HealthNav360° Basic Package Application

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I am applying for the BASIC PACKAGE to obtain HealthNav360°s Human Sensor™ support and services immediately as a patient, who is scheduled soon or is now undergoing a hospital stay or as a family member.

I understand that:
• Health Navigation 360° LLCs Human Sensors™ will support, educate, orient and assist me in preparing me to maximize the efficiency of my healthcare, including hospital admission, inpatient and discharge processes and communication.

• I agree that Health Navigation 360° LLC has no direct medical roles and does not perform or administer any medical procedures, carry out medical instructions or nursing functions. I agree to seek legal advice from one or more duly licensed attorneys before making any decision related to legal matters.

• I authorize Health Navigation 360° LLCs Human Sensors™ to collect data assessments indicative of my emotional states through contactless face to face assessments.

• I understand that a completed application requires a prepayment of a partially refundable Initial Retainer of $500. $100 hourly fees billed at 15 minute intervals or part thereof are deducted from the Retainer as they accrue. A minimum prepayment for 2 hours of Services is required upon Registration. Health Navigation 360° LLC will alert you when you are not maintaining a minimum balance of 1/2 of the Initial Retainer and that you are facing immediate suspension of services. As the Initial Retainer is depleting, and to continue Services uninterrupted, I will immediately pay, upon Health Navigation 360° LLCs notice, additional sums in whatever amount necessary to bring the total Retainer balance back up to the amount of Initial Retainer.

• I agree to be prepared to provide these payments by cash, credit card or check.

• Fees may not be covered by my insurance and I agree to pay all Fees and Retainers myself.

Please complete all *required fields below
How did you hear about Health Navigation 360° LLC? *

How did you hear about Health Navigation 360° LLC? Friend or Relative Internet Physician Other Other
Indicate how Health Navigation 360° LLC can help you: (Check all that apply) *
Emotional support and guidance Coordinating and scheduling appointments/treatments/tests Attending appointments and communicating with family/caregivers Managing your hospital stay: before, during, after, ongoing Billing/claims/insurance issues Other Other
Client Name * First Last
Birthdate * / MM / DD YYYY
Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone * - ### - ### ####
Alternate Phone - ### - ### ####
Email *
Confirm Email *
Fax - ### - ### ####
Authority of Human Sensor™ (Scroll to read all)
To provide services, Health Navigation 360° LLC usually needs to communicate with essential others (e.g. nursing staff, hospital billing or scheduling offices, nursing/medical/hospital staff, doctors, family members, loved ones and any others who provide healthcare and related services) about your needs.  

To my family and all concerned with my care: I hereby appoint as my Human Sensor™ and / or Agent Health Navigation 360° LLC. To enable her reasonable functioning, I authorize a Health Navigation 360° LLC representative to act on my behalf and discuss/disclose necessary information. I understand I can withdraw this permission any time. These instructions express my wishes about my health care. I want my family, doctors and everyone else concerned with my care to act in accordance with them.  Whenever the term Health Navigation 360° LLC is used in this document, Health Navigation 360° LLC shall be recognized as my designated Personal Representative (as that term is defined in HIPAA) or Agent. 

HIPAA: I hereby designate Health Navigation 360° LLC to act as my designated Personal Representative or Agent, as that term is defined in the Health Insurance Portability and Accountability Act (“HIPAA”), and (ii) authorize (without any limitation whatsoever) anyone or any entity to disclose to my Agent my individually identifiable health information and all health-related billing information.

Description of Information That May Be Disclosed: My Agent is authorized and directed to disclose any and all information relating to my physical, mental and emotional healthcare, without limitation. If my Agent is unable to serve, I authorize my Agent to substitute another person for itself/herself/himself by designating such person as a successor Agent.

Purpose of Disclosure: Any purpose delineated by my Agent.

Re-Disclosure: By signing this Authorization, I acknowledge that the information used or disclosed pursuant to this Authorization may be re-disclosed by and the information once disclosed will no longer be protected by the rules created by HIPAA. No Covered Entity shall require my Agent to indemnify the Covered Entity or require to agree to perform any act in order for the Covered Entity to comply with this Authorization.

My Agent is authorized to sign any documents that my Agent deems appropriate to obtain any information of mine protected by HIPAA. Revocation: I may revoke this Authorization in writing at any time. 

Valid Document: A copy or facsimile of this original Authorization shall be accepted as though it were an original document.

My waiver and release: I hereby release any Entity that acts in reliance on this Authorization from any liability that may accrue from releasing any information of mine protected by HIPAA to my Agent and from any actions taken by my Agent in re-disclosing or otherwise using any information of mine protected by HIPAA which the Covered Agent disclosed to my Agent. I also specifically prohibit my Agent LLC or any other person designated as my Agent in any capacity from filing a complaint of any kind against any Entity that complies with the directions of my Agent hereunder to the extent that such a complaint purports to charge said Entity with any violation of HIPAA, any privacy rules or other federal or state laws related to disclosure of medical records as a result of their compliance with said directions.
Credit Card Authorization
Health Navigation 360° LLC is authorized to use the card on the following page and I will provide and update Health Navigation 360° LLC with the current and valid information and hereby authorize charging all Fees for all Services rendered according to the Terms. I understand that a fee of $40 will be charged for each failure of my card/insufficient funds in checking account. *
I Agree
I have read, understand and agree with all of the Terms page and Registration materials in this website and hereby request Health Navigation 360° LLCs Services. *
I Agree
Digital Signature *

Please type full name.
Today's Date * / MM / DD YYYY
Basic Package (Please choose both to continue) *
Health Navigation 360° LLC Basic Package Initial Retainer $300 (unused portion refundable) Health Navigation 360° LLC Basic Package Required 2 Service Hours $200 (not refundable)

HealthNav360° Basic Package Application

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