Thank you for registering for the Heads Up Checkup survey. Please be advised that the following terms and conditions contain a binding arbitration clause and class action waiver that impact your rights about how to resolve disputes. Please read it carefully.
INTERNET ACCESS: Completing the survey takes about 10-15 minutes and requires consistent internet access. The survey must be completed all at once. You cannot save your progress and continue later. If you decide not to complete the survey, you may stop at any point before you finish. To exit the survey in progress, simply close the browser window. If you stop the survey in progress, or your internet connection is repeatedly interrupted, none of your responses will be recorded.
SECURITY: Your responses and results are encrypted and secured in a cloud-based HIPAAcompliant
database. Access to your responses and results is protected and only provided to
others upon your consent. Disclosure of the survey results may be required by your health
insurance carrier to process claims. Only the minimum necessary information will be
communicated to the carrier.
RESULTS: Your Heads Up Checkup survey results will be sent to you via email. You also
have the option to give consent for your survey results to be sent directly to a parent/
guardian, school, or doctor.The questions contained in Heads Up Checkup survey are based
on considerations and criteria as published in the International Statistical Classification of
Diseases and Related Health Problems V10.
ARBITRATION AGREEMENT: Unless you opt-out of this Arbitration Agreement, any dispute or
claim relating in any way to your use of Heads Up Checkup, or to any products or services sold
or distributed by Well Street, will be resolved by binding arbitration, rather than in court, except
that either party may assert claims in small claims court if such claims qualify. We each agree
that any dispute resolution proceedings will be conducted only on an individual basis and not in
a class, consolidated, or representative action. We also both agree that you or we may bring suit
in court to enjoin infringement or other issue of intellectual property rights. The Federal
Arbitration Act and federal arbitration law apply to this agreement.
Opt-out of Agreement to Arbitrate: You can decline this Arbitration Agreement. To optout
you must notify Well Street in writing, within 30 days of the date you first became
subject to this arbitration provision. You must use this address to opt-out: Well Street,
100 S Imperial Hwy, Anaheim, CA 92807. You must include your name and residence
address, the email address used to set up your account, and a clear statement that
you want to opt-out of this arbitration agreement.
Arbitration Procedures: The arbitration will be conducted by the American Arbitration
Association (AAA) under its rules, including the AAA’s Supplementary Procedures for
Consumer-Related Disputes. The AAA’s rules are available at www.adr.org or by
calling 1-800-778-7879. Payment of all filing, administration, and arbitrator fees will be
governed by the AAA’s rules. We will reimburse those fees for claims totaling less
than $5000 unless the arbitrator determines the claims are frivolous. Likewise, Well
Street will not seek attorneys’ fees and costs in arbitration unless the arbitrator
determines the claims are frivolous. All arbitration shall take place in Anaheim,
HIPAA PRIVACY NOTICE: This notice describes how medical information about you may be used and disclosed and how you can get access to this information.
By law, Well Street (provider) is required to insure your Private Health Information (PHI) is kept
private. The PHI constitutes information about your past, present, or future health or condition or
the payment for such health care. Use of PHI means when your provider shares, applies,
utilizes, or analyzes information within the practice; PHI is disclosed when your provider
releases, transfers, gives, or otherwise reveals it to a third party outside the practice. With some
exceptions, your provider may not use or disclose more of your PHI than is necessary to
accomplish the purpose for which the use or disclosure is made; however, your provider is
always legally required to follow the law described in this Notice. Most disclosures will require
your prior written authorization; others will not. Below you will find categories of your provider’s
uses and disclosures.
Disclosures Related to Treatment, Payment, or Health Care Operations That Do Not Require Prior Written Consent:
Other Uses and Disclosures Require Your Prior Written Authorization. For situations not described above, your provider will require written authorization before disclosing any of your PHI. This includes communication with family members or other health care providers. Even if you signed an authorization to disclose your PHI, you may later revoke that authorization, in writing, to stop any future disclosures.
The Right to See and Get Copies of Your PHI. In general, you have the right to see or get
copies of your PHI from your provider. You must request it in writing, and your provider will
respond within 5 days of receiving your written request. Under certain circumstances, your
provider may deny your request and will give you, in writing, the reasons for the denial. You
have the right to have the denial reviewed. If you ask for copies of your PHI, you will not be
charged more than $.25 per page. Your provider may see fit to give you a summary or
explanation of the PHI, but only if you agree to it, as well as to the cost, in advance.
The Right to Choose How Your PHI is Sent to You. It is your right to ask that your PHI be sent to
you at an alternate address (for example, sending information to your work address rather than
your home address) or by an alternate method (for example, via email instead of by regular
The Right to a List of the Disclosures Your Provider Has Made. You are entitled to a list of
disclosures of your PHI that your provider has made after April 15, 2003. The list will not include
uses or disclosures made before April 15, 2003. After April 15, 2003, disclosure records will be
held for six years.
The Right to Amend Your PHI. If you believe that there is some error in your PHI or that
important information has been omitted, it is your right to request that your provider correct the
existing information or add the missing information. Your request must be made in writing. Your
provider may deny your request, in writing, if your provider finds that the PHI is (a) correct and
complete, (b) forbidden to be disclosed, (c) not part of their records, or (d) written by someone
other than your provider. Your provider’s denial must be in writing and must state the reasons for
the denial. You have a right to file a written statement objecting to the denial. You have the right
to ask that your request and the denial be attached to any future disclosures of your PHI. When
approved, your provider will advise others who need to know about the change to your PHI.
The Right to Get a Copy of This Notice. You have the right to get a copy of this notice by email or paper hard copy.
File a Complaint About Your Provider’s Privacy Practices. If, in your opinion, your provider may
have violated your privacy rights, or if you object to a decision your provider made about access
to your PHI, you are entitled to file a complaint with your provider or if applicable, their clinical
supervisor. You may also send a written complaint to the Secretary of the Department of Health
and Human Services at 200 Independence Avenue S.W. Washington, D.C. 20201. If you file a
complaint about privacy practices, your provider will take no retaliatory action against you.