Patient Terms
Effective Date: 01/05/2026
INTRODUCTION
By signing and submitting your patient intake, you (“Patient,” “you,” or “your”) agree to be bound by these Terms and Conditions and acknowledge that you have read, understood, and agree to comply with all provisions herein. These Terms and Conditions govern your relationship with Haven Health Group, Inc. (“Haven,” “we,” “our,” or “us”) and all healthcare services provided by Haven.
SECTION 1: HIPAA NOTICE OF PRIVACY PRACTICES ACKNOWLEDGMENT
Haven has provided you with our Notice of Privacy Practices, which describes how your medical information may be used and disclosed by Haven and your rights regarding your protected health information pursuant to 45 CFR Part 164. By signing below, you acknowledge that you have received Haven’s Notice of Privacy Practices and have had the opportunity to review it. You understand that Haven may amend the Notice of Privacy Practices at any time and that the current version will be made available upon request and will be posted at Haven’s offices and on our website. You further understand that your protected health information will be used and disclosed in accordance with applicable federal and state privacy laws.
SECTION 2: CONSENT TO TREAT
You hereby consent to and authorize Haven and its physicians, nurse practitioners, physician assistants, and other healthcare providers to provide medical care, treatment, and services to you as they deem necessary and appropriate. This consent includes examinations, diagnostic procedures, laboratory tests, imaging studies, therapeutic procedures, medications, and any other medically necessary treatments. You acknowledge and understand that the practice of medicine is not an exact science and that no guarantees have been made to you regarding the outcome of any treatment or procedure. You consent to the participation of supervised residents, medical students, physician assistant students, nurse practitioner students, and other trainees in your care under the appropriate supervision of licensed providers. You understand that you have the right to refuse any recommended treatment, procedure, or medication, and you acknowledge that such refusal may affect your health and treatment outcomes. This consent shall remain valid for all future visits and treatment at Haven unless you revoke it in writing.
SECTION 3: FINANCIAL RESPONSIBILITY
You acknowledge and agree that you are financially responsible for all charges incurred for services provided by Haven that are not covered by your insurance or other third-party payor. You agree to pay all applicable co-payments, co-insurance amounts, and deductibles at the time services are rendered. You are responsible for paying all outstanding balances within thirty (30) days of the statement date. You authorize Haven to bill your insurance carrier on your behalf and assign insurance benefits directly to Haven; however, you remain ultimately responsible for all charges if your insurance carrier denies payment for any reason. Haven reserves the right to charge interest at a rate of one and one-half percent (1.5%) per month (or the maximum rate allowed by California law, whichever is less) on all balances that remain unpaid after sixty (60) days from the statement date. You authorize Haven to use collection agencies to collect unpaid balances and agree to pay all reasonable collection costs and attorneys’ fees incurred by Haven to the extent permitted by applicable law. Haven reserves the right to require payment in full at the time of service or require deposits for patients who are uninsured or have outstanding balances. You authorize Haven to keep your credit card information on file and to charge your card for services rendered, provided that Haven will provide advance notice for charges exceeding $1,000 USD.
SECTION 4: PATIENT RIGHTS AND RESPONSIBILITIES
Patient Rights. You have the right to: (a) receive respectful and considerate care from Haven’s staff and providers; (b) privacy and confidentiality of your medical information in accordance with applicable laws; (c) receive information about your diagnosis, treatment options, and prognosis in terms you can understand; (d) participate in decisions about your care and treatment; (e) refuse treatment (understanding the consequences of such refusal); (f) review your medical records in accordance with California and federal law; (g) be informed of Haven’s policies and procedures that affect your care; and (h) file complaints regarding your care without fear of retaliation or discrimination.
Patient Responsibilities. You agree to: (a) provide accurate, complete, and honest information about your health history, current medications, and any changes in your condition; (b) inform your healthcare providers promptly of any changes in your condition or any concerns you may have; (c) follow treatment plans and instructions provided by your healthcare providers, or inform them if you are unable or unwilling to comply; (d) keep scheduled appointments or provide timely notice of cancellation; (e) treat all Haven staff, providers, and other patients with respect and courtesy; (f) comply with Haven’s policies and procedures; (g) provide accurate insurance and contact information and notify Haven promptly of any changes; and (h) fulfill your financial obligations promptly.
