Privacy

Center for Holistic Medicine Practice Policies

Effective January 2018

Office Policy:

We require a non-refundable deposit at the time the appointment is scheduled or paperwork is handed in for review. To be considered an active patient an onsite visit must be made at least 1 time per calendar year. All follow up must be done in person or by telephone (as recommended by your physician).

Cancellation Policy:

All services are provided by appointment only and this scheduled time is for your exclusive use. Cancellation policy differs by type of appointment as written below.

Initial Functional medicine/Autism Spectrum consult:

All new patients are required to give a 1 week cancellation notice due to the length of the appointment and time spent by the physician reviewing your records. Center for Holistic Medicine retains the deposit of 200.00 as non-refundable. If you do not call or just do not show up for your appointment you will be billed for the remaining amount of 200.00. (These appointments are very involved and time consuming)

Note: Appointments can be rescheduled at the physician’s discretion.

Follow up appointment Cancellations:

We require 48 hours’ notice for follow up cancellations for Functional Medicine/Autism Spectrum management which includes office visits and telephone consults with the doctor. Center for Holistic Medicine retains the right to bill 100.00 of the standard fee for any consultations not cancelled within 48 hours prior to the visit.

Cancellation for follow up Medical Acupuncture treatment:

We require 48 hours’ notice for cancellations of follow up acupuncture visits. Center for holistic medicine retains the right to bill 50.00 of the standard fee for any consultations not cancelled within 48 hours of scheduled visit.

ALL DEPOSITS:

Note: Any deposits made on an initial examination of any kind is non-refundable. We will hold these deposits to be applied toward your first exam for 6 months. Should you decide to cancel and not reschedule within that allotted time, the deposit will be applied as a cancellation fee and another deposit would be required for any future scheduling.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Center for Holistic Medicine

PRIVACY NOTICE ACKNOWLEDGEMENT

Purpose: This form is used to document (a) an individual’s acknowledgement of receipt of our Privacy Practices Notice or (b) when we have not obtained this acknowledgement, our good faith effort to obtain the acknowledgement.

Acknowledgement of receipt of Privacy Practices Notice:

, acknowledge that I have received a Privacy Practices Notice from Center for Holistic Medicine.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

• I give authorization to release information to the following people:

If a personal representative on behalf of the individual signs this authorization, please complete the following:

Signature Office Representative (office use only):

I attest that the above information is correct.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Center for Holistic Medicine Practice Policies

Email Policy:

Email is not 100% secure therefore it is not HIPAA compliant and we cannot use email as a part of our office.

Patient Portal

As a part of our effort to provide you with the very best medical care, we have implemented a patient portal that is HIPAA compliant in protecting your healthcare records. We encourage everyone to sign up for the patient portal. Once you sign up for the patient portal you can correspond with our office. You will receive notification via your private email to log into the secure portal for your messages or office notes etc.

DISCLAIMER: By typing initialing below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.