• I as a patient have a right to be informed about my condition and recommended care. This disclosure is to help me become better informed so I may make the decision to give or withhold my consent to undergo treatment having had the opportunity to discuss potential benefits, risks and hazards involved.

    • I hereby voluntarily authorize and consent to medical examination, evaluation, and treatment for myself (or for the patient named below, for whom I am legally responsible) in person or via telehealth, by Marianna Guy, Family Nurse Practitioner, at Thrive GVL LLC.

    • I understand that holistic evaluation and treatment may include, but is not limited to, clinical history taking, physical examination, nutrition response testing, ordering diagnostic imaging and tests, ordering specialty lab tests, prescription of certain medications and nutritional supplements, dietary counseling, and homeopathic formulas referred to as remedies.

    • I understand that the U.S. Food and Drug Administration does not formally evaluate or approve nutritional, herbal, and homeopathic supplements, for any medical treatments. I understand that vitamins, minerals, herbs, and other dietary supplements are not FDA-approved to treat or prevent disease. The Nutrition Response Testing system, wellness products, and statements about dietary supplements, have not been evaluated by the Food and Drug Administration. These products are not intended to diagnose, treat, cure, or prevent any disease. I understand that these treatments and dietary supplements are not FDA approved for any given indications of treatment and are not considered a medical necessity.

    • I understand that, as with any prescription medication, nutritional supplements, herbal and homeopathic remedies may exhibit some side effects in certain sensitive individuals, may interact with certain prescription medications or lab test results, and users may show symptoms due to certain pre-existing disease conditions.

    • I have had the opportunity to ask questions and discuss treatments with Marianna Guy, FNP, to my satisfaction:

      • My suspected diagnosis or condition

      • The nature, purpose and potential benefit of the proposed care

      • The inherent risks, complications, potential hazards, or side effects of the treatment or procedure

      • The probability or likelihood of success

      • Reasonable available alternatives to the proposed treatment / procedure

      • The possible consequences if treatment or advice is not followed and/or nothing is done.

    • I do not expect the provider to be able to anticipate and explain all risks and complications, and I wish to rely on the provider to exercise judgment during the course of the procedure which the provider feels at the time, based on the facts then known, that are in my best interest. I further acknowledge that no guarantees or assurances have been made to me concerning the results intended from the treatment.

    • I have informed Thrive GVL LLC, Marianna Guy NP, and the medical staff of all the medications, supplements, and allergies that I have. I understand that serious adverse events could happen if I do not disclose all of my drug/food/vitamin/and additional allergies and medications/supplements that I am currently taking.

  • Payments for Appointments: Full payment is required at the time of service for in-office and Telehealth appointments. We reserve the right to collect a 50% deposit at least 48 hours prior to the appointment. A superbill and/or itemized receipt is available upon request. All sales are final. No refunds or exchanges will be given for professional medical services, or any products purchased including prescription medication and nutritional supplements.

    Forms of Payment: We accept all major credit cards, cash, HSA and FSA cards.

    Self-Pay Policy: This is a self-pay (cash-pay) office. We do not bill insurance or Medicare, and do not accept insurance for any services, prescription medication, or nutritional supplements provided at this office. We do not provide or submit any forms for insurance reimbursement, prior authorization, workers' compensation, disability, or insurance billing. Any special requests to complete additional forms will be billed at the current hourly rate. By agreeing to receive care at this office you waive your Medicare benefits for services at this office, and agree that you will not submit any claims to Medicare for services received at this office.

    Missed Appointment and No-Show Fee: A charge of 50% of the appointment rate, or a minimum fee of $60, will be charged for same day cancellations, missed appointments, and no-shows. We require a 24-hour notice to cancel or reschedule an appointment. Call or text (864) 729-2757 if you need to make any scheduling changes.

    Anti-Violence Policy: Patient and staff safety is a priority. Any patient who exhibits aggressive behavior, sexual harassment, physical or verbal harassment towards any staff member or towards other patients, will be subject to immediate dismissal from the practice.

    By signing below I agree to the Office Policies & Self-Pay Agreement.

    - I am responsible to pay in full at the time of service for all charges related to the services provided to me, and/or my dependents.

    - I understand that Thrive GVL and its providers are not in network with any insurance plans, and do not bill Medicare.

    - I understand that all sales are final, and that no refunds or exchanges will be given.

