OUR LEGAL RESPONSIBILITIES
We are required by law to give you this notice. It provides you with how we may use and disclose protected health information about you and describes your rights and our obligations regarding the use and disclosure of that information. We shall maintain the privacy of protected health information and provide you with notice of our legal duties and privacy practices with respect to your protected health information. We have the right to change these policies at any time. If we change our privacy policies, we will notify you of these changes immediately. This current policy is in effect unless stated otherwise. If the policy is changed, it will apply to all your current and past health information. You may request a copy of our notice any time. You may contact Reach Revive at 204 Perimeter Park Drive at any time to request a copy of this privacy policy. 

HOW WE MAY USE OR DISCLOSE YOUR PROTECTED HEALTH INFORMATION  

The following examples describe ways that we may use your protected health information for your treatment, payments, healthcare operations etc. but please be advised that not every use or disclosure in a particular category will be listed. 

Treatment: We may use and disclose your protected health information to provide you with treatment. This includes disclosing your protected health information to other medical providers, trainees, therapists, medical staff, and office staff that are involved in your health care. 

For example, your medical provider might need to consult with another provider to coordinate your care. Also, the office staff may need to use and disclose your protected health information to other individuals outside of our office such as the pharmacy when a prescription is called in.  

Payment: Your protected health information may also be used to obtain payment from an insurance company or another third party. This may include providing an insurance company with your protected health information for pre-authorization for a medication we prescribed. 

Health Care Operations: We may use or disclose your protected health information in order to operate this medical practice. These activities include training students, reviewing cases with employees, utilizing your information to improve the quality of care, and contacting you by telephone, email, or text to remind you of your appointments. 

If we must share your protected health information to third party “business associates” such as a billing service, we will have a written contract that contains terms that will protect the privacy of your protected health information.  

We may also use and disclose your protected health information for marketing activities. For example, we might send you a thank you card in the mail with a coupon for specialized services or products. We may also send you information about products or services that might be of interest to you. You can contact us at any point to stop receiving this information.  

We will not use or disclose your protected health information for any purpose other than those identified in this policy without your specific, written Authorization. You may give us written authorization to use your protected health information or to disclose it to anyone for any purpose. You can revoke this authorization at any time, but it will not affect the protected health information that was shared while the authorization was in effect.  

Appointment reminders: We may contact you as a reminder that you have an appointment for your initial visit, follow up visit, or lab work via text, phone or email. 

Others Involved in Your Health Care: We may disclose protected health information about you to your family members or friends if we obtain your verbal agreement to do so, or if we give you an opportunity to object to such a disclosure and you do not raise an objection. For example, we may assume that if your spouse or friend is present during your evaluation, that we can disclose protected professional information to this person. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment if there is an urgent or emergent need.  

Research: We will not use or disclose your health information for research purposes unless you give us authorization to do so. 

Organ Donation: If you are an organ donor, we may release protected health information to organizations that handle organ procurement or organ, eye or tissue transplantation if it is necessary to facilitate this process. 

Public Health Risks: We may disclose your protected health information, if necessary, to prevent or control disease, report adverse events from medications or products, prevent injury, disability or death. This information may be disclosed to healthcare systems, government agencies, or public health authorities. We may have to disclose your protected health information to the Food and Drug Administration to report adverse events, defects, problems, enable recalls etc. if required by FDA regulation. 

Health Oversight Activities: We may disclose protected health information to health oversight agencies for audits, investigations, inspections or licensing purposes. These disclosures might be necessary for state and federal agencies to monitor healthcare systems and compliance with civil law. 

Required by Law: We will disclose protected health information about you when required to do so by federal, state and/or local law. 

Workman’s compensation: We may disclose your protected health information to workman’s comp or similar programs. 

Lawsuits: We may disclose your protected health information in response to a court action, administrative action or a subpoena.  

Law Enforcement: We may release protected health information to a law enforcement official in response to a court order, subpoena, warrant, subject to all applicable legal requirements. 

YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION 

Access to medical records: You have the right to access and receive copies of your protected health information that we use to make decisions about your care. You must submit a written request to obtain your protected health information to the individual listed at the end of this privacy policy. We reserve the right to charge you a fee for the time it takes to obtain and copy the protected health information and provide it to you.  

