FM Consent/HIPAA Forms

Functional Medicine Informed Consents

Please initial below to acknowledge and agree to the following consents and conditions of our FM Program
ACKNOWLEDGEMENT OF REVIEW OF NOTICE OF PRIVACY PRACTICES
I understand that under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. The information obtained by the office of Dr. Vivian Asamoah can and
- Conduct, plan, and direct treatment
- Obtain payment from third-party payers
- Conduct normal healthcare operations such as quality assurance
I have had the opportunity to read and understand the Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I also understand the office of Dr. Vivian Asamoah has the right to amend this notice and that I am entitled to an updated copy of this notice if requested. I understand I may request in writing to restrict how my health information is used or disclosed by the office of Dr. Vivian Asamoah to carry out treatment and healthcare operations. However, I understand that the facility may not accept these requested restrictions, but if accepted must abide by treatment. I understand that I have the right to review and copy my health information and request a change to any information that I believe is not a complete list of each disclosure of my protected health information.
Power of Attorney (POA)
I have a designated Legal/Medical Power Of Attorney (POA) who is responsible for making all medical decisions on my behalf
Name of POA

First NameLast Name
Relationship to Patient
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
I understand that a copy of the legal Power Of Attorney form must be provided to the office of Dr. Vivian Asamoah before services can be rendered.
Authorized Persons to Receive Health Information
Patient OnlyOther (Enter information below)
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to patient
A. Disclose and discuss my complete health record (including but not limited to diagnoses, lab tests, prognosis, treatment, and billing, for all conditions) with appointment access/scheduling as needed.C. Appointment/Scheduling Information and modifications onlyOther
I understand this disclosure is only valid for 1 year. I may revoke or terminate this authorization at any time by submitting a written request to the office of Dr. Vivian Asamoah, Attn: Privacy Officer.
Signature of Patient or Representative:
Date

MonthDayYear
Date
Print Patient Name
If Rrepresentative, Name and Relationship to patient
Please initial below to acknowledge and agree to the following consents and conditions of our Functional Medicine Clinic
Laboratory Testing
The purpose of using laboratory testing for functional medicine is to evaluate nutritional, biochemical, or physiological imbalance and todetermine any need for medical referral. These tests we recommend are not intended to diagnose disease. This office utilizes conventional lab testing as well as specialty lab testing for functional medicine assessments. Functional medicine assessment is designed to assist our doctors and other healthcare providers in finding the underlying causes of your condition. Functional medicine has evolved through the efforts of scientists and clinicians from the fields of clinical nutrition, molecular biology, biochemistry, physiology, conventional medicine, and a wide array of scientific disciplines. Functional medicine evaluates the body as a whole, with special attention to the relationship of one body system to another and the nutrient imbalances and toxic overload that may adversely affect these relationships. Your medical physician may or may not agree with the necessity for - or our interpretation of - these tests. If you have any questions or concerns, please discuss them with our agreed doctors.
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Sale of Nutritional Supplements at DVA
You are under no obligation to purchase nutritional supplements in the office or directly through DVA. As a service to you, we make nutritional supplements available in our office. We purchase these products only from manufacturers who have gained our confidence through considerable research and experience. We determine quality by considering: (1) the quality of science behind the product; (2) the quality of the ingredients themselves; (3) the quality of the manufacturing process; and (4) the synergism among product components. The brands of supplements that we carry in our facility are those that meet our high standards and tend to produce predictable results. While these supplements may come at a higher financial cost than those found on the shelves of pharmacies or health food stores, the value must also include assurance of their purity, quality, bioavailability (ability to be properly absorbed and utilized by the body), and effectiveness. The chief reason we make these products available is to ensure quality. You are not guaranteed the same level of quality when you purchase your supplements from the general marketplace. We are not suggesting that such products have no value; however, given the lack of stringent testing requirements for dietary supplements, product quality varies widely.
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Telehealth or Virtual Medicine
Telehealth is available and primarily used for consultations, and check in calls for our functional medicine visits. Much of your care can take outside the office. For the safety of our patients, we recommend virtual medicine when applicable and possible. You may opt for in-person visits as well, schedule permitting. Your initials here agree to the use of virtual medicine during care with Dr. Vivian Asamoah Functional Medicine.
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Circle of Care & Appropriate Use
Our Functional Medicine Program is not an acute clinic. This means that we do not treat illness that could be deemed an emergency. We treat chronic GI illness to get to the focal root cause to allow for optimal GI health. We do not offer after-hour follow-ups and all calls are returned during regular clinic hours. You should go to the nearest emergency room for an emergency and schedule with your Primary Care Physician for all acute needs.
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Advanced Beneficiary Notice
Functional Medicine is designed outside the traditional health insurance model. Your health plan, should you elect to use one, will only pay for services that it determines reasonable and necessary. These services are outlined in the explanations of benefits provided by your insurance carrier under your benefit plan. If your health plan determines that a particular service, although deemed important to you by your Physician and yourself, is not reasonable and necessary under your health plan standards, your health plan will deny payment for that service. As a participant in our Functional Medicine Program, you are responsible for the payment for any service rendered not otherwise covered by your medical plan.
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Group Visits Confidentiality Agreement

Group visits involve patients disclosing personal medical and social information. That information is private and confidential.
I agree to participate in the group visit. I understand that I, or my family member, has the right to be seen by the physician in this group or individually. And I agree to respect the confidentiality of personal information shared by other group visit participants and will NOT share that information with other parties
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Consent for Use of Videos and Pictures on Social Media

I hereby grant consent to Houston Gastro Institute and its representatives to use videos and pictures of me for the purpose of posting them on social media platforms.
I understand and agree that the purpose of using these videos and pictures is for educational, promotional, and informational purposes related to Houston Gastro Institute, its services, and healthcare topics in general.
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Group Visit HIPAA Notice

During a group visit, it is possible that some of my personal health information will be disclosed. For example, at a group visit for Constipation, it might be assumed all patients attending have a similar or same diagnosis as me.
I understand that individually identifiable health information may be shared during group discussions. It is possible that information used or disclosed in a group visit may be redisclosed among other group visit participants. This Group Visit HIPAA Notice supplements the HIPAA Notice of Privacy Practice originally provided to me.
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NON REFUNDABLE

ALL PAYMENTS ARE NON REFUNDABLE , $100 ADMIN FEE WILL BE APPLIED FOR SERVICES NOT YET RENDERED
Patient Signature
Patient Printed Name
Date

MonthDayYear
Date
Should be Empty:

Functional Medicine Informed Consents

ACKNOWLEDGEMENT OF REVIEW OF NOTICE OF PRIVACY PRACTICES

Power of Attorney (POA)

Authorized Persons to Receive Health Information

Please initial below to acknowledge and agree to the following consents and conditions of our Functional Medicine Clinic

Laboratory Testing

Sale of Nutritional Supplements at DVA

Telehealth or Virtual Medicine

Circle of Care & Appropriate Use

Advanced Beneficiary Notice

Group Visits Confidentiality Agreement

Consent for Use of Videos and Pictures on Social Media

Group Visit HIPAA Notice

NON REFUNDABLE