Terms of service.
I acknowledge I am at least 18 years of age, hereby requst and consent to receive health coaching services from Cheryl Syta, Nurse Practitioner, PLLC. I acknowledge the information on this website is not a substitute for professional medical advice, diagnosis or treatment.
General Terms and Conditions:
I understand that my participation in health coaching Services is voluntary. I understand and agree that I may terminate Services at any time for any reason by notifying Coach orally (in person or by telephone - followed by written notice) or in writing where written notice includes electronic mail (email). Likewise, I agree that Coach may terminate Services at any time for any reason.
I understand that I may choose to receive Services to address nutrition/diet, exercise, sleep, stress management, finding meaning and purpose, and other health challenges.
I understand that I may choose to receive Services through one-to-one personal sessions (Individual sessions), group classes, or full-day workshops.
I acknowledge and understand that Services do not replace medical evaluation, clinical or diagnostic testing, medical treatment, or other medical advice or recommendations from licensed medical professionals involved in my care. I understand that Coach will not order diagnostic tests or treatments.
I understand that results from Services are not guaranteed.
I fully understand and agree that I remain solely responsible for my own lifestyle choices and decisions and the consequences of those choices and decisions.
Confidentiality:
Coach will maintain strict confidentiality regarding all information shared by the Client except to the extent Coach has reasonable cause to believe that the Client or others may be at risk of imminent harm. In such instances, Coach will comply with all applicable New York State laws governing mandatory reporting.
Fees and Payment for services:
Fee per Session:
Package Fee
20- Minute Intro Demo
No charge
75-minute Initial Individual Session
$ 200
4 sessions $496
Individual Sessions (40 minutes)
$ 100
6 sessions $596
Group Classes (90 minutes; 1 Class/week)
$ 75 / 6 classes
One Day Workshop
$ 30
I understand and agree to pay all fees in advance or at the time services are provided. I understand that payment may be made by cash, check, and Venmo (@Cherylsyta). Payment for a package of sessions shallbe made in advance of the first session. If I am paying by check, I agree to mail my check in advance of my first session to: Cher in Health, 1857 Western Ave, Albany, NY 12203.
A super bill will be provided to me by request to submit to my insurance company. I understand this does not guarantee payment or reimbursement by my insurance company.
Refund policy:
Individual sessions: No refund once session has started. Full refund provided Client cancels at least 24 hours before the scheduled session. If Client cancels less than 24 hours in advance of session for reason such as illness or family emergency, Client may reschedule session, but no refund will be available.
Package purchase for individual sessions: Full refund for any remaining unused sessions as of the date of notice of cancellation. No questions asked.
Group Classes: Package purchase of 6 weekly sessions: Full refund provided Client cancels at least 48 hours before the first class. No reason needed. Client will receive a 50% refund of total package fee if Client cancels any time after first or second class. Client shall not be entitled to a refund if Client cancels after the third class.
One Day Workshop: No refund will be provided unless Client cancels at least 48 hours before the scheduled Workshop begins, in which case, Client will receive full refund.
I understand and agree that if/when I cancel scheduled Services according to this agreement, I must expressly request a refund by telephone or by email.
Refunds will be sent to Client within 10 business days from Client’s request for refund. Refund shall be paid by check mailed to Client’s home address.
Scheduling and Cancellation policy:
Services sessions will be scheduled in advance and shall take place in person at Coach’s offices located at 17 Executive Park Dr., Clifton Park, NY or 1857 Western Ave, Albany, New York; or at Client’s request, remotely on a HIPAA compliant Zoom platform.
I agree that I must arrive at my scheduled appointment on time so that Coach is able to dedicate the time necessary to provide the best possible services to me and other clients.
I agree that I must contact the office at least 24 hours in advance if I want to cancel or re-schedule my Individual session.
I agree that I must contact the office at least 48 hours prior to start time of my scheduled class/workshop if I wish to cancel my attendance.
No show policy:
Individual Session: First “no-show” For reasons such as illness or emergency, no penalty. I will contact coach via phone or email to reschedule session within 3 weeks. Second “no-show” – I understand that if my session is part of a pre-purchased package, I am not entitled to a refund or make-up session if I fail to cancel or reschedule timely. If a stand-alone session, I will be charged $100. Third “no show” - I understand that Coach will terminate Services and payment made for sessions after the date of termination will be refunded.
