 

If participants have paid separately, the organizer must ensure the fee is paid before Sunset Moth Wellness issues any refunds.

If Sunset Moth Wellness cancels your class:
If Adrienne needs to cancel your class for any reason, you and your participants will be issued full refunds. Expect a refunds on the payment cards you used within 3-10 business days.

Trying to rescheduling but there are no future class dates available:

If you would like to reschedule but there are no future time slots available or time slots that would work with your schedule, please cancel your request or class and join the waitlist.  If you are owed a refund, expect it on the payment card you used within 3-10 business days.

Financial and Scheduling Agreement-Group Movement Class Organizer

Financial Agreement- Group Movement Class Participant

Your group organizer has either opted to pay the entirety of the payment via one invoice or for each participant to pay separately. If the organizer has opted for participants to pay separately, payment is due to complete this registration. 

 

If you are not able to attend the class, but you have paid, expect a refund from Sunset Moth Wellness within 3-10 business days. 

 

Please note that if the agreed upon retainer amount between the organizer and Sunset Moth Wellness has not been paid at least 48 hours before the start time of the class, the class will be cancelled. If you have already paid, expect a refund from Sunset Moth Wellness within 3-10 business days. 

Financial and Scheduling Agreement- Group Class Participant

HIPAA/Personal Healthcare Rights/GDPR Rights Notices

This notice describes how medical information about you may be used and disclosed by Sunset Moth Wellness and how you can get access to this information. Please review it carefully.

 

Sunset Moth Wellness (SMW) protects your sensitive information and rights to your healthcare information in accordance with HIPAA (Health Insurance Portability and Accountability Act) standards: "The HIPAA Privacy Rule gives individuals a fundamental right to be informed of the privacy practices of their health plans and of most of their health care providers, as well as to be informed of their privacy rights with respect to their personal health information." 

SMW is using only HIPPA compliant virtual and manual tools, with signed business associate agreements when applicable, to protect all of the ways you communicate your sensitive information to us. For more information about HIPPA visit:https://www.hhs.gov/hipaa/index.html. 

 

Your Rights


When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you. You can:

 

  •  get an electronic or paper copy of your medical record.

  •  ask to see or get an electronic or paper copy of your medical record and other health information we have about you. 

  •  ask SMW can provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

  • ask SMW to correct health information about you that you think is incorrect or incomplete. 

  • request changes to your health records. SMW may say “no” to your request, but will tell you why in writing within 60 days.

  • ask SMW to contact you in a specific way (for example, home or office phone) or to send mail to a different address. SMW will say “yes” to all reasonable requests especially as it refers to safety.

  •  ask SMW not to use or share certain health information for treatment, payment, or operations.  SMW is not required to agree to your request, and may say “no” if it would affect your care.

  • ask SMW not to share specific information you use to pay for a service or health care item out-of-pocket with others, unless a law requires SMW to share that information.

  • ask for a list of the times SMW shared your health information for six years prior to the date you ask, who SMW shared it with, and why. SMW will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked SMW not to make). SMW will provide one accounting a year, and only more for a specific legal need.

  • ask for a copy of this privacy notice. You can ask for a paper copy of this notice at any time. SMW will provide you with a paper copy within 30 days.

  • ask that someone make decisions on your behalf. If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. If you provide SMW with this person's contact information, SMW will make a concerned effort to contact this person if appropriate, before taking any action on behalf of your health.

  • file a complain directly to SMW by contacting: Adrienne Banks at connect@sunsetmothwellness.com

  • file a complaint with the U.S. Department of Health and Human Services Office Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, or by calling , calling 1-877-696-6775. SMW will not retaliate against you for filing a complaint.

Your Choices

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us to:

  • share information with your family, close friends, or others involved in your care after a consent form has been signed by you

  • share information in a disaster relief situation

  • include your information in a hospital directory

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety. SMW will never share your information without written and expressed permission:

  • marketing purposes

  • sale of your information

  • sharing of psychotherapy notes when it is not necessary to care for you in a crisis situation 


Our Uses and Disclosures

Collecting your personal information is only for the following reasons:

  • to treat you. 