    Self-Pay Rates:

    - New Patient Visit to Establish Care - $350.00

    - Established Patient Visit (up to 30 min) - $125.00

    - Established Patient Visit (30-60 min) - $250.00

    - Lab Testing/Bloodwork: Price based on test and quoted at time of order.

    - Nutritional Supplements and healthcare products are priced separately, and subject to SC state and local sales tax.

    By signing below I acknowledge I have read, or have had read to me, and understand the above Consent to Medical Treatment. I voluntarily authorize and consent to medical examination, evaluation, and treatment, in person and via telehealth. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment. By signing below I agree to the Office Policies & Self-Pay Agreement.

  • HIPAA Notice of Privacy Practices

    IN COMPLIANCE WITH THE FEDERAL REGULATIONS OF HIPAA’S PRIVACY RULE, THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN OBTAIN ACCESS TO IT

    We respect our legal obligation to keep health information, that may identify you, private. We are obligated by law to provide you with notice of our privacy practices. This notice describes how we protect your health information and your rights.

    1. TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS: The most common reasons we would use or disclose your health information is for treatment, payment, or business operations. We routinely use and disclose your medical information within the office on a daily basis. We do not need specific permission to use or disclose your medical information in the following matters, although you have the right to request that we do not.

    Examples of how we may use or disclose health information for treatment purposes may include: Scheduling or rescheduling appointments; reminding you about your upcoming appointments; notifying you that your order is ready; sending you postcards or letters; and reminding you it is time for continued care. These types of notifications may include leaving messages with those at your home or office who may answer the phone, leaving voicemails on answering machines, sending emails, and text massages to the phone numbers and emails that you have provided to us. Calling your name, or part of your full name, out in a reception room environment. Prescribing dietary supplements and medications as well as relaying this information to suppliers and our business associates, by phone, fax or other electronic means including initial prescriptions and requests from suppliers for refills. Referring you to another doctor for care not provided by this office. Obtaining copies of health information from doctors you have seen before us. Discussing your care with you directly or with family or friends you have inferred or agreed may listen to information about your health. At your request, we can provide you with a copy of your medical records via email transmission.

    Examples of how we may use or disclose health information for payment purposes may include: Asking you about sources of payment. Preparing and sending bills to you. Sending notices of payment due on your account to the person designated as responsible party or head of household on your account, with fee explanations that may include procedures performed and for what diagnosis. Collecting unpaid balances either through our office or through a collection agency, attorney, or district attorney’s office. At the patient’s request, we may not disclose health care information that you have paid for out of pocket. This only applies to those encounters related to the care you want restricted.

    Examples of how we may use or disclose health information for business operations may include: Financial audits; internal quality assurance programs; defense of legal matters; business planning; certain research functions; informing you of products or services offered by our office; compliance with local, state, or federal government agencies request for information; oversight activities such as licensing of our doctors; providing information regarding your health status to your employer, school nurse, or agency qualifying for disability status.

    2. USES AND DISCLOSURES FOR OTHER REASONS NOT NEEDING PERMISSION: In some other limited situations, the law allows us to use or disclose your medical information without your specific permission. Most of these situations may never apply to you, but you should still be aware of them in case they do apply. When a state or federal law mandates that certain health information be reported for a specific purpose. For public health reasons, such as reporting of a contagious disease, investigations or surveillance, and notices to and from the federal Food and Drug Administration regarding drugs or medical devices. Disclosures to government or law authorities about victims of suspected abuse, neglect, domestic violence, or when someone is or suspected to be a victim of a crime; for judicial and administrative proceedings, such as in response to subpoenas or orders of courts or administrative hearings; to a medical examiner to identify a deceased person or determine cause of death or to funeral directors to aid in burial; to organizations that handle organ or tissue donations; disclosures related to a workman’s compensation claim. Uses or disclosures for health related research; to prevent a serious threat to health or safety of an individual or individuals; to aid military purposes or lawful national intelligence activities. Disclosures of a “limited data set” for research, public health, or health care operations; of de-identified information. Incidental disclosures that are an unavoidable by-product of permitted uses and disclosures. Disclosure of information needed to complete a school related health screening form, information to the Department of Public Safety, information related to certification for occupational or recreational licenses. Disclosures to business associates who perform health care operations for our office and who commit to respect the privacy of your information. We also require any business associate to require any sub-contractor to comply with our privacy policies. Unless you object, disclosure of relevant information about your health to family members or friends who are helping you with your care, or by their allowed presence, cause us to assume you approve of their exposure to your health information.

