Last Updated March 24th, 2022.
This page is a required part of the new client intake process with Myodetox to provide written information of important Terms, Conditions, and Disclosures (“Intake Forms”) as required by California and US law. Please read the Intake Forms carefully. To confirm your understanding and acceptance of the Intake Forms, click “Agree” under the Terms, Conditions, and Disclosures section on the digital Intake on our clinic management software (“Jane”) and then click “Submit Intake Form”. The totality of items listed herein, and all items with confirmed “Agree” on our clinic management software represents the “Agreement”.
A. TERMS AND CONDITIONS OF SERVICES & PAYMENT
By confirming your understanding and acceptance of the Terms, Conditions and Disclosures section within Jane, you are agreeing to the following Terms and Conditions of your engagement with Myodetox California PC, Inc. (“Myodetox”).
Insurance Not Accepted; Client’s Responsibility for Payment
I understand and acknowledge that Myodetox, its affiliates, and its personnel are not paid or reimbursed for any items and services provided by managed care plans, Medicare, Medicaid, commercial health insurance, or any other third party payor programs and do not accept insurance for such services.
BY CONFIRMING MY UNDERSTANDING AND ACCEPTANCE OF THE TERMS, CONDITIONS, AND DISCLOSURES SECTION, I AFFIRMATIVELY CERTIFY THAT I AM NOT COVERED BY ANY FEDERAL OR STATE HEALTH CARE PROGRAM INCLUDING, BUT NOT LIMITED TO, MEDICARE, MEDICAID, AND TRICARE.
Furthermore, I agree to notify Myodetox immediately and prior to any new services being rendered should my status change with respect to any state or federal health care program. I also agree and acknowledge that no services received from Myodetox will be submitted to any federal or state health care program for reimbursement. Myodetox does NOT treat clients who are covered by any federal or state health care program.
I understand that I will be billed directly and shall be personally responsible for payment, regardless of whether I will be reimbursed by an insurance company, managed care plan or other third party payer. I hereby agree to pay all charges due or that become due to Myodetox for care and treatment. All payment is due prior to the delivery of any services.
Your appointment time is reserved just for you. A late cancellation or missed visit leaves a hole in the providers’ day that could have been filled by another client. As such, we require 24 hours’ notice for any cancellations or changes to your appointment. Clients who provide less than 24 hours’ notice will be charged a cancellation fee equal to the full appointment fee. Clients who miss or do not show for an appointment with no notice will be charged a cancellation fee equal to 100% of their appointment cost.
Running late? Late arrivals will be seen for the remainder of their appointment time only. It is our goal to stay on schedule to the best of our abilities. We will do our utmost to accommodate your needs.
Consent for Calls and Texts
Client agrees Myodetox and/or its agents/affiliates may call or text Client on any phone number provided, for any purpose, including via Automatic Telephone Dialing System and/or artificial or pre-recorded voice, and that such consent is not a condition of any good or service.
Except for any dispute as to medical malpractice (which shall be governed by the Patient-Provider Arbitration Agreement below), I understand and agree that any and all claims arising from or relating to this Agreement or any service provided by Myodetox to me shall be subject to binding arbitration under the Federal Arbitration Act (“FAA”). This includes claims based on contract, tort, equity, statute, or otherwise, as well as claims regarding the scope and enforceability of this provision. It includes all claims by or against me, Myodetox, and others providing or receiving any product or service related to this Agreement or my account with Myodetox.
A single Arbitrator shall decide all claims and shall render a final, written decision. You may choose the American Arbitration Association (“AAA”), Judicial Arbitration and Mediation Service (“JAMS”), or other similar arbitration service provider acceptable to Myodetox to administer the arbitration. Consistent with the FAA, the appropriate AAA rules, JAMS rules, or other service provider rules shall apply, as determined by the Arbitrator. For AAA and JAMS, these rules are found at www.adr.org and www.jamsadr.com.
Unless otherwise agreed by the parties, the arbitration shall take place in Los Angeles, California.
Each party to the arbitration shall pay his, her, or its own costs of arbitration. If you cannot afford your arbitration costs, you may apply for a waiver under the relevant rules.
Class Action Waiver
The parties waive any right to bring representative claims on behalf of a class of individuals, on behalf of the public, as a private attorney general, or otherwise (the “class action waiver”). Except for this class action waiver, this clause may be severed or modified if necessary to render it enforceable under the FAA.
