ND New Patient Intake Form

General Information:  Inside Health Institute clinicians incorporate a wide variety of clinical tools in their practice.  Most patients will receive a combination of treatments, drawing from varied backgrounds in psychology, massage therapy,  herbal medicine, and naturopathic medicine. Diagnosis and treatment may include methods from any or all of the following treatment types:  Naturopathic Medicine, Physical Medicine, Acupuncture, Homeopathy, Mental Health Counseling, and Lifestyle and Nutritional Counseling and Guidance.  

Methods, Procedures and Therapeutic Approaches:  IHI clinicians  may perform any of the following procedures as necessary to give a proper diagnosis, determine treatment approaches, treat or otherwise address your health concerns:

l General Diagnostic Procedures:  including but not limited to: blood collection, imaging orders (ultrasound, x-ray, MRI, CT), lab analysis of blood, urine, and stool, general physical exam, neurological and musculoskeletal assessments.
l Counseling:  Compassionate and reflective listening, coaching in healthy lifestyle changes, nutrition and exercise.
Topical Treatments and Prepping:  prepping skin for puncture with alcohol, iodine or other antiseptic agents.  
l Herbs and Natural Medicines:  prescription of vitamins, minerals, and dietary supplements to achieve therapeutic goals; prescription and/or application of herbs in capsules, powders, teas, tinctures, plasters, pastes, suppositories, creams, salves, etc.; as well as highly dilute homeopathic remedies, intramuscular vitamin injections.
l Soft Tissue and Osseous Manipulation:  use of massage, neuro-muscular techniques, muscle energy stretching, visceral manipulation, osseous manipulation of the spine and extremities, prescription and fitting for orthotics.
l Electromagnetic and Thermal Therapies:  includes the use of ultrasound, low and high-volt electrical muscle stimulation, microcurrent, infrared heat, moxibustion, and hydrotherapy.  
l Minor Office Procedures:  laceration care, cerumen removal
Contraception:  counseling and prescription
l Pharmaceutical prescriptions: of herbs, nutrients, hormones and antimicrobials when necessary

Potential Risks:  Pain, discomfort, blistering, discolorations, infection, burns, loss of consciousness or deep tissue injury from needle insertions, topical procedures, heat or frictional therapies, electromagnetic and hydrotherapies; allergic reactions to prescribed herbs or supplements; soft tissue or bone injury from physical manipulations; and aggravation of pre-existing symptoms.  

Potential Benefits:  Restoration of health and the body’s maximal functional capacity; relief of pain and symptoms of disease, assistance in injury and disease recovery, and prevention of disease or its progression.  

Notice to Pregnant Women:  All female patients must alert the doctor if they know or suspect that they are pregnant, since some of the therapies used could present a risk to the pregnancy.  A treatment intended to induce labor requires a letter from a primary care provider authorizing or recommending such a treatment.   

I understand that I may ask questions regarding my treatment before signing this form and that I am free to withdraw my consent and to discontinue participation in these procedures at any time.  With this knowledge, I voluntarily consent to the above procedures, realizing that no guarantees have been given to me by Inside Health Institute, regarding cure or improvement of my condition. I understand that a record will be kept of the health services provided to me.  This record will be kept confidential and will not be released to others unless so directed by my representative or me or otherwise permitted or required by law.  

Fees 

Office Visits: Fees for appointments are determined by our sliding scale application. Anyone may fill out the application to see if they qualify for discounted services.   

Insurance:  We are out-of-network with all insurance companies. All visits must be paid for in full at the time you are seen. Some lab orders may be eligible for insurance coverage. Any non-covered services or any non-covered fees are the patient’s responsibility. You may be eligible for out-of network reimbursement for visits or other services. Please request a “coded bill” at your visit to submit to your insurance company for possible patient reimbursement. Each person’s insurance policy is different from the next; please check with your insurance company to ask about out-of-network reimbursement. 

Laboratory Testing: All laboratory tests will be billed to the patient’s insurance company by the laboratory or billed to the patient if you do not carry insurance. Sliding scale or charitable discounts may be available for those in need.  Any remainder balance not covered by the insurance company is the sole responsibility of the patient. Some labs ordered may require patient payment and may not be eligible for insurance payment.

E-Mails: Fees may apply. Providers may be available by email for simple clarification or updates on health status. E-mail is not to be used for sole case management. Providers may not have your case information in front of them while replying to your email so be sure to include all pertinent information in your email correspondence. If your questions or health needs exceed a simple email reply, we will ask you to make an appointment for an in office visit to address your healthcare needs. Multiple emails sent per day requiring multiple responses will be subject to a fee that will not be billable through insurance. Please allow 24-48 hours (during business hours/days only, currently Thursdays only) to receive your email reply.