    For example, evaluating your health information to develop a customize wellness plan for you.

     

  • to use your health information and share it with other professionals who are treating you if you have signed a consent form. If and only if, SMW believes sharing your health information may save you from imminent death or serious injury or illness, SMW may share your health information without a consent form.

    For example, you would like SMW to confer with other health care providers of yours.


     

  • to use and share your health information to run the practice, improve your care, and contact you when necessary.

    For example, SMW uses health information about you to manage your treatment and services.

     

  • use and share your health information to bill and get payment from health plans or other entities with your permission.

    For example, SMW gives information about you to your Health Saving Account provider so you can use it to pay for our services.

     

  • to help with public health and safety issues.

            SMW can share health information about you for certain situations such as:

  • preventing the spread of a communicable disease

  • helping with product recalls

  • reporting adverse reactions to supplements

  • reporting suspected abuse, neglect, or domestic violence

  • preventing or reducing serious threat to anyone's healthy and safety
     

  •  to conduct research.

    SMW may use or share your information for health research. If this occurs, you will first be contacted, for which you have the right to refuse such use. Either your health information will be de-identified ( i.e. your name or any info that would make it possible for someone to figure out who you are would not be included) or SMW will ask for your permission to use your identifying information. If you do not respond to requests for permission, SMW still has the right to use your de-identified data for analytic purposes.


     

  • to comply with the law.

    SMW will share information about you if state or federal laws require it, including with the U.S. Department of Health and Human Services.

    For example:

     

    • to ensure that SMW is complying with federal privacy law.

    • respond to organ and tissue donation requests

    • work with a medical examiner or funeral director

    • share health information with a coroner, medical examiner, or funeral director when an individual dies

    • address workers’ compensation, law enforcement, and other government requests.

    • for law enforcement purposes or with a law enforcement official

    • health oversight agencies for activities authorized by law

    • special government functions such as military, national security, and presidential protective services

    • respond to lawsuits and legal actions, court or administrative order, or in response to a subpoena.


SMW's Responsibilities

SMW will not use or share your information other than as described here unless you  given written permission.

  •  SMW is required by law to maintain the privacy and security of your protected health information.

  •  SMW will let you know promptly if a breach occurs that may have compromised the privacy or

    security of your information.

  •  SMW must follow the duties and privacy practices described in this notice and give you a copy of it.

Sunset Moth Wellness adheres to privacy laws via the use and signed agreements between Practice Better (Better Practice Privacy and Security) and Google WorkPlace (Google Workspace Privacy and Security)

Changes to the Terms of this Notice

Terms may update to this notice, and the updates will apply to all information Sunset Moth Wellness is storing. The updates will be available upon request.

HIPAA/Personal Healthcare Rights/GDPR Rights Notices

Consent of Care-Wellness Support Sessions

The following agreement is for the health and safety of both the client and the wellness practitioner, Adrienne Banks.

Adrienne Banks agrees to the following rules of care, and to receive a service, you must also consent to the following rules of care.

 

You, the client or legal guardian of a client under the age of 18, understand that:

 

  • Adrienne Banks is not a medical doctor or licensed mental health clinician. She cannot diagnose health conditions, prescribe pharmaceutical medication, or clinically manage any medical diagnosis including a mental illness diagnosis. Any services rendered by Adrienne Banks should not be construed as a substitute for medical examination, diagnosis, or treatment. Services at Sunset Moth Wellness may compliment treatment by a medical doctor or clinical therapist, and Adrienne Banks can collaborate with a client's other healthcare providers with consent.

 

  • A service can be stopped by the client at any time without needing to give an explanation to Adrienne Banks.
     

  • Adrienne Banks has the right to refuse or discontinue care if she believes the relationship with a client to be a conflict of interest, unhealthy, or unsafe for her at anytime. A refusal of care  statement will be sent to the client, but an expressed purpose may not be stated in order to protect Adrienne Banks. However, if Adrienne Banks deems it unsafe to further communicate with a client, she may not send a refusal of care statement and will in turn seek legal counsel.