This Agreement shall be governed by the laws of the State of California, without regard to its conflicts of law rules. The provisions of this Agreement shall be severable, and if any provisions shall be prohibited by law, or invalid, or unenforceable in whole or in part for any reason, the remaining provisions shall remain in full force and effect. No party hereto shall be considered to be the drafter of this Agreement or any paragraph or term hereof and no presumption shall apply to any party as the “drafter.”
B. INTRODUCTION TO THE PATIENT-PROVIDER ARBITRATION AGREEMENT
What is the Patient-Provider Arbitration Agreement?
The Patient-Provider Arbitration Agreement is an agreement between you and your provider to resolve disputes without going to court. You should read this document carefully before deciding whether or not to sign the Agreement.
What claims are covered?
All present or future claims of any kind between you, your family, and your provider for which you might sue your provider are covered, except for claims for limited amounts of money which may be resolved in small claims court.
What is arbitration?
Arbitration is an alternative way of resolving disputes. Instead of taking your disagreement through the long and expensive process of court litigation, you and your provider agree in advance to submit any disputes to a panel of arbitrators. After a hearing, which is usually less formal than a court proceeding, the arbitrators make the decision. Although the procedures are different, generally the same laws and same measure of damages applied in court proceedings apply in arbitration.
Who is bound by the Agreement?
If you choose to sign the Arbitration Agreement, you will be agreeing to bind yourself and anyone who could bring suit in connection with treatment or services provided to you by your provider. If you sign on behalf of a family member or some other person for whom you have responsibility, you will bind that person as well as anyone who could sue in connection with treatment or services provided to that person by the provider with whom the client
enters into the Agreement. Likewise, the provider, or anyone suing on behalf of the provider, is bound by the Agreement. If the provider is temporarily absent from practice and refers you to a substitute provider who has agreed in advance to be bound by the terms of the Agreement, then any disputes between you and the substitute provider, or vice versa, will also be subject to arbitration. Any other person with an interest in the dispute will be permitted to participate in the arbitration proceeding so that the entire matter may be arbitrated at one time.
May I be represented by an attorney of my choice?
Yes. Any party to arbitration may be represented by an attorney of his or her choice, at his or her own expense. The arbitrators will hear the facts and decide the case whether or not the parties are represented by lawyers.
What does arbitration cost?
The arbitrators’ fees are shared equally by the parties. While the total amount of the arbitrators’ fees and the other costs of having a claim(s) adjudicated will depend upon the complexity and length of the case as well as other factors, generally speaking, arbitration can be less expensive for the parties than litigating in court.
If either party does not like the arbitration result, could there still be a jury trial in court?
Generally, the answer is “no.” The whole purpose of arbitration is to avoid the expense, delay, and inconvenience of going to court. Arbitration awards may be appealed to a court under very limited circumstances.
Do I really have a choice?
Yes. You are not required to sign the Arbitration Agreement in order to receive treatment. You are free to sign or not to sign. If you do sign the Agreement and change your mind, you can cancel the Agreement by giving written notice of such cancellation to your doctor within 30 days of the date you sign the Agreement.
If you have questions that are not answered by the Arbitration Agreement, you should ask a Myodetox staff person or seek legal advice.
C. PATIENT-PROVIDER ARBITRATION AGREEMENT
It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contractual agreement were unnecessary or unauthorized or were improperly, negligently, or incompetently rendered, will be determined by submission to arbitration as provided by California law, and not by a lawsuit or resort to court process except as California law provides for judicial of arbitration proceedings. Both parties to this contractual agreement, by entering into it, are giving up their constitutional right to have such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration.
I understand and agree that this Arbitration Agreement binds me and anyone else who may have a claim arising out of or related to all treatment or services provided by the provider, including any spouse or heirs of the patient and any children, whether born or unborn at the time of the occurrence giving rise to any claim. This includes, but is not limited to, all claims for monetary damages exceeding the jurisdictional limit of the small claims court, including, without limitation, suits for loss of consortium, wrongful death, emotional distress or punitive damages. I further understand and agree that if I sign this Agreement on behalf of some other person for whom I have responsibility, then, in addition to myself, such person(s) will also be bound by this Agreement, along with anyone else who may have a claim arising out of the treatment or services rendered to that person. I also understand and agree that this Agreement relates to claims against the provider and any consenting substitute provider, as well as the provider’s partners, associates, association, corporation or partnership, and the employees, agents, and estates of any of them. I also hereby consent to the intervention or joinder in the arbitration proceeding of all parties relevant to a full and complete resolution of any dispute arbitrated under this Agreement, as set forth in the Medical Arbitration Rules of the California Medical Association and the California Hospital Association.
