Client Intake Form

CITIZEN OXYWELLNESS CLIENT ACKNOWLEDGEMENTS, CONSENTS, AND HEALTH INFORMATION:

Citizen OxyWellness, LLC (referred to as “CO”)

Payment/Cancellation/No Show/Late Fees Policy

At Citizen OxyWellness (CO) we strive to ensure adequate availability of our Therapy services for our community. We understand that situations may arise where you will need to reschedule or cancel your appointment. Please notify us at your earliest convenience if you will not be able to attend your scheduled Therapy session to enable us to book the chamber for another Client. Some Therapies require bookings and some do not. Unbooked sessions may require a wait to begin a session. Any booking may be canceled with a full refund if canceled 24 hours prior to session. Bookings within 24 hours of session may not be canceled, and any deposit will be forfeited, or an additional charge assessed with any monthly membership.

If a Client is late for a scheduled Therapy session, the session may need to be shortened accordingly—e.g., if a Client is 30 minutes late for a scheduled 90-minute dive, their time in the HBOT chamber may be shortened by 30 minutes or less. NOTE: Shortened Therapy sessions still deliver significant Therapy benefits, although less than a full-length session. No refunds will be made for shortened Therapy due to a Client being late for their session.

On rare occasions, a Therapy session may have to be stopped due to an equipment problem or if a Client has a problem adjusting to the pressure changes during a HBOT dive or to the light brightness or heat produced in our PBM Light Therapy chamber. If any session is stopped due to any of these specific problems, a full credit will be issued for the session, and applied to another session to be conducted in the future, or a full refund will be issued.

General Consent for Citizen OxyWellness, LLC Therapy and Liability Disclaimer

The undersigned hereby consents to treatment of themselves as Client, their minor child or a person they are guardian of as designated below as the Client, with Hyperbaric Oxygen Therapy and/or Photobiomodulation (PBM) Light Therapy and the other related therapies and services (the Therapy) provided by Citizen OxyWellness, LLC (CO). Persons who use CO’s Therapy services are called a “CLIENT” As a CLIENT, the undersigned hereby acknowledges and understands that our therapy for the CLIENT’S condition is not purported to be a standard therapy or cure for illness or health conditions. It is to be considered a supportive therapy only. CO does not make any other claims of benefits for the treatment of CLIENT’S condition. CLIENT hereby warrants that they have read the Therapy contraindications information provided by CO, and have discussed with and informed CO of any health issues/conditions that CLIENT currently has or has previously experienced prior to CO Therapy.

The CLIENT recognizes that CO has no medical doctors or physicians on staff and CO is not giving any medical advice to CLIENT. The CLIENT also understands that CO Therapy is not an exact science and that no guarantees have been made concerning the results or potential side effects of the proposed services. Further, CO cannot control all possible risks to or interactions with CLIENT’S other medical care, treatment or procedures outside of the CO Center. CO does not warrant or guarantee any results of the Therapy, and HEREBY EXPRESSLY DISCLAIMS ANY LIABILITY WHATSOEVER FOR ANY anticipated or unanticipated effects or results of the Therapy services provided. In consideration for Therapy services received, CLIENT voluntarily and knowingly agrees to release, hold harmless, indemnify and forever discharge CO, its affiliates, suppliers, equipment manufacturers and related entities, and any representatives, agents, employees, physicians, contractors, officers, directors, members, managers, successors and assigns thereof (collectively, “Released Entities”), from and against any and all liability, claims, suits, demands, or causes of action for any and all direct or consequential loss personal or financial, injury or death arising out of or related to the CO Therapy services, including payment of interest, and reasonable attorney’s fees and costs related to such actions occurring.

CLIENT’S or their legal representative's signature below represents that the CLIENT or representative is competent to execute this Agreement, that the CLIENT or representative has read and understands the above, was given the opportunity to discuss this form and have any questions answered, has had ample opportunity to discuss our Therapy with his/her doctor or physician, and knowingly consents to the conditions set forth above.

CITIZEN OXYWELLNESS, LLC HIPAA- NOTICE OF PRIVACY

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. This Notice of Privacy Practices is NOT an authorization. This Notice of Privacy Practices describes how we, our Business Associates, and their subcontractors, may use and disclose your protected health information (PHI) to carry out therapy, payment, or health care operations (TPO) 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 condition and related health care services.

USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION. Your protected health information may be used and disclosed by our office staff and others outside of our office that are involved in your care and therapy for the purpose of providing wellness care services to you, to pay your wellness care bills, to support the operation of the business, and any other use required by law. Therapy: We will use and disclose your protected health information to provide, coordinate, or manage your wellness care and any related services. This includes the coordination or management of your wellness care with a third party. For example, your protected 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. Payment: Your protected wellness information will be used, as needed, to obtain payment for your wellness care services. For example, obtaining confirmation that hyperbaric oxygen therapy or PBM Light Therapy is a covered benefit may require that your relevant protected wellness information be disclosed to the health plan to obtain confirmation for hyperbaric oxygen therapy or PBM Light Therapy. Healthcare Procedures: We may use or disclose, as-needed, your protected wellness information in order to support our business activities. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name. We may also call you by name in the waiting room when your operator is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment, and inform you about treatment alternatives or other health-related benefits and services that may be of interest to you. We may use or disclose your protected health information in the following situations without your authorization. These situations include: as required by law, public health issues as required by law, communicable diseases, health oversight, abuse or neglect, food and drug administration requirements, legal proceedings, law enforcement, coroners, funeral directors, organ donation, research, criminal activity, military activity and national security, workers’ compensation, inmates, and other required uses and disclosures. Under the law, we must make disclosures to you upon your request. Under the law, we must also disclose your protected health information when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements under Section 164.500.

USES AND DISCLOSURES THAT REQUIRE YOUR AUTHORIZATION. Other Permitted and Required Uses and Disclosures will be made only with your consent, authorization or opportunity to object unless required by law. Without your authorization, we are expressly prohibited to use or disclose your protected health information for marketing purposes. We may not sell your protected health information without your authorization. You may revoke the authorization, at any time, in writing, except to the extent that we have taken an action in reliance on the use or disclosure indicated in the authorization.

YOUR RIGHTS. The following are statements of your rights with respect to your protected health information. You have the right to inspect and copy your protected health information – Pursuant to your written request, you have the right to inspect or copy your protected health information whether in paper or electronic format. Under federal law, however, you may not inspect or copy the following records: Psychotherapy notes, information compiled in reasonable anticipation of, or used in, a civil, criminal, or administrative action or proceeding, protected health information restricted by law, information that is related to medical research in which you have agreed to participate, information whose disclosure may result in harm or injury to your or to another person, or information that was obtained under a promise of confidentiality. 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 healthcare 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 the 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 your requested restriction except if you request that the physician not disclose protected health information to your health plan with respect to healthcare for which you have paid in full out of pocket. You have the right to receive an accounting of certain disclosures – You have the right to receive an accounting of disclosures, paper or electronic, except for disclosures: pursuant to an authorization, for purposes of therapy, payment and healthcare operations. You have the right to receive notice of a breach – We will notify you if your unsecured protected health information has been breached. You have the right to obtain a paper copy of this notice. We reserve the right to change the terms of this notice and we will notify you of such changes on the following appointment. We will also make available copies of our new notice if you wish to obtain one.

COMPLAINTS. You may complain to us if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying Dena Malugen, President, at EMAIL ADDRESS: info@citizenoxywellness.com. We will not retaliate against you for filing a complaint. We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information. We are also required to abide by the terms of the notice currently in effect. If you have any questions in reference to the form, please ask to speak with our Compliance Officer in person or by phone. Please note that by signing the “Acknowledgment” form you are only acknowledging that you have received or been given the opportunity to receive a copy of our Notice of Privacy Practices.

NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT. I understand that under Health Insurance Portability and Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to: • Conduct, plan and direct my therapy and follow-up among multiple healthcare providers who may be involved in the treatment directly or indirectly. • Obtain payment from third party payers • Conduct normal healthcare operations such as quality assessments and physician certifications. I understand that I may request in writing that CO restrict how my private information is used or disclosed to carry out therapy, payment, or healthcare procedures. I also understand that CO is not required to agree to my requested restrictions, but if agreed, is bound to abide by such restrictions. I have received, read and understand CO's Notice of Privacy Practices containing more complete description of the uses and disclosures of my health information. I understand that CO has the right to change its Notice of Privacy Practices from time to time and I may contact at any time during normal business hours and obtain a current copy of the Notice of Privacy Practices. MOREOVER, I HAVE ALSO RECEIVED from CO, if I requested a copy, THE U.S. Department of Health and Human Services Office for Civil Rights HIPAA - HIPAA Administrative Simplification - Regulation Text 45 CFR Parts 160, 162, and 164 (Unofficial Version, as amended through March 26, 2013), INCORPORATED BY REFERENCE AS IF FULLY SET FORTH HEREIN