 

  • Certain health conditions or injuries can be negatively affected by movement, activities, diet, supplements, or any other suggestions recommended by Adrienne Banks (Here forth- recommendations). Therefore, the client agrees to provide truthful and complete health information to the best of their knowledge and agree to keep Adrienne Banks updated on how their body is feeling throughout any session or report back any adverse reactions while participating in any recommendations. Adrienne Banks is not liable for any adverse reactions that occur by partaking in recommendations because of withheld, misleading, and/or untruthful information by the client. 

 

  • Adrienne Banks will be assessing the health of clients through all services. If a client exhibits signs or symptoms of a medical emergency, she will respond to the situation based on emergency training protocols.

 

  • Adrienne Banks may opt out of suggesting certain recommendations or stop the session depending on the current health of the client , any contraindications, or any needs outside her scope of practice.

 

  • For the comfort and safety of the client, if the client experiences any pain or discomfort during any of their sessions or while engaging in any recommendations by Adrienne Banks , it is the client's responsibility to cease the activity, and if needed, inform Adrienne Banks so the recommendations can be adjusted.

 

  • Any recommendations made to the client by Adrienne Banks are specifically for that client. Adrienne Banks is not liable for any consequences for someone other than her client, who partakes in a recommendation suggested by a client of Adrienne Banks'. 

 

  • Services provided by Adrienne Banks are never sexual in nature. If the client makes sexual advances or remarks of any kind, the session may be immediately terminated without a refund.

 

  • Sunset Moth Wellness adheres to consent laws for HIPAA and GDPR via Practice Better and Google Workspace. Learn more: Privacy and Security through Practice BetterGoogle Workspace Privacy and Security
     

If you have any questions, please email connect@sunsetmothwellness.com.

Consent of Care-Wellness Support Sessions

Mandated Reporting

Reporting Suspected Abuse to Yourself or Others:

Healthcare providers are mandated reporters. What this means is if Adrienne Banks of Sunset Moth Wellness, who is a certified holistic health practitioner and licensed massage therapist, becomes suspicious  during a client interaction, that someone is being abused, neglected, or is a danger to themselves or others, she must report this information to an appropriate authority. This particularly applies to abuse or neglect towards people under the age of 18 and over the age of 59. This may mean divulging otherwise confidential information to an appropriate third party.

All Fifty (50) States and the District of Columbia in the United States of America have enacted laws which address mandatory reporting of child and elder abuse to protect the health and safety of these vulnerable populations.

 

For more information, visit https://www.childwelfare.gov/topics/systemwide/laws-policies/state/ and https://www.americanbar.org/content/dam/aba/administrative/law_aging/2020-elder-abuse- reporting-chart.pdf

If you are a client living in another country, and Adrienne Banks suspects any form of abuse is occurring to you or anyone directly connected to you and deems it medical and ethically appropriate to report, she will research reporting laws in your region and follow those laws accordingly.

Mandated Reporting

Liability Waiver-Physical Activity-Wellness Support Sessions

This liability waiver applies to any movement the client may participate in that is hosted my Sunset Moth Wellness (SMW) regardless of age. If you are the guardian registering a minor (a person under the age of 18), note that the following information applies to the minor, and you are agreeing to take full responsibility for their health and safety while they participate.

 

  • I understand that services at SMW's may include guiding me through physical movements. As is the case with any physical activity, the risk of injury, even serious or disabling, is always present and cannot be entirely eliminated. If I experience any pain or discomfort, I will listen to my body, discontinue the activity, and ask for support from the instructor. I assume full responsibility for any and all injuries and accidents to myself or others, or damages to, or loss of property, which may incur through participation. I will make sure that my place of practice is as safe as possible.

 

  • Any information expressed by the instructor is not a substitute for medical attention, examination, diagnosis or treatment. I affirm that if there is any question about my health, a licensed physician has verified my good health and physical condition to participate in this class.

 

  • I will make the instructor aware of any current medical conditions, pregnancies, post-natal or post-surgical information, or physical limitations by notifying SMW either through answering the health questionnaire during the registration for a class or  by email (connect@sunsetmothwellness.com) as soon as I can, as needed, before each virtual class I attend.