I agree that the arbitrators have the same immunity from civil liability as that of a judicial officer when acting in the capacity of arbitrator under this Agreement. This immunity shall supplement, not supplant, any other applicable statutory or common law.
I UNDERSTAND THAT I DO NOT HAVE TO SIGN THIS AGREEMENT TO RECEIVE SERVICES FROM MYODETOX, AND THAT IF I DO SIGN THIS AGREEMENT AND CHANGE MY MIND WITHIN 30 DAYS OF TODAY, THEN I MAY CANCEL THIS AGREEMENT BY GIVING WRITTEN NOTICE TO MYODETOX WITHIN 30 DAYS OF THE DATE OF MY SIGNATURE BELOW STATING THAT I WANT TO WITHDRAW FROM THIS ARBITRATION AGREEMENT.
On behalf of myself and all others bound by this Agreement as set forth in Article 2, agreement hereby given to be bound by the Medical Arbitration Rules of the California Medical Association and the California Hospital Association, as they may be amended from time to time, which Rules are hereby incorporated into this Agreement. A copy of these Rules is available from the California Medical Association, 1201 J Street, Suite #200 Attention: Publication Department, Sacramento, CA 95814. I understand that disputes covered by this Agreement will be covered by California law applicable to actions against health care providers, including the Medical Injury Compensation Reform Act of 1975 (including any amendments thereto).
I understand that in the case of any pregnant woman, the term “patient” as used herein means both the mother and the mother’s expected child or children.
If any provision of this Arbitration Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision.
NOTICE: BY INDICATING YOUR UNDERSTANDING AND ACCEPTANCE OF THIS CONTRACTUAL AGREEMENT, YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS AGREEMENT.
D. THE PHYSICAL THERAPY BOARD OF CALIFORNIA
The Physical Therapy Board of California licenses and regulates your Physical Therapy and Physical Therapist Assistant. A Physical Therapy Aide, while regulated by the Board, is not licensed.
Visit the Board’s website at www.ptbc.ca.gov for information on:
- Verifying a license
- What to expect when you receive care
- Your rights as a client
- How to file a complaint
Board Contact Information
2005 Evergreen Street, Suite 1350
Sacramento, CA 95815
E. DIRECT PHYSICAL THERAPY ACCESS IN CALIFORNIA
Notice Regarding Wellness Programs
California law permits physical therapists to provide unlimited wellness services without a referral from a physician. A wellness program is different from other treatment services in that it is not intended to treat or correct a medical condition. For instance, wellness services include massages, instruction in general flexibility, and strength and conditioning exercise programs. Wellness programs are designed and intended solely to promote and maintain physical fitness, not to treat or correct a medical condition.
For physical therapy that is intended to treat or correct a medical condition, California law requires us to provide the following notice:
Direct Physical Therapy Treatment Services
You are receiving direct physical therapy treatment services from an individual who is a physical therapist licensed by the Physical Therapy Board of California.
Under California law, you may continue to receive direct physical therapy treatment services for a period of up to 45 calendar days or 12 visits, whichever occurs first, after which time a physical therapist may continue providing you with physical therapy treatment services only after receiving, from a person holding a physician and surgeon’s certificate issued by the Medical Board of California or by the Osteopathic Medical Board of California, or from a person holding a certificate to practice podiatric medicine from the California Board of Podiatric Medicine and acting within his or her scope of practice, a dated signature on the physical therapist’s plan of care indicating approval of the physical therapist’s plan of care and that an in-person client examination and evaluation was conducted by the physician and surgeon or podiatrist.
E. DISCLOSURE OF FINANCIAL INTERESTS
THE FOLLOWING NOTICE IS REQUIRED BY CALIFORNIA LAW
To our clients:
You may be referred to one or more of the practitioners or facilities listed below for services. Each of these practitioners (or a member of their family) listed below has a financial interest with or provides services to one or more of the other practitioners and/or facilities listed.
You are free to choose any practitioner or facility you wish for obtaining the services that may be ordered or requested for you by any of the practitioners listed below. Potential sources of information concerning alternatives can be obtained from the Yellow Pages, the Internet or the county medical association.