Phone Consultations: Phone consultations are provided for established clients only under special circumstances determined by the provider. The minimum fee is charged for any phone consultation up to 30 minutes. Phone consultations that extend beyond 30 minutes will be rounded up to a full 60 minute visit. This fee is not charged in the following cases: when you require clarification of on-going therapy and when the provider has asked you to call. If there is any question about this service you are welcome to ask in your call or your email inquiry. The provider will respond to your inquiry within 24 hours; however, due to unexpected medical emergencies a response is sometimes delayed. If the provider  has not responded within 24 hours, please call or email the provider again. 

Copies/Administrative Fees: Copies of patient chart notes or any request that incurs an expense to the clinic will be charged to the client. Fees will be variable depending on the extent of the request.

Appointment cancellations: Any no-show appointments or appointments cancelled without 24 hours notice will be billed $55.00.  These fees will be the patient’s responsibility.

Payment

Payment is due at the time of service for office visits. Inside Health Institute accepts checks, cash, credit card (Visa, Mastercard and Discover).  Invoices and receipts are available by request.  

Returned Check Fee: There is a $25 fee for each returned check.

All fees are subject to change and patients will be kept abreast of these changes. If you have any questions regarding these guidelines please feel free to ask.  

By signing below you are acknowledging agreement with the above clinic policies.

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW CAREFULLY.

The Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential. This Act gives you, the patient, significant new rights to understand and control how your health information is used. HIPAA provides penalties for covered entities that misuse personal health information.

As required by HIPAA, we have prepared this explanation of how we are required to maintain the privacy of you health information and how we may disclose your health information.

We may use and disclose your medical records only for each of the following purposes: treatment, payment, and health care operations.

l Treatment means providing, coordinating, or managing health care and related services by one or more health care providers. An example of this would include a physical examination.
l Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities, and utilization review. An example of this would be sending a bill for your visit to an insurance company for payment.
l Health Care Operations include the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis, and customer service. An example would be an internal quality assessment review.

We may also create and distribute de-identified health information by removing all references to individually identifiable information.

We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization.

You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to the Privacy Officer:

l The right to reasonable requests on certain uses and disclosures of protected health information, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you. We are, however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it.
l The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or at alternative locations.
l The right to inspect and copy your protected health information.
l The right to amend your protected health information.
l The right to receive an accounting of disclosure of protected health information.
l The right to obtain a paper copy of this notice from us upon request.

We are required by law to maintain the privacy of your protected health information and to provide you with notice of our legal duties and privacy practices with respect to protected health information.

This notice is effective as of June 10, 2002, and we are required to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right to change the terms of our Notice of Privacy Practices and to make the new notice provisions effective for all protected health information that we maintain. We will post and you may request a written copy of a revised Notice of Privacy Practices from this office.

You have recourse if you feel that your privacy protections have been violated. You have the right to file a formal, written complaint with our office or with the Department of Health and Human Services, Office of Civil Rights, about violations of the provisions of this notice or the policies or procedures of our office. We will not retaliate against you for filing a complaint.

Please contact us for more information, by asking to speak to our Privacy Officer or for written inquiries, note “Attention Privacy Officer.”

For more information about HIPAA or to file a complaint:
The U.S. Department of Health and Human Service Office of Civil Rights
200 Independence Ave. S.W.
Washington D.C. 20201
(202) 619-0257
Toll Free: 1-877-696-6775

I, {fullName}, acknowledge that I have reviewed the Notice of Privacy Practices of Inside Health Institute.

The World Health Organization has declared the novel Coronavirus (COVID-19) a worldwide pandemic. Due to its capacity to transmit from person-to-person through respiratory droplets, the government has set recommendations, guidelines, and some prohibitions which Inside Health Institute (the "Organization") adheres to comply.

By signing below I acknowledge that I have read the foregoing Liability Release Waiver and understand its contents; that I am at least eighteen (18) years old and fully competent to give my consent; That I have been sufficiently informed of the risks involved and give my voluntary consent in signing it as my own free act and deed; that I give my voluntary consent in signing this Liability Release Waiver as my own free act and deed with full intention to be bound by the same, and free from any inducement or representation.

This waiver will remain effective until laws and mandates relevant to COVID-19 are lifted.