New Patient Form

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

New Patient Registration

Consents to Contact:

I authorize HMHB's office to contact me by telephone, text and/or email to remind us of upcoming appointments.

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

Consent for Telehealth Services:

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

Financial Policy:

I have read, understand, and agree to abide by the financial policy.
There are no refunds for missed appointments
I understand that if my account goes into collections, I am responsible for all collections fees and costs incurred by HMHB, PLLC

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

Notice of Privacy Practices

This notice describes how medical information about you may be used and disclosed and how you can get access to this information.

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 amend your medical record

• You can ask us to amend 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.

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 ensure the person has this authority 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 2.
• 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 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.

In these cases we never share your information unless you give us written permission:

• Marketing purposes
• Most sharing of psychotherapy notes
• Sale of your information

In the case of fundraising we may contact you for fundraising efforts, but you can tell us not to contact you again.

Our Uses and Disclosures

We typically use or share your health information in the following ways.
We can use your health information and share it with other professionals who are treating you.
We can use and share your health information to run our practice, improve your care, and contact you when necessary.
We can use and share your health information to bill and get payment from health plans or other entities.

Electronic Exchange. Your information may be shared w/ other providers, labs and radiology groups through our EHR system as listed:

1. Lab Corp
2. Quest Diagnostics

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
• Preventing or reducing a serious threat to anyone's health or safety
• Helping with product recalls
• Reporting suspected abuse, neglect, or domestic violence
• Reporting adverse reactions to medications

Do research
Comply with the law
Respond to organ and tissue donation requests
Work with a medical examiner or funeral director
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.

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

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.

Acknowledgement of Privacy Policy

hereby acknowledge that I have reviewed and received a copy of this practice’s Notice of Privacy Practices, which has been updated for the new Omnibus Rule and has an effective date of July 16, 2015. The notice describes:

• the ways that the Privacy Rule allows our practice to use and disclose protected health information. How our practice will get your permission, or authorization, before using your health records for any other reason.
• the practice’s duties to protect health information privacy.
• the patient’s privacy rights, including the right to complain to HHS and to the covered entity if you believe your privacy rights have been violated.
• how to contact our practice for more information and to make a complaint.

I understand that the Notice of Privacy Practices may be revised from time to time and that I have a right to receive an updated copy upon request.

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

AUTHORIZATION FOR TREATMENT

In the event that I am unable to bring my child(ren) to the office, I consent for the following persons to authorize medical care that is recommended by any of the HMHB Providers.

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

Medical History

Please review this form to ensure that your health information is accurate. You will be able to discuss any questions or concerns that you have with your provider during your appointment.

Surgical History

Please review this form to ensure that your health information is accurate. You will be able to discuss any questions or concerns that you have with your provider during your appointment.

Medication History

Please review this form to ensure that your health information is accurate. You will be able to discuss any questions or concerns that you have with your provider during your appointment.

List all current medications. Include prescribed and over-the-counter drugs, such as vitamins and inhalers.

Drug/Food Allergies

Please review this form to ensure that your health information is accurate. You will be able to discuss any questions or concerns that you have with your provider during your appointment.

List all known allergies.

Family History

Please review this form to ensure that your health information is accurate. You will be able to discuss any questions or concerns that you have with your provider during your appointment.

Check all diseases and conditions that apply.

Social History

Please review this form to ensure that your health information is accurate. You will be able to discuss any questions or concerns that you have with your provider during your appointment.

AUTHORIZATION TO USE AND/OR DISCLOSE MEDICAL RECORDS

I give authorization to the provider listed below to disclose a copy of the specific health/medical information identified below:

RECORDS FROM: (Who is Releasing the Records)

For the Following Purposes:

By Checking the Boxes Below, I Specifically Authorize the Use and/or Disclosure of the Following Health Information And/or Medical Records, If Such Information And/or Records Exist:

The Following Items Must Be Initialed to Be Included in the Use And/or Disclosure:

I understand that, if the person or entity receiving the information is not a health care provider or health plan covered by federal privacy regulations, the information described above may be re-disclosed and no longer protected by HIPAA and other federal and state regulations. However, the recipient may be prohibited from disclosing substance abuse information under the Federal Substance Abuse Confidentiality Requirements.