SECTION 5: TELEHEALTH CONSENT
Telehealth services, as defined by California Business and Professions Code Section 2290.5, include the delivery of healthcare services through the use of information and communication technologies, including video conferencing, audio-only communication, store-and-forward technologies, and other electronic means. You consent to receive healthcare services from Haven via telehealth platforms when deemed appropriate by your provider. You understand the potential benefits of telehealth, including increased access to care, convenience, and reduced travel time and costs. You also understand the potential risks of telehealth, including but not limited to: technology failures that may interrupt or degrade the quality of communication; reduced ability for your provider to perform physical examinations; potential for misdiagnosis due to limitations in remote assessment; and security risks despite encryption and other protective measures. You agree that you are responsible for ensuring a private location for telehealth visits and for having adequate technology and internet connectivity. You retain the right to withdraw your consent to telehealth services and request an in-person visit at any time. You understand that telehealth may not be appropriate for all medical conditions and that your provider retains the discretion to require in-person visits when clinically indicated. You acknowledge that telehealth visits will be billed at the same rates as in-person visits unless otherwise specified by Haven. Haven reserves the right to discontinue telehealth services if technology is inadequate or if you are non-compliant with telehealth protocols. You consent to the recording of telehealth sessions for medical record purposes, and you will be notified if any session is being recorded.
SECTION 6: CONSENT FOR HAVEN’S USE OF AI TOOLS
You acknowledge and consent to Haven’s use of artificial intelligence (AI) and machine learning tools to assist in clinical decision support, administrative functions, medical documentation, appointment scheduling, and patient communications. You understand that AI tools are used to supplement, not replace, the clinical judgment and decision-making of Haven’s healthcare providers. All AI-generated recommendations, analyses, or outputs are reviewed and validated by qualified healthcare professionals before being acted upon in your care. You specifically consent to Haven’s use of AI for: transcription and medical documentation; clinical decision support and diagnostic assistance; appointment scheduling and automated reminders; patient portal communications and chatbots; billing and coding assistance; and care coordination activities. You understand that AI systems may process your protected health information in accordance with HIPAA regulations and Haven’s Notice of Privacy Practices. Haven commits to using only AI vendors that comply with HIPAA requirements and maintain appropriate Business Associate Agreements. You have the right to request information about specific AI tools used in your care. Haven shall not be liable for errors in AI tool outputs where Haven has exercised reasonable professional judgment in reviewing and acting upon such outputs.
SECTION 7: PATIENT CODE OF CONDUCT
You agree to treat all Haven staff, healthcare providers, and other patients with respect and courtesy at all times. You agree that you will not engage in harassment, threats, violence, abusive language, discriminatory conduct, or any other behavior that creates an unsafe or uncomfortable environment. You agree not to possess weapons of any kind on Haven’s premises. You agree to comply with all instructions from Haven staff regarding safety protocols, operational procedures, and facility policies. You agree not to record, photograph, or video Haven staff or other patients without their express written consent. Haven reserves the right to terminate the physician-patient relationship for violations of this code of conduct, with appropriate notice as required by law, except in emergency situations. Haven reserves the right to refuse non-emergency services if your behavior is disruptive, threatening, or non-compliant with this code of conduct. Haven reserves the right to involve law enforcement if your behavior poses a safety risk to staff, providers, or other patients.
SECTION 8: CANCELLATION AND NO-SHOW FEE AGREEMENT
You agree to provide at least twenty-four (24) hours advance notice for any appointment cancellation or rescheduling request. You will be charged a no-show fee of $150 for standard appointments, or $150 for specialist consultations or extended appointments, if you miss a scheduled appointment without providing twenty-four (24) hours notice. You will be charged a late cancellation fee of $150 if you cancel an appointment with less than twenty-four (24) hours notice. These fees are not billable to insurance and are your sole financial responsibility. Repeated no-shows (three or more within a twelve-month period) may result in dismissal from the practice with appropriate notice. Haven may, in its sole discretion, waive these fees for documented medical emergencies or other extraordinary circumstances. You acknowledge that missed appointments prevent other patients from receiving timely medical care and result in inefficient use of healthcare resources.
SECTION 9: CONSENT TO CONTACT VIA EMAIL OR TEXT
You consent to Haven contacting you via email, text message, and telephone at the contact information you have provided. Such communications may include: appointment reminders and confirmations; non-urgent laboratory and test results; billing statements and payment notices; prescription notifications and refill reminders; health information, educational materials, and wellness reminders; and patient satisfaction surveys. You acknowledge that email and text messaging are not completely secure forms of communication and you assume the risk that such communications may be intercepted by unauthorized parties. You are responsible for notifying Haven immediately of any changes to your contact information. You may opt out of non-essential communications by following the instructions provided in such communications or by notifying Haven in writing; however, Haven reserves the right to contact you regarding treatment-related matters, appointment scheduling, and billing communications regardless of your opt-out preferences. Haven is not responsible for missed communications due to incorrect contact information you have provided, spam filters, delivery failures, or carrier-related issues. You understand that message and data rates may apply for text messages as determined by your mobile carrier.