Amendment: If you believe the protected health information we have about you is incorrect or incomplete, you may ask us to amend the information. You will need to submit a written request on why you feel the health information should be amended. We may deny your request to amend it if you did not send a written request or give a reason why it should be amended. If we deny your request, we will provide you with a written explanation. We may deny your request if we believe the protected health information is accurate and complete.  

Accounting of Disclosures: You have the right to receive a list of instances in which we disclosed your personal health information unless the disclosure was used for treatment, payment, healthcare operations, was pursuant to a valid authorization and as otherwise provided in applicable federal and state laws and regulations. You must submit a written request to obtain this “accounting of disclosures” to the individual listed at the bottom of this policy. After your request has been approved, we will provide you the dates of the disclosure, the name of the individual or entity we disclosed the information to, a description of the information that was disclosed, the reason why it was disclosed, and any additional pertinent information.  This information may not be longer than (STATUTE OF LIMITATIONS) years ago prior to the date the accounting is requested. We reserve the right to charge a reasonable fee for this process. 

Restriction Requests: You have the right to request a restriction or limitation on the protected health information we use or disclose about you for treatment, payment, or healthcare operations. We shall accommodate your request except where the disclosure is required by law. We require this to be a written request submitted to the individual at the end of this policy. 

Confidential Communication: You have the right to request that we communicate with you about healthcare matters in a certain way and at a certain location.  We must accommodate your request if it is reasonable and allows us to continue to collect payments and bill you. 

Paper copy of this notice: You may request a hard copy of this practice policy if you reviewed and signed it via electronic means. To obtain this copy, contact the individual at the end of this privacy policy. 

Complaints: If you believe your privacy rights have been violated, you may file a complaint with our office. You also file a complaint with the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request.  

IV Infusion and Injection Consent Form 

This form outlines that you understand that a peripheral intravenous catheter will be inserted into a vein in your body, and you will have fluids, vitamins, minerals, nutrients, and/or medications infused directly into your body. This is considered “IV Infusion Therapy”. If you are having injection therapy, then you understand that a vitamin, mineral, nutritional compound, and/or medication will be injected directly into the subcutaneous fat or muscle of your body. This is considered “Injection Therapy.” 

Please initial each point below acknowledging that: 

_________ I understand that IV infusion and injection therapy at Reach Revive is not intended to diagnose or treat a specific medical condition. 

_________ I understand that IV infusion and injection therapy will not prevent, treat, or cure a medical condition or disease. Furthermore, I understand that I am here seeking IV infusion and/or injection therapy voluntarily to assist with certain symptoms or ailments I may be experiencing. 

_________ I have informed the staff at Reach Revive of all the medications, supplements, and allergies that I have. I understand that serious adverse events could happen if I do not disclose all my drug/food/vitamin/and additional allergies and medications/supplements that I am currently taking. 

_________ I understand that IV and injectable therapy and any claims made about these treatments have not been evaluated by the US Food and Drug Administration (FDA) and are not intended to diagnose, treat, cure, or prevent any medical disease. I understand that these treatments are not FDA approved for any given indications of treatment and are not considered a medical necessity.   

_________ I understand that I have been informed of the procedure involving IV infusion and injections, the alternative treatment options, and the risks and benefits of the mutually agreed upon treatment.  

_________ I understand that the procedure involves inserting a needle into a vein or having a solution injected into my muscle or body fat. 

_________ I understand that common risks involved with IV and injection therapies include, but are not limited to, irritation, pain, discomfort, bruising, and bleeding at the site of the IV insertion or injection.  

_________ I understand that less common risks involved with IV and injection therapies include, but are not limited to, infection at the site of the IV insertion or injection, injury to the tissue, phlebitis, low blood pressure, fainting, fluid volume overload, medication interactions, and drops in blood sugar levels. 

_________ I understand that rare risks involved with IV and injection therapies include, but are not limited to, sepsis, severe allergic reactions, severe medication/supplement interactions, anaphylaxis, blood clots, shock, cardiac arrest, and death.  

_________ I understand that the benefits of IV and injection therapies include, but are not limited to, enhanced absorption of vitamins and minerals as they bypass the digestive tract, increased total body hydration, alleviation of certain symptoms, increased total body nutrient density, and improved performance/recovery. 

_________ I affirm that I am voluntarily seeking IV infusion and injection therapies at Reach Revive and have not been coerced into doing so. 