Practitioners and Facilities:
- Myodetox California PC, Inc.
- Kayla Hamm
- Kurt Hoverson
- Shane Yap
- Ariana Middleman
- Jasen Yamount
- Nirja Gajjar
- Samuel Zemede
- Christian Ramirez
- Monica Vetter
- John Gan
- Casey Campbell
- Yu-King Wong
- Diane Lee
- Jackson Bates
- George Cheng
- Tony Dang
- Tigran Parvanian
- Jason Park
- Kevin So
- Claire Kassian
- Elizabeth Riggins
- Kendalll Green
- Bahar Gord
- Angela Faissal
- Joyce Nguyen
- Nina Green
F. OUR COMMITMENT TO QUALITY CARE
Myodetox is committed to providing you with high quality care. We participate in continuing education to keep our knowledge and skills current and strive to ensure that our clients receive high quality care from this practice.
We also understand that as a client, you may at times have concerns or complaints about our services. We encourage you to communicate your concerns to us or our staff. Please tell us if you have a complaint – we value your feedback. Please tell us if you have questions about your care, suggestions to improve the delivery of health care in this office, or complaints about any aspect of your treatment. We appreciate being part of your health care team and greatly value your feedback.
We offer this NOTICE TO CONSUMERS:
Medical doctors are licensed and regulated by the Medical Board of California
(800) 633-2322 or www.mbc.ca.gov
Chiropractors are licensed and regulated by the Board of Chiropractic Examiners (866) 543-1311 or www.chiro.ca.gov
Physical therapists are licensed and regulated by the Physical Therapy Board of California (800) 832-2251or www.ptbc.ca.gov
G. NOTICE OF PRIVACY PRACTICES
Effective Dec 4th, 2018.
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
If you have any questions about this notice, please contact:
Myodetox California PC, Inc.
Attn: Scott Marcaccio
8354 Santa Monica Blvd.
West Hollywood, CA 90069
WHO WILL FOLLOW THIS NOTICE
This notice describes our practices and applies to:
▪ Any health care professional authorized to enter information into your medical record
▪ All employees, staff and other personnel
OUR PLEDGE REGARDING MEDICAL INFORMATION
We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive at Myodetox California PC, Inc. (“Myodetox”, “we” or “our”). We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by Myodetox, whether made by Myodetox personnel or your personal doctor.
This notice will tell you about the ways in which we may use and disclose medical information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of medical information.
We are required by law to:
- Make sure that medical information that identifies you is kept private (with certain exceptions)
- Give you this notice of our legal duties and privacy practices with respect to medical information about you
- Notify you in the event of a breach of your unsecured protected health information
- Follow the terms of the notice that is currently in effect
HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU
The following categories describe different ways that we use and disclose medical information. For each category of uses or disclosures we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.
DISCLOSURE AT YOUR REQUEST
We may disclose information when requested by you. This disclosure at your request may require a written authorization by you.
We may use medical information about you to provide you with medical treatment or services, and share it with other professionals who are treating you. For example, another physician involved in your care asks a Myodetox physician about treatment received at Myodetox.
We may use and disclose medical information about you so that the treatment and services you receive at Myodetox may be billed to and payment may be collected from you, an insurance company or a third party. For example, we may give information about you to your health insurance plan so it will pay for your services.
FOR HEALTH CARE OPERATIONS
We may use and disclose medical information about you for health care operations. These uses and disclosures are necessary to run Myodetox and to make sure that all of our clients receive quality care. For example, we use medical information about you to manage your treatment and services.
We may contact you for fundraising efforts, but you can tell us not to contact you again.
MARKETING AND SALE
Most uses and disclosures of medical information for marketing purposes, and disclosures that constitute a sale of medical information, require your authorization. In these cases, we never share your information unless you give us written permission.
TO INDIVIDUALS INVOLVED IN YOUR CARE OR PAYMENT FOR YOUR CARE
We may release medical information about you to a friend or family member who is involved in your medical care. We may also give information to someone who helps pay for your care.
Under certain circumstances, we may use and disclose medical information about you for research purposes.
AS REQUIRED BY LAW
We will disclose medical information about you when required to do so by federal, state or local law.
TO AVERT A SERIOUS THREAT TO HEALTH OR SAFETY
We may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.
ORGAN AND TISSUE DONATION
We may release medical information to organ procurement organizations.
