Nick Health 24/7 Comprehensive Cancer Support
Consent and Membership Agreement
Welcome to Nick Health.
Our 24/7 Comprehensive Cancer Support Membership provides access to an expert-led, culturally sensitive care team committed to your cancer journey. Please read the terms below carefully.
As a member, you will receive:
- Dedicated Care Navigator Team (MD-Led): Your primary point of contact for guidance, communication, and care coordination.
- US-Based, World-Class Oncologist: Access to leading experts recognized globally.
- Cancer-Specific Nutritionist: Personalized nutritional guidance to support healing and strength.
- Mental Health Expert: Support to address emotional well-being and psychological challenges.
- Clinical Trial, Cutting-Edge & Alternative Medicine (CT-CAM) Specialist: Exploration of advanced and complementary treatment options aligned with your values.
- 24/7 Messaging and Emergency Guidance: Unlimited secure communication with your care team, including emergency escalation.
- Culturally Aligned Support: Care delivered in your language and respectful of your background.
Membership Pricing
- Initial Month (Onboarding & Planning): USD $1,000 – Payment is due upon enrollment.
- Ongoing Monthly Membership: USD $600 – Billed in advance.
Terms & Conditions
- Membership Duration: This is a monthly service. If you wish to cancel your monthly subscription, please provide a written notice at least 7 days before the start of your next billing cycle. This helps us process your request smoothly and avoid any unintended charges.
- Communication Platform: All services are delivered virtually via secure video, phone, or encrypted messaging platforms.
- Consent for Services:
By signing this agreement, you authorize Nick Health to:
- Coordinate your care and share your records with our care team and consulting healthcare professionals.
- Store and manage your records securely in compliance with HIPAA and GDPR.
- Communicate with you through chat, email, phone, or video.
- Member Responsibilities:
- Submit accurate, up-to-date medical records and information.
- Participate actively in care planning and follow-up.
- Engage respectfully on our platform; abuse or misuse may result in termination.
- Medical Liability Disclaimer: Nick Health provides education, support, and coordination. We do not diagnose, treat, prescribe medication, or replace your local physician. Use of this service does not establish a physician-patient relationship or any other provider-patient relationship. The information provided is for informational purposes only and is not a substitute for professional medical advice, diagnosis, or treatment.
- Confidentiality: All personal and medical information will remain confidential, in full compliance with applicable laws and privacy regulations.
- Refund Policy: Due to the personalized nature of our services, all payments are non-refundable.
AUTHORIZATION FOR RELEASE OF PERSONAL DATA
Name:
In connection with my request for certain medical support services, which may include consultation, second opinions, care management and navigation, education, and related services (collectively, “Services”), I hereby authorize the use or disclosure of my personal and health data (“Data”) as described in this form. I understand that this authorization is voluntary; however, the ability of Nick Global Medical Group, PC and its affiliated professionals to provide me with Services is contingent on their ability to review my Data. As such, I acknowledge that my refusal to provide this voluntary authorization may impact my ability to obtain Services. I further understand that once my Data is disclosed pursuant to this voluntary authorization, the disclosed Data may no longer be protected by applicable data privacy laws.
| Persons/organizations providing the information: |
Persons/organizations receiving the information: |
| Nick Global Medical Group, PC and its affiliated professionals |
Nick Health Inc. (administrative services provider)
Case Navigator (to be assigned by the above organizations) |
Description of information:
This voluntary authorization applies to all Data that I voluntarily provide to Nick Global Medical Group, PC and its affiliated professionals. It covers all information and documentation that I provide online through Nick Global Medical Group, PC’s website or any third-party vendor’s platform, or send to a Nick Global Medical Group, PC representative or my personal Case Navigator (who will be assigned to me) via email, chat, or regular mail or over the telephone. I understand that the exact type(s) of Data that I provide will depend on the specific Services that I have requested.
Statement of the use or disclosure of information:
Nick Global Medical Group, PC and its affiliated professionals will use my Data to provide the specific Services that I have requested, and otherwise as permitted or required by applicable law. My Data will be shared with Nick Health Inc. and my personal Case Navigator, who will each use it to provide administrative services in connection with my Services.
Will the persons or organizations requesting the authorization receive financial or in-kind compensation in exchange for selling, sharing, or further disclosing the health information described above?
Yes ___ No X
* YOU MAY REFUSE TO SIGN THIS AUTHORIZATION *