_________ I understand the risks and benefits of the procedure, IV infusion therapy, and injection therapy and have had all my questions answered to my full satisfaction. 

_________ I understand that unforeseeable complications can arise when an IV is placed and medications/fluids/minerals/vitamins are infused into the body.  

_________ I understand that I have the right to refuse any treatments or treatment recommendations at any time. 

• I give my consent to taking Semaglutide injections as prescribed by my healthcare provider. 

• Semaglutide is a human-based glucagon-like peptide-1 receptor agonist used to manage weight loss and diabetes. 

• I have been informed of the correct method of administering semaglutide injections and the dosage. 

• I will not take this medication if I have a history of the following:

• you are pregnant or plan to become pregnant while taking this medication

• you have a personal or family history of medullary thyroid cancer 

• you have Neoplasia Syndrome Type 2 (MEN2)

• you have a history of pancreatitis, kidney failure or disease, liver failure or disease, or digestive ulcers

•  you are allergic to Semaglutide or any other GLP-1 agonist medication or you have other undisclosed allergies

•  you are diabetic and currently take medication to lower your blood sugar or have diabetic retinopathy

• Potential side effects: nausea, vomiting, diarrhea, constipation, heartburn, burping, abdominal pain

• Common site reactions: itching, burning, skin thickening (welting)

• In case of a severe allergic reaction, such as itching, rash, swelling of the face, tongue or throat and anaphylaxis, seek immediate assistance. 

• Possible drug interactions: anti-diabetic agents such as insulin and Sulfonylureas can lead to a high risk for hypoglycemia (low blood sugar).

• Do not combine with other GLP-1 MEDICATIONS.

• I have inform my provider about other medications that I take to lower your blood sugar 

• I understand that Semaglutide is one part of a comprehensive lifestyle approach that includes a healthy diet and exercise and regular follow up visits to adjust dosages.

By signing, I confirm that I have been fully informed of the potential risks and benefits  and complications and I voluntarily agree to taking Semaglutide. I have had the opportunity to ask questions and all of my concerns have been addressed to my satisfaction. I release Reach Revive and Jessica Foutch, NP from any liability or claims arising from the treatment. 

Reach Revive Clinical Policies 

PATIENT CONSENT FOR IV INFUSION AND INJECTION THERAPIES WITH REACH REVIVE. 

If you have any questions, please feel free to ask us. Please initial each point acknowledging that you understand: 

_______ If you are late or miss your appointment, you may be subject to a $50 fee.

_______ Services must be paid for at the time of service. 

_______ I understand that treatments used at REACH REVIVE are not to be considered a medical

necessity. Treatments rendered are for the purpose of improving your quality of life. 

_______ I agree that if I am having any side effects or become sick, that I will follow up with my Primary

Care Provider or go to an Urgent Care or Emergency Department. 

_______ I acknowledge that REACH REVIVE, Dr. Jeffrey Cloyd, MD and Jessica Foutch, FNP are not 

my primary care providers. I agree that I will continue with routine care through my primary

care provider and notify them of treatments prescribed and performed at REACH REVIVE. 

_______ I understand that there are no refunds for services or products rendered.

_______ I understand that having an appointment with REACH REVIVE does not necessarily entitle me

to having an IV infusion or injection procedure performed. Every individual is different, and it

is at the medical provider's discretion to issue treatment.

_______ I understand that I must maintain my follow up appointments and follow post procedural care

instructions to remain on treatment. It is important that Jessica Foutch, FNP manages my

treatment and it is at their discretion to provide me ongoing therapies if desired.

_______ I acknowledge that I have been advised of the risks and benefits of treatment. I also

acknowledge that I have been advised of possible complications and side effects. I understand

the risks, benefits, complications, and side effects of treatment. 

_______ I am voluntarily requesting treatment with REACH REVIVE and Jessica Foutch, FNP in regard

to IV infusion therapy and injection therapy as determined by a mutual decision between

myself and the medical provider even if it is not considered a medical necessity. 

_______ I do not hold any medical practitioner of REACH REVIVE responsible for performing

age-related preventive care. I agree that I will follow up with my primary care provider to

obtain these screenings and I hold REACH REVIVE and Dr. Jeffrey Cloyd, MD and 

Jessica Foutch, FNP harmless if an adverse event occurs during my treatment.