SECTION 10: CONSENT TO REQUEST RECORDS FOR TRANSFER
If you have indicated that you wish to transfer medical records from prior healthcare providers, you hereby authorize Haven to request and obtain such medical records on your behalf from the providers you have identified or, if selected, from all of your prior healthcare providers. This authorization shall remain valid for twelve (12) months from the date of your signature below. You may revoke this authorization in writing at any time, although such revocation will not affect records already requested or obtained prior to Haven’s receipt of your written revocation. You understand that your prior healthcare providers may charge fees for copying and transferring medical records, and you agree that you are responsible for paying such fees. You authorize Haven to disclose the minimum necessary information about you to your prior providers to facilitate the identification and transfer of your medical records.
SECTION 11: DATA USAGE AND PRIVACY
Haven is committed to protecting your personal and health information in accordance with the Health Insurance Portability and Accountability Act (HIPAA), the California Confidentiality of Medical Information Act (Civil Code Section 56 et seq.), and the California Consumer Privacy Act/California Privacy Rights Act (CCPA/CPRA). Haven will use and disclose your protected health information only for the following purposes: treatment, payment, healthcare operations, as required by law, and with your written authorization. Haven may de-identify your health information in accordance with HIPAA standards and use such de-identified information for research, quality improvement, population health analytics, and other lawful business purposes without obtaining additional consent from you. Under the CCPA/CPRA, you have the right to know what personal information Haven collects about you, the right to request deletion of your personal information (subject to medical record retention requirements), the right to opt-out of the sale of your personal information (Haven does not sell personal information), and the right to non-discrimination for exercising your privacy rights. Haven will retain your medical records in accordance with California law, which requires retention for a minimum of seven (7) years for adult patients and longer periods for minor patients. Haven will make disclosures of your information to third parties only as permitted by applicable law or with your written authorization. Haven reserves the right to use aggregated, de-identified patient data for operational improvements, clinical research, quality assessment, and healthcare analytics.
SECTION 12: GENERAL PROVISIONS
Entire Agreement. These Terms and Conditions, together with Haven’s Notice of Privacy Practices and any specific consent forms you may sign, constitute the entire agreement between you and Haven regarding the subject matter hereof and supersede all prior agreements and understandings.
Severability. If any provision of these Terms and Conditions is found to be invalid, illegal, or unenforceable, the remaining provisions shall remain in full force and effect.
Amendment. Haven may amend these Terms and Conditions at any time by providing notice to you. Your continued receipt of treatment from Haven after such notice shall constitute your acceptance of the amended terms.
Governing Law. These Terms and Conditions shall be governed by and construed in accordance with the laws of the State of California.
Dispute Resolution. Any disputes arising out of or relating to these Terms and Conditions or your care at Haven must first be addressed through good faith negotiations. If such negotiations fail to resolve the dispute within sixty (60) days, any remaining disputes (excluding small claims court matters) shall be resolved through binding arbitration administered by the American Arbitration Association in accordance with its Commercial Arbitration Rules. The arbitration shall take place in the county in California where Haven’s primary office is located. YOU HEREBY WAIVE YOUR RIGHT TO A JURY TRIAL AND TO PARTICIPATE IN CLASS ACTION LAWSUITS.
Assignment. You may not assign your rights under these Terms and Conditions. Haven may assign its rights and obligations to successor entities or affiliates.
No Waiver. Haven’s failure to enforce any provision of these Terms and Conditions shall not be deemed a waiver of such provision or Haven’s right to enforce it in the future.
PATIENT (OR AUTHORIZED REPRESENTATIVE) ACKNOWLEDGMENT
By signing and submitting my patient intake, I acknowledge that I have read, understood, and agree to be bound by these Terms and Conditions. I confirm that I have received a copy of these Terms and Conditions and Haven’s Notice of Privacy Practices.
Contact Us
You may contact us in connection with this Policy at the following:
Haven Health
Email: legal@havenhealth.care
Attn: Michael Piscadlo
6221 Wilshire Blvd, Suite 216
Los Angeles, CA 90048