    3. USES OR DISCLOSURES TO PATIENT REPRESENTATIVES: It is the policy of our office staff to take phone calls from individuals on a patient’s behalf requesting information about making or changing an appointment; the status of prescriptions or supplements ordered by or for the patient. During a telephone call or in person contact, every effort will be made to limit the encounter to only the specifics needed to complete the transaction required. No information about the patient’s health status may be disclosed without proper patient consent. Our staff and doctors will also infer that if you allow another person in an examination room, treatment room, or any business area within the office to accompany you while testing is performed or discussions held about your health care or your account, you willfully consent to the presence of that individual.

    4. OTHER USES AND DISCLOSURES: We will not make any other uses or disclosures of your health information unless you sign a written Authorization for Release of Identifying Health Information. The content of this authorization is determined by federal law. The request for signing an authorization may be initiated by our office or by you as the patient. We will comply with your request if it is applicable to the federal policies regarding authorizations. If we ask you to sign an authorization, you may decline to do so. If you do not sign the authorization, we may not use or disclose the information we intended to use. If you do elect to sign the authorization, you may revoke it at any time. Revocation requests must be made in writing to our office.

    5. YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION: The law gives you many rights regarding your personal health information. You may ask us to restrict our uses and disclosures for purposes of treatment (except in emergency care), payment, or business operations. This request must be made in writing to our office. We do not have to agree to your request, but if we agree, we must honor the restrictions you ask for. You may ask us to communicate with you in a confidential manner. Examples might be only contacting you by telephone at your home or using a special email address. We will accommodate these requests if they are reasonable and if you agree to pay any additional cost, if any, incurred in accommodating your request. Requests for special communication requests must be made in writing to our office. You may ask to view or obtain a copy of your health information. There are limited situations in which we may refuse your access to your health information. In majority of cases we are happy to provide you with the opportunity to either view or obtain a copy of your medical information upon your request. All requests to view or obtain a copy of medical information must be made in writing to our office. While we typically respond to these requests in 1-2 business days, by law we have fifteen (15) days to respond to your request. We may request an additional thirty (30) day extension in certain situations. Health care information that you request a copy of may be delivered to you in electronic format. The e-formats that our office has approved as secure and that protect the integrity of your health care information include: secure email, an authorized Electronic Health Information system and storage media supplied by our office. You may ask us to amend or change your health care information if you think it is incorrect or incomplete. If we agree, we will make the amendment to your medical record within thirty (30) days of your written request for change sent to our office. We will then send the corrected information to you or any other individual you feel needs a copy of the corrected information. If we do not agree, you will be notified in writing of our decision. You may then write a statement of your position and we will include it in your medical record along with any rebuttal statement we may wish to include. You may request a list of any non-routine disclosures of your health information that we might have made within the past six (6) years (or a shorter period if you wish). Routine disclosures would include those used your treatment, payment, and business operations of our office. These routine disclosures will not be included in your list of disclosures. You are entitled to one such list per year without charge. If you want more frequent lists, you must pay for them in advance at a fee of $25.00 per list. We will usually respond to your written request within thirty (30) days but we are allowed one thirty (30) day extension if we need the time to complete your request. You may obtain additional copies of this Notice of Privacy Practices from our business office or online at our website address shown at the beginning of this Notice.

    6. CHANGING OUR NOTICE OF PRIVACY PRACTICES: By law, we must abide by the terms of this Notice of Privacy Practices until we choose to substantially change the Notice. We reserve the right to change this Notice at any time. If we change this Notice, the new privacy practices will apply to your existing health information as well as any additional information generated in the future. If we change this Notice, we will post a new Notice in our office and on our website.

    7. COMPLAINTS: If you think that anyone at our office has not respected the privacy of your health information, you are free to submit a complaint to the office manager. We will carefully review your complaint and do our best to resolve any concern you may have in writing. If we cannot resolve your concern at this level, you may also file a complaint with the U.S. Department of Health and Human Services, Office of Civil Rights or the state Attorney General’s Office. Our office will not retaliate against you if you make such a complaint.

    The law requires that Thrive GVL, Marianna Guy, NP make every effort to inform you of your rights related to your personal health information.

    By signing this document, I acknowledge that I have read or had explained to me Thrive GVL's Notice of Privacy Practices and I agree to continue my care with Thrive GVL, Marianna Guy, NP under said terms. I have read and understand this form. I am signing it voluntarily.