Thank you for registering for the Heads Up Checkup screening. 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: The screening takes about 10-15 minutes to complete and requires consistent internet access. The screening must be completed all at once. You cannot save your progress and continue later. If you decide not to complete the screening, you may stop at any point before you finish. To exit the screening in progress, simply close the browser window. If you stop the screening in progress, or your internet connection is repeatedly interrupted, your responses will not be recorded.
SECURITY: Your responses and results are encrypted and secured in a cloud-based HIPAA compliant database. Access to your responses and results is protected and only provided to others upon your consent with the exceptions noted below in the HIPAA Privacy Notice.
DATA: Heads Up Checkup may use de-identified (anonymous) data from your screening results to support research and inform programs. Your personal health information (PHI) will be protected and your results will remain confidential.
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 Heads Up Checkup, Inc., 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 Heads Up Checkup, Inc. in writing, within 30 days of the date you first became subject to this arbitration provision. You must use this address to opt-out: Heads Up Checkup, Inc., 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, California.
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, Heads Up Checkup, Inc. (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:
-
When disclosure is required by federal, state, or local law; judicial, board, or administrative proceedings; or law enforcement, your provider may make a disclosure to the appropriate officials when the law requires them to report information government or, law enforcement agencies, or if any one places your mental condition as part of any litigation (such as divorce, custody, or personal injury)
-
Disclosure is compelled or permitted when you are in such mental or emotional condition as to be dangerous to yourself or when you tell your provider of a serious/imminent threat of physical violence by you against a reasonably identifiable victim or victims. For example, suicidal or serious self-destructive behavior.
-
Confidentiality does not apply to disclosure of crimes planned for the future. This applies to interests of national security.
-
Disclosure is mandated by the California Child Abuse/Elder/Dependent Adult Abuse and Neglect Reporting law. For example, if your provider has a reasonable suspicion of child/elder abuse or neglect or dependent adult abuse, your provider is legally obligated to report it to the appropriate State Department of Children and Family Services.
-
When disclosure is required to obtain payment for treatment. Your provider might send your PHI to your insurance company, health plan, or other third party payer to receive payment for services.
-
Appointment reminders and health related benefits or services. Your provider may use PHI to provide appointment reminders.
- When disclosure is otherwise specifically required by law.
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 mail).
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.
