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Cancellation Policy

I, understand and acknowledge the importance of adhering to the cancellation policy of Ikigai Energy to ensure efficient scheduling and respect for both my time and the Ikigai Energy's time. By signing below, I agree to the terms outlined in this policy.

I must provide a minimum of 24 hours’ notice if I need to cancel or reschedule my appointment. This enables Ikigai Energy to accommodate other clients and adjust schedules accordingly.

I understand that a "no-show" occurs when I miss an appointment without a minimum of 24 hour notice. In the event of a “no-show”, I acknowledge that I will be charged $100 cancellation fee. I also understand that future appointments may require prepayment to secure the reservation

I acknowledge that if I arrive late more than 15 minutes may be treated as a “no-show”, subject to the corresponding fee(s) outlined above.

I acknowledge that cancellations made within 24 hours of my appointment will be subject to a $100 cancellation fee

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Purpose of Nutrition Coaching

Scope of Services

• Ikigai Energy staff member(s) are not licensed registered dietitians (unless otherwise specified).

• Provides general nutrition advice based on current guidelines and my individual information.

• Will refer me to a qualified healthcare provider if I have medical or nutritional conditions requiring specialized care.

Client Responsibilities

I agree to

• Provide accurate and complete information regarding my health history, medications, and lifestyle.

• Follow the recommendations as best as I can but understand results may vary.

• Inform my healthcare provider about my participation in nutrition coaching.

Confidentiality

All personal and health information shared during coaching sessions will be kept confidential, except as required by law or where disclosure is necessary to protect my health and safety.

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HIPAA Authorization

Authorization for Use and Disclosure of Personal Health Information

This authorization is prepared pursuant to the requirements of the Health Insurance Portability and Accountability Act of 1996 (P.L. 104-191), 42 U.S.C. section 1320d, et seq., and regulations promulgated there under, as amended from time to time (collectively referred to as “HIPAA”).

This authorization affects your rights in the privacy of your personal healthcare information. Please read it carefully before signing. Ikigai Energy, LLC will not condition treatment,
payment, enrollment in a health plan, or eligibility for benefits as applicable, on you providing authorization for the requested use or disclosure.

You May Refuse To Sign This Authorization.

By signing this authorization, you acknowledge and agree that Ikigai Energy, LLC may use or disclose your personal healthcare information for the purpose(s) of treatment, payment and operation at Ikigai Energy, LLC.

By signing this authorization, you agree that Ikigai Energy, LLC may disclose your personal healthcare information to those recipients who need it for treatment, payment, and/or operations. Further by signing this authorization you acknowledge that Ikigai Energy, LLC Authorization for Use and Disclosure of Personal Health Information containing a complete description of your rights.

In accordance with your rights under, and subject to certain restrictions imposed by HIPAA, you may inspect or copy your PHI in the designated record set maintained by Ikigai Energy, LLC for as long as the PHI is maintained in the designated record set.

You have the right to revoke this authorization, in writing, at any time, except to the extent that Ikigai Energy, LLC has acted in reliance on it. A revocation is effective upon receipt by Ikigai Energy, LLC of a written request to revoke and a copy of the executed authorization form to be revoked at the address listed above. Authorization shall expire upon the earlier occurrence of: revocation of the authorization, a finding by the Secretary of the U.S. Department of Health and Human Services, Office of Civil Rights that this authorization is not in compliance with requirements of HIPAA Complete satisfaction of the purposes for which this authorization was originally obtained, to be determined in the reasonable discretion of Ikigai Energy, LLC or six years from the date this authorization was executed.

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Telehealth Consent

Ikigai Energy, LLC located at 812 E. Oskaloosa Street, Pella, Iowa 50219 utilizes telehealth services to provide high quality care to all its patient(s). Telehealth, also known as telemedicine, involves the use of electronic communications to enable health care providers in various locations to share patient information for diagnostic purposes, therapy recommendations, follow up consultations, and/or patient education. The medical practitioners involved in my care may include but are not limited to a supervising physician, physician’s assistants, nurse practitioners, registered nurses, medical assistants, and other HIPAA certified professionals.

Telemedicine requires transmission of health information through the internet via electronic devices ranging from computers to handheld devices and may include:

1) Provider progress reports

2) Assessments

3) Other intervention related documents

4) Bio-physiological data transmitted electronically

5) Videos, pictures, text messages, audio

6) Any digital form of data

The laws that are currently in place for protected health information will be applied to the data obtained during a telehealth visit. Information obtained during telehealth/telemedicine that identifies me will not be given to anyone without my consent except for the purposes of treatment, education, billing, and healthcare operations.

As with any Internet-based communication, I understand that there is a risk of security breach. Electronic systems used will incorporate network and software security protocols to protect the confidentiality of my identity and will include measures to safeguard the data to ensure its integrity against intentional or unintentional corruption.

Telehealth sessions may not always be possible due to disruptions of signals or problems with the Internet’s infrastructure. Issues related to this may cause problems such as poor picture or sound quality, dropped connections, audio interference that prevent effective interaction between consulting clinician(s), patient, or care team.

Telehealth sessions may also be conducted by phone. With the agreement and permission by the patient. By signing this document, you are agreeing to this statement and wish to proceed with your Telehealth visits (by phone) with Ikigai Energy, LLC practitioners and clinical staff.