I also understand that the person I am authorizing to use and/or disclose the information may not receive compensation for doing so.

I, further understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment or payment of my eligibility for benefits. I may inspect or copy any information to be used and/or disclosed under this authorization.

Finally, I understand that I may revoke this authorization, in writing, at any time, provided that I do so in writing, except to the extent that action has been taken in reliance upon this authorization. Unless Revoked Earlier, this Authorization Will Expire in Six (6) Months from the Date of Signing or until (Insert Date):

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

Functional Medicine and Nutritional Services – Consent, Waiver, and Acknowledgment Form

This agreement sets forth the terms and conditions under which I voluntarily participate in the Functional Medicine and Nutritional Program (the “Program”) offered by Dr. Kostur (the “Provider”). By signing this consent form, I acknowledge, understand, and agree to be legally bound by the terms outlined below.

1. No Medical Diagnosis or Treatment

   I understand and acknowledge that the Program is for educational and informational purposes only and is not intended to diagnose, treat, cure, or prevent any disease. The Program is not a substitute for medical advice, diagnosis, or treatment from a licensed physician or healthcare provider. I further acknowledge that the Provider is not acting as my primary care provider or physician.

2. Voluntary Participation and Assumption of Risk

   I voluntarily elect to participate in the Program and understand that all recommendations regarding diet, nutrition, lifestyle, and supplementation are optional and implemented at my own risk and discretion. I acknowledge that individual responses to such recommendations vary and no guarantees have been made as to outcomes or results.

3. Medical Responsibility

   I agree that it is my sole responsibility to consult with my physician or other qualified healthcare provider regarding any medical condition I may have and before making any changes to medications, diet, or lifestyle. I understand that participation in the Program is not appropriate for individuals who are not under regular medical supervision if they are managing significant medical conditions or taking prescription medications.

4. Telehealth Consent

   I understand that some or all of the services provided through the Program may be delivered via telehealth, which includes the use of audio, video, or other electronic communication to interact remotely with the Provider.
   I acknowledge and agree to the following:
   • Telehealth involves electronic transmission of personal information, which may be subject to data breaches or interruptions despite reasonable security measures.
   • There may be limitations in the ability to fully assess or respond to my condition due to the nature of remote interaction.
   • I have the right to refuse or discontinue telehealth services at any time without affecting my access to future in-person services (if applicable).
   • All relevant privacy, confidentiality, and consent protections that apply to inperson services also apply to telehealth interactions.
     I voluntarily consent to participate in telehealth sessions and understand the inherent risks and limitations involved.

5. Release of Liability

   I, on behalf of myself, my heirs, personal representatives, and assigns, hereby waive, release, and discharge Dr. Kostur, and any affiliated entities, employees, contractors, or agents from any and all claims, demands, damages, or causes of action, known or unknown, arising out of or related to my participation in the Program, including services delivered through telehealth. This release includes, but is not limited to, any loss, damage, or injury caused or alleged to be caused in whole or in part by the negligence of the Provider.

6. Indemnification

   I agree to defend, indemnify, and hold harmless Dr. Kostur from any and all liabilities, claims, costs (including reasonable attorneys’ fees), and damages arising out of or relating to my participation in the Program or any breach of this agreement by me.

7. Intellectual Property and Confidentiality

   I acknowledge that all materials, methodologies, protocols, documents, and intellectual property provided through the Program are proprietary and confidential. I agree not to reproduce, distribute, publish, or exploit such materials for personal or commercial gain without express written consent from the Provider.

8. Governing Law and Dispute Resolution

   This agreement shall be governed by and construed in accordance with the laws of the State of Florida, without regard to conflict of law principles. Any dispute arising from or related to this agreement shall be resolved through binding arbitration in Jacksonville, FL, pursuant to the rules of the American Arbitration Association. Each party shall bear its own costs, including attorneys’ fees.

9. Acknowledgment of Understanding

   I confirm that I have had the opportunity to ask questions, and all such questions have been answered to my satisfaction. I understand and agree that I am solely responsible for the choices I make regarding my health, diet, and lifestyle. I acknowledge that I have read, fully understand, and voluntarily accept the terms of this Authorization and Consent.

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