 

  • I understand that services provided by Adrienne Banks are never sexual in nature. If I make sexual advances or remarks of any kind, my participation in the class may be immediately terminated without a refund.

 

I hereby agree to release and waive any claims that I have now or may have hereafter against Sunset Moth Wellness and Adrienne Banks (practitioner). I affirm that my participation or the minor’s participation is voluntary, and at my or their own risk.

 

If you have a question about these terms, please wait to book your class and email connect@sunsetmothwellness.com or through your Practice Better portal with your question. 

Liability Waive-Physical Activity-Wellness Support Sessions

Liability Waiver-Physical Activity-Group Movement Classes

This liability waiver applies to the participant of any class that is hosted my Sunset Moth Wellness (SMW) regardless of age. If you are the guardian registering a minor (a person under the age of 18), note that the following information applies to the minor, and you are agreeing to take full responsibility for their health and safety while they participate.

 

  • I understand that SMW's virtual classes includes guiding me through physical movements. As is the case with any physical activity, the risk of injury, even serious or disabling, is always present and cannot be entirely eliminated. If I experience any pain or discomfort, I will listen to my body, discontinue the activity, and ask for support from the instructor.  I assume full responsibility for any and all injuries and accidents to myself or others, or damages to, or loss of property, which may incur through participation. I will make sure that my place of practice is as safe as possible. 

 

  • Any information expressed by the instructor is not a substitute for medical attention, examination, diagnosis or treatment. I affirm that if there is any question about my health, a licensed physician has verified my good health and physical condition to participate in this class. 

 

  • I will make the instructor aware of any current medical conditions, pregnancies, post-natal or post-surgical information, or physical limitations by notifying SMW either through answering the health questionnaire during the registration process for a class or by email (connect@sunsetmothwellness.com) as soon as I can, as needed, before each virtual class I attend.

 

  • I understand that services provided by Adrienne Banks are never sexual in nature. If I make sexual advances or remarks of any kind, my participation in the class may be immediately terminated without a refund.

 

I hereby agree to release and waive any claims that I have now or may have hereafter against Sunset Moth Wellness and Adrienne Banks (instructor). I affirm that my participation or the minor’s participation is voluntary, and at my or their own risk.

Liability Waiver-Physical Activity-Group Movement Class

Information on Recording Virtual Services at Sunset Moth Wellness

There may be times when it would be helpful to you to have a recording of your service. For example, if Adrienne shows you a specific exercise she  want you to practice, or if she explain an assignment and it would be easier for you understand and remember it if you rewatched her explanation of it.  She does not automatically record sessions, and it will be at her discretion to accept a request to do so.  Except in certain situations, she will not tape live private classes.   

 

If you would like a recording or if I think it would be helpful to you to record all or part of our session, then Adrienne or you can bring that up in the session and Adrienne can begin and stop recording at any time. If you do agree to recording the session, Adrienne will ask you both before and after the start of the recording that you have consented to the recording of the session. You have the right to ask for the recording to be stopped at any time and to request that it be deleted from my files at any time. 

 

Adrienne will be making this recording through through computer and storing it on the Sunset Moth Wellness's HIPAA compliant google drive for up to thirty (30 days).  Be sure to save your recording if you would like to keep it for more than thirty (30) days. She will send it to you via your Practice Better portal or via your google drive, if you have one, or an agreed upon alternative. This will depend on file size and ease of access. 

 

You agree to not use any of your recordings from Sunset Moth Wellness for your own promotion or post any of your recordings on any social media platforms or any other public forum without written permission from Adrienne Banks, owner of Sunset Moth Wellness.  

 

You will not hold Sunset Moth Wellness or Adrienne Banks liable for any outcome that occurs if you share your recordings with anyone else. You understand that any recordings sent to you are specifically for your healthcare and no one else's.

 

In compliance with HIPAA laws, Adrienne will not share a recording that states any of your private, sensitive, or identifying information with anyone else without your consent. If the recording has no private, sensitive, or identifying information, Adrienne has the right to reuse the recording for other clients or for promotional reasons. 

Informaton on Recording Virtual Sevice at Sunset Moth Wellness

Last Updated: May 2022

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