Terms and Conditions
USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION
I consent to allow Quantified Wellness LLC dba DexaFit Vancouver to use their DXA scanner to perform a body composition and/or bone densitometry scan, with full awareness that the technology uses low-dose x-rays. The Bone Densitometry scan is Tech Only and is not read by a Radiologist with DexaFit and will not be reviewed with the client.
RECORDS REVIEW FOR RESEARCH
I also authorize Quantified Wellness LLC dba DexaFit Vancouver to review my records to determine my body scan’s qualifications for approved clinical studies and to contact me if I have potential as a research candidate. No records are ever provided to other persons for research purposes, except by specific written approval from me.
FINANCIAL RESPONSIBILITY
I accept financial responsibility for all charges for services provided to me and/or my family members. I verify that I am the cardholder and authorize Quantified Wellness LLC dba DexaFit Vancouver to charge the card on file in my account for purchases, no show fees, late cancellation or reschedule fees. In the event Quantified Wellness LLC dba DexaFit Vancouver is not able to charge the card on file, whatever fees may be applicable are required to be paid immediately and are subject to collections if remain unpaid. Fees must be paid before next service appointment will be honored.
No refunds on tests rendered. All packages expire 12 months from date of purchase. No refunds or partial refunds on tests left unused on packages purchased. Tests do not roll over year to year. We do not remind clients of unused tests. No extensions will be granted on packages.
Vouchers codes, gift cards, or discount codes must be applied at scheduling. Please contact us at (971) 245-4010 if you have issues applying the code. If an appointment is paid in full at scheduling, we do not refund in order to apply a voucher, code, or gift card to the appointment. The voucher, gift card, or discount code can be used toward the next appointment.
We do accept HSA/FSA cards but it is the clients responsibility to check coverage for services. We can provide an itemized receipt upon request for reimbursement.
Please DO NOT bring guests/children/pets to your appointment. Due to radiation concerns in the facility, the comfort of other clients, and our goal to provide a distraction free appointment, guests, children, or pets are prohibited and will be asked to leave upon arrival, no exceptions. If necessary, the appointment will be cancelled or rescheduled and late cancel fee will apply. If two clients are scheduled back to back they are permitted to come in together.
CANCELLATION/LATE ARRIVAL POLICY: DexaFit Vancouver is an appointment based office. If you are unable to make your appointment please give us as much notice as possible so that others have the opportunity to get in. Please notify us of cancellation or reschedule 24hrs prior to your appointment. If you are more than 10 minutes late your appointment may need to be rescheduled to avoid disrupting other appointments and late cancellation fee will be applied. If you are more than 10 minutes late without notification to our DexaFit Vancouver team, your appointment will be cancelled. If you arrive unprepared for a test or decide not to do a scheduled test during the appointment, a late cancel fee will be applied to the test we are unable to perform.
In the event of reschedules/cancellations after 24 hours prior to the appointment or no show, client will be charged $75 per test scheduled, regardless of when the appointment was booked or how many spaces were available at the time. Prepaid appointments or packages: the late cancel/no show fee will be applied to the prepayment and the remaining amount can be used as credit for next visit or the test will be deducted from the package. No partial refunds.
WAIVER AND AGREEMENT
1. I do hereby release all representatives of Quantified Wellness LLC dba DexaFit Vancouver and/or DexaFit, Inc. that are acting upon their behalf from any responsibility or liability for any injury or damage to myself, including those caused by the negligent act or omission of any of those mentioned or others acting on their behalf or in any way arising out of or connected with my participation in services, activities, or programs of Quantified Wellness LLC dba DexaFit Vancouver and/or DexaFit, Inc.
2. I am voluntarily participating in the Quantified Wellness LLC dba DexaFit Vancouver and/or DexaFit, Inc DXA scan service and/or other Quantified Wellness LLC dba DexaFit Vancouver and/or DexaFit, Inc services, including but not limited to RMR Metabolic Analysis and VO2max testing. I hereby agree to expressly assume any and all risks of injury and death resulting from participation in the aforementioned services.
3. I further hereby declare myself to be physically sound and suffering from no condition, impairment, disease, infirmity, or other illness that disqualifies me from receiving services from Quantified Wellness LLC dba DexaFit Vancouver and/or DexaFit, Inc. I acknowledge that I have permission to participate or that I have decided to participate in these services without the approval of my physician and do hereby assume all responsibility for my participation. I also certify that I am not pregnant or trying to become pregnant.
4. I take full responsibility for any action taken by me after my visit to Quantified Wellness LLC dba DexaFit Vancouver and/or DexaFit, Inc. I do not hold any representatives of Quantified Wellness LLC dba DexaFit Vancouver or DexaFit, Inc responsible or liable for any adverse effects or complications arising from the services or opinions offered by them.
5. Confidentiality. The information based on the observations made during the DXA scan, VO2max, or RMR analysis, and subsequent report is treated as privileged and confidential. However, it may be used for statistical or scientific purposes with your right to privacy retained.
6. I understand that Quantified Wellness LLC dba DexaFit Vancouver and/or DexaFit, Inc does not diagnose or interpret the DXA results, and that any further review or analysis of the report is between the individual and their primary care physician.
CLIENT HIPAA CONSENT FORM
I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I authorize Quantified Wellness LLC dba DexaFit Vancouver and/or DexaFit, Inc to use and disclose my protected health information to carry out:
Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment);
Obtaining payment from third party payers (e.g. my insurance company);
The day-to-day operations of Quantified Wellness LLC dba DexaFit Vancouver and/or DexaFit, Inc. practice.
I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment and health care operations, but that you are not required to agree to these requested restrictions. However, if you do agree, you are then bound to comply with this restriction.
I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date I revoke this consent is not affected.
AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION
I hereby authorize Quantified Wellness LLC dba DexaFit Vancouver and/or DexaFit, Inc to forward the health and fitness information resulting from their services to me or any parties authorized by me by means of email, fax, mail, or through the private login page on the DexaFit website. I also understand that this Authorization is subject to revocation/withdrawal by me at any time in writing to DexaFit Vancouver info.vancouver@dexafit.com, except to the extent that the action has already been taken to release this information. This Authorization shall remain valid unless revoked. Quantified Wellness LLC dba DexaFit Vancouver and/or DexaFit, Inc will not forward my health and fitness information if I do not consent to this Authorization.
I have read the above and do consent to participate in the services rendered by Quantified Wellness LLC dba DexaFit Vancouver.