Group classes: I agree that I am not entitled to any refund and I will not be able to make up missed classes.
One day workshop: No refund is available.
Coach does not intend to offer any clinical advice or counsel and Services are not a substitute for professional clinical advice and should not be relied upon as such. Coach shall not be responsible or liable for harm, loss or damages that arise directly or indirectly as a result of any actions or inaction taken by Client. Client remains solely responsible for Client’s own acts, decisions, and lifestyle choices.
I acknowledge that I have read this document or had it read to me, fully understand and agree to its terms and all of my questions have been answered to my satisfaction.
Privacy Policies
Your Information. Your Rights. Our Responsibilities.
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
Cheryl Syta, Nurse Practitioner in Adult Health, PLLC
Your Rights
You have the right to:
• Get a copy of your paper or electronic medical record
• Correct your paper or electronic medical record
• Request confidential communication
• Ask us to limit the information we share
• Get a list of those with whom we’ve shared your information
• Get a copy of this privacy notice
• Choose someone to act for you
• File a complaint if you believe your privacy rights have been violated
Your Choices
You have some choices in the way that we use and share information as we:
• Tell family and friends about your condition
• Provide disaster relief
Our Uses and Disclosures
We may use and share your information as we:
• Treat you
• Run our organization
• Comply with the law
• Respond to lawsuits and legal actions
Your Rights
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.
Get an electronic or paper copy of your medical record
• You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.
• We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
Ask us to correct your medical record
• You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
• We may say “no” to your request, but we’ll tell you why in writing within 60 days.
Request confidential communications
• You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
• We will say “yes” to all reasonable requests.
Ask us to limit what we use or share
• You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.
• If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.
Get a list of those with whom we’ve shared information
• You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
• We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
Get a copy of this privacy notice
You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
Choose someone to act for you
• If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
• We will make sure the person has this authority and can act for you before we take any action.
File a complaint if you feel your rights are violated
• You can complain if you feel we have violated your rights by contacting us using the information on page 1.
• You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.
• We will not retaliate against you for filing a complaint.
Your Choices
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.
In these cases, you have both the right and choice to tell us to:
• Share information with your family, close friends, or others involved in your care
• Share information in a disaster relief situation
If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
Our Uses and Disclosures
How do we typically use or share your health information?
We typically use or share your health information in the following ways.
Treat you
We can use your health information and share it with other professionals who are treating you.
Example: A doctor treating you for an injury asks another doctor about your overall health condition.
Run our organization
We can use and share your health information to run our practice, improve your care, and contact you when necessary.
Example: We use health information about you to manage your treatment and services.
Create a SuperBill for your services
We can use and share your health information to create a superbill for you to submit to your health plan or other entities. This does not guarantee reimbursement to you.
Example: We give information on your superbill about you, for you to submit to your health insurance plan so it may (or may not) pay for your services.
How else can we use or share your health information?
We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
Help with public health and safety issues
We can share health information about you for certain situations such as:
• Preventing disease
• Helping with product recalls
• Reporting adverse reactions to medications
• Reporting suspected abuse, neglect, or domestic violence
• Preventing or reducing a serious threat to anyone’s health or safety
Comply with the law
We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.
Address workers’ compensation, law enforcement, and other government requests
We can use or share health information about you:
• For workers’ compensation claims
• For law enforcement purposes or with a law enforcement official
• With health oversight agencies for activities authorized by law
• For special government functions such as military, national security, and presidential protective services
Respond to lawsuits and legal actions
We can share health information about you in response to a court or administrative order, or in response to a subpoena.
Our Responsibilities
• We are required by law to maintain the privacy and security of your protected health information.
• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
• We must follow the duties and privacy practices described in this notice and give you a copy of it.
• We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.
Changes to the Terms of this Notice
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.
Other Instructions for Notice
• Effective Date of this Notice: 1/5/2023
• Contact privacy official: Cheryl Syta at cheryl@cherinhealth.com or 518-300-3144.
• Cheryl Syta, Nurse practitioner in Adult Health, PLLC will never sell personal information. You may opt to sign up for our email list, and can opt out and unsubscribe at any time. Your email will never be sold or shared with others.