Patient Agreement and Disclosure Statement

PATIENT AGREEMENT & DISCLOSURE STATEMENT:

I acknowledge and understand that I am voluntarily becoming a PeopleOne Health patient and that this agreement is nontransferable.

I acknowledge and understand that this agreement does not provide comprehensive health insurance coverage nor is it a contract of insurance.

I acknowledge and understand that PeopleOne Health must maintain a record of my health information and must protect the privacy of my health information as per the terms of the Notice of Privacy Practices. I understand and acknowledge that this policy is available upon request.

I acknowledge and understand that I may terminate this Patient Agreement at any time and for any or for no reason by providing written notice to PeopleOne Health.

RIGHTS AND RESPONSIBILITIES

I understand that I have the right to a fair, fast and objective review of any complaint I have against my health care clinician(s) or any other staff, including complaints about wait times, operating hours, conduct of personnel, business practices, and adequacy of health care services and facilities. I agree to first bring any complaints to the attention of PeopleOne Health staff and to participate in the PeopleOne Health complaint and grievance process.

In order to receive the best possible care, I agree to be actively involved in my health care decisions and to disclose all relevant information to my PeopleOne Health health care clinician(s) so that they can help me achieve my health goals. I also agree to inform my PeopleOne Health health care clinician(s) of any health care services I receive outside of PeopleOne Health (such as the emergency room, specialist, or hospital services).

I understand that I am responsible for not exposing myself or others to disease or danger. I understand that I can receive information from my PeopleOne Health health care clinician(s) about protecting the health and safety of myself and others.