Notice of Insurance Practices and of Client Financial Responsibility
I acknowledge that, with respect to services rendered by Robyn Tiger, Stress Free, LLC, a North Carolina Limited Liability Company, and their employees and agents (collectively “Company”), I understand the following.
General Office Policies
No Guarantees. Company does not guarantee any specific result. It is the client’s responsibility to follow through on seeking medical care and treatment by a licensed medical provider.
Not a Medical Provider: Company is not a medical provider and may not provide medical advice or treatment. You should seek medical treatment, care, and follow-up with a licensed medical provider. Company requires that every adult client have a primary care physician, and that every pediatric patient have a pediatric physician. In my case, such physician is:
Online and phone communication; Electronic signatures. Provider stores office records digitally. While Provider makes reasonable efforts to keep the data secure according to legal requirements, and maintains the privacy and confidentiality of client data, you understand that no system is 100% secure. You agree that electronic signatures below are the legal equivalent of manual signatures on this Agreement, and manifest consent to be legally bound by this Agreement’s terms and conditions. You also agree and understand that any information that is shared with you by Company is confidential and proprietary.
Office Insurance Practices and Client Financial Responsibility
No Participation in Insurance Plans or Medicare: Company does not participate in any insurance panels, and does not accept assignment from any insurance company. Consequently, you are responsible for payment in full at time of service and charges are determined by Company.
No Responsibility To Determine Eligibility for Benefits: Company is not responsible for determining eligibility for benefits or for assisting you with collecting insurance benefits and has no responsibility to correspond with or telephone or email any insurer.
My Financial Responsibility: You are financially responsible for any charges for services. You also agree to be responsible for costs and expenses, including court costs, attorney fees and interest, should it be necessary for Company to take action to secure payment of an outstanding balance.
Intellectual Property: Company’s copyrighted and original materials will be provided to you for individual use only and a single-user license. You are not authorized to use any of Company’s intellectual property for your business purposes. You are not authorized to share, copy, distribute, or otherwise disseminate any materials received from Company electronically or otherwise without the prior written consent of Company. All intellectual property, including Company’s copyrighted course materials, shall remain the sole property of Company. No license to sell or distribute Company’s materials is granted or implied.
Disclaimer of Warranties; Limitation of Liability. Company disclaims all warranties, both express and implied, including any warranty of non-infringement, fitness for a particular purpose or merchantability; and Company’s liability hereunder shall be limited to the aggregate fees paid to Company by you for the Program until termination. Company has no liability to you for any incidental and consequential damages, whether or not foreseeable or contemplated by Company (including but not limited to any loss, cost, injury, or expense caused by, or resulting from, a delay in responding to Client, whether from technical failures or otherwise).
No assignment: This Agreement is not transferrable or assignable without Company’s prior written consent.
Governing Law. This Agreement shall be governed by and construed in accordance with laws of the State of North Carolina without regard to North Carolina’s choice of law provisions.
Arbitration. In the event that any dispute arises between the parties arising out of or related to the validity, interpretation, enforcement, or performance of this Agreement, or otherwise arising out of the relationship between the parties or the termination of that relationship, and a party wishes to pursue the dispute, such party shall submit the dispute to binding arbitration in accordance with the Commercial Rules of the American Arbitration Association (“AAA”). The Arbitration shall be held in Charlotte, North Carolina. The arbitrator(s) shall apply North Carolina substantive law, or federal substantive law where state law is preempted. The arbitrator(s) shall have the power to grant all legal and equitable remedies provided by the above state law and award compensatory damages provided by the above state law, except that punitive damages shall not be awarded. The arbitrator(s) shall prepare in writing and provide to the parties an award including factual findings and the legal reasons on which the award is based. The arbitrator(s) shall not have the power to commit errors of law or legal reasoning. Any judicial review of the arbitrator(s) decision shall be governed by the above state law. EACH PARTY HAS READ AND UNDERSTANDS THIS SECTION, WHICH DISCUSSES MEDIATION AND ARBITRATION. EACH PARTY UNDERSTANDS THAT BY SIGNING THIS AGREEMENT, THE PARTY AGREES TO SUBMIT ANY CLAIMS ARISING OUT OF, RELATING TO, OR IN CONNECTION WITH THIS AGREEMENT, OR THE INTERPRETATION, VALIDITY, CONSTRUCTION, PERFORMANCE, BREACH, OR TERMINATION THEREOF TO ARBITRATION, AND THAT THE DISPUTE RESOLUTION PROVISIONS SET FORTH IN THIS SECTION CONSTITUTE A WAIVER OF THE PARTY’S RIGHT TO A JURY TRIAL.
I have carefully read this form, which is printed in English, and acknowledge that English is a language I read and understand, and that I understand the form. I do not feel rushed or impaired, nor am I under the influence of a sedative or sleep-inducing medication.
I accept and agree to all of the terms above. I am free to refuse or withdraw my consent and to discontinue participation in any treatment, service, or research at any time without fear of reprisal against or prejudice to me. No representations, statements, or inducements, oral or written, apart from the foregoing written statement, have been made. I may request and receive a copy of this form from the Practice. If any portion of this form is held invalid, the rest of the document will continue in full force and effect.