WORKERS’ COMPENSATION, LAW ENFORCEMENT, AND OTHER GOVERNMENT REQUESTS
We may use or share health information about you:
- For workers’ compensation claims
- For law enforcement purposes or with law enforcement official
- With health oversight agencies for activities authorized by law
- For special government functions such as military, national security, and presidential protective services
PUBLIC HEALTH ACTIVITIES
We may disclose medical information about you for public health activities such as:
- Preventing disease
- Helping with product recalls
- Reporting adverse reactions to medications
- Reporting suspected abuse, neglect, or domestic violence
- Preventing or reducing a serious threat to anyone’s health or safety
LAWSUITS AND DISPUTES
If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a court or administrative order. We may also disclose medical information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request (which may include written notice to you) or to obtain an order protecting the information requested.
CORONERS, MEDICAL EXAMINERS AND FUNERAL DIRECTORS
We can share health information with a coroner, medical examiner, or funeral director when an individual dies.
YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU
You have the following rights regarding medical information we maintain about you.
RIGHT TO INSPECT AND COPY
You have the right to inspect and obtain a copy of medical information that may be used to make decisions about your care. Usually, this includes medical and billing records, but may not include some mental health information. To inspect and obtain a copy of medical information that may be used to make decisions about you, you must submit your request in writing to Myodetox California PC, Inc., Attn: Scott Marcaccio, 8354 Santa Monica Blvd., West Hollywood, CA 90069. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request.
We may deny your request to inspect and obtain a copy in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. Another licensed health care professional chosen by Myodetox will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.
RIGHT TO AMEND
If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for Myodetox.
To request an amendment, your request must be made in writing and submitted to Myodetox California PC, Inc., Attn: Scott Marcaccio, 8354 Santa Monica Blvd., West Hollywood, CA 90069. In addition, you must provide a reason that supports your request.
We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:
▪ Was not created by us, unless the person or entity that created the information is no longer available to make the amendment
▪ Is not part of the medical information kept by or for Myodetox
▪ Is not part of the information which you would be permitted to inspect and copy
▪ Is accurate and complete
RIGHT TO AN ACCOUNTING OF DISCLOSURES
You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
RIGHT TO REQUEST RESTRICTIONS
You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend.
We are not required to agree to your request, except to the extent that you request us to restrict disclosure to a health plan or insurer for payment or health care operations purposes if you, or someone else on your behalf (other than the health plan or insurer), has paid for the item or service out of pocket in full. Even if you request this special restriction, we can disclose the information to a health plan or insurer for purposes of treating you.
If we agree to another special restriction, we will comply with your request unless the information is needed to provide you emergency treatment.
To request restrictions, you must make your request in writing to Myodetox California PC, Inc., Attn: Scott Marcaccio, 8354 Santa Monica Blvd., West Hollywood, CA 90069. In your request, you must tell us: 1) what information you want to limit; 2) whether you want to limit our use, disclosure or both; and 3) to whom you want the limits to apply, for example, disclosures to your spouse.
RIGHT TO REQUEST CONFIDENTIAL COMMUNICATIONS
You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail.
To request confidential communications, you must make your request in writing to Myodetox California PC, Inc., Attn: Scott Marcaccio, 8354 Santa Monica Blvd., West Hollywood, CA 90069. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
RIGHT TO A PAPER COPY OF THIS NOTICE
You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.
You may obtain a copy of this notice at our website: [insert website address]
To obtain a paper copy of this notice, please contact us at:
Myodetox California PC, Inc.
Attn: Scott Marcaccio
8354 Santa Monica Blvd.
West Hollywood, CA 90069
CHANGES TO THIS NOTICE
We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. The new notice will be available upon request, in Myodetox, and on our web site.
If you believe your privacy rights have been violated, you may file a complaint with Myodetox or with the Secretary of the U.S. Department of Health and Human Services. To file a complaint with Myodetox, contact:
Myodetox California PC, Inc.
Attn: Scott Marcaccio
8354 Santa Monica Blvd.
West Hollywood, CA 90069
All complaints must be submitted in writing.
You will not be penalized for filing a complaint.
OTHER USES OF MEDICAL INFORMATION
Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permission. Additionally, we will need your authorization for most uses and disclosures of psychotherapy notes. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, this will stop any further use or disclosure of your medical information for the purposes covered by your written authorization, except if we have already acted in reliance on your permission. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.