Pediatric Patient Intake

You are almost done! Lastly, we need your signature for consent for our HIPPA practices, consent to bill your insurance and transparency around our financial practices and our promise to protect your privacy. Want a copy of these? We'd be happy to supply one.

INFORMED CONSENT FOR TREATMENT

 

The purpose of this informed consent form is for Collaborative Natural Health Partners to provide you with written information regarding naturopathic medicine, integrative and functional medicine services and the potential risks, benefits and alternatives so that you may make an informed decision about whether to proceed with evaluation and treatment. This material serves as a supplement to the discussion you have with your Collaborative Natural Health Partners’ doctor about any potential treatment or course or care.

By signing below, you acknowledge and agree to the following:

I understand that the doctors of Collaborative Natural Health Partners are licensed providers in Connecticut, and some may be licensed in other states.

Naturopathic physicians are trained as specialists in integrative medicine. Naturopathic physicians are experts in advanced diagnostic testing, nutrition, botanicals and supplements. Some of the naturopathic physicians at Collaborative Natural Health Partners are also trained in craniosacral therapy, acupuncture, bowen and other specific modalities.

Osteopathic physicians are Board certified in family medicine with additional training in osteopathic manipulation. These doctors are primary care doctors who are open to integrative medicine and can act as your primary care doctor but also can be an adjunctive care offering compounded prescriptive medications such as bioidentical hormones, low dose naltrexone, and glandular thyroid prescriptions.

I understand that all recommendations and treatments will be discussed with me before implementation, and that I am encouraged to ask questions including: my suspected diagnosis(es) or condition(s); the nature, purpose, and potential benefits of the proposed course of care and treatment; the potential risks, complications or side effects of the proposed treatment; reasonable available alternatives to the proposed treatment; and potential consequences if treatment or advice is not followed and/or nothing is done.

I hereby request and authorize the doctors of Collaborative Natural Health Partners to perform, order or recommend, as applicable, primary care, osteopathic medicine, functional medicine, and naturopathic medicine care (the “Integrative Medicine Services”) for me or the patient named below for whom I am legally responsible. All Integrative Medicine Services will be performed within the scope of the license of the provider providing care to me, and the providers of Collaborative Natural Health Partners provide the standard of care for primary medicine while offering natural alternatives when possible.  Integrative Medicine Services may include, but are not limited to:

·        Physical Exams and Common Diagnostic Procedures: Including physical exams and assessments, venipuncture/phlebotomy, Pap smears, ordering and interpreting conventional and functional laboratory testing of blood, urine, stool, saliva, and breath, and ordering diagnostic imaging as necessary.

·        Minor office procedures: including dressing a wound, ear irrigation, suture removal, cryosurgery

·        Dietary Advice and Therapeutic Nutrition: Including nutritional counseling, dietary plans, nutritional supplements (with vitamins, minerals and amino acids).

·        Nutrigenomics: Review of genetic information for nutritional purposes. *I acknowledge that Collaborative Natural Health Partners does not employ any geneticists and none of the providers at Collaborative Natural Health Partners should be considered a substitute for a geneticist.

·        Botanical/Herbal Medicines: Botanical substances and plant derivatives may be prescribed as teas, alcohol or glycerin tinctures, capsules, tablets, creams, or suppositories.

·        Homeopathic Medicine: The use of highly dilute quantities of naturally occurring plants, animals, and minerals to gently stimulate the body's healing responses.

·        Bioidentical Hormone Replacement Therapy and other Pharmaceutical Medications *(only prescribed by Osteopathic physicians): The use of bioidentical hormone replacement therapy, including thyroid medication, to help restore and balance hormone levels as needed. Other medications may be prescribed as necessary as permitted within the scope of practice of the provider.

·        Physical Medicine and Acupuncture: The use of massage, stretching, resistance, and therapeutic exercise; craniosacral therapy (a gentle hands-on manual therapy used to balance the nervous system); visceral manipulation (a gentle hands-on manual therapy used to assess restrictions of the viscera); intersegmental traction, cupping and acupuncture.

·        Hydrotherapy: Applications of hot and/or cold water via various forms (water bath, soaked towels, etc.), including peat bath and paraffin bath

·        Lifestyle Counseling and Hygiene: Recommendations to promote improved lifestyle strategies including exercise/movement, stress management practices, sleep and environment.

I understand the providers at Collaborative Natural Health Partners are not psychologists or psychiatrists and any counseling is for support of improved lifestyle strategies only. I also understand the U.S. Food and Drug Administration has not approved nutritional, herbal, and homeopathic substances to treat specific diseases.

No Guarantee and Patient Responsibility:  I understand that results from the Naturopathic Medicine Services are not guaranteed, and that Collaborative Natural Health Partners does not make any representations, promises, claims, warranties, assurances or guarantees that my medical problems or conditions will be helped or cured by undergoing any of Integrative Medicine Services. I understand that my failure to comply with any treatment recommendations and instructions may impede results, and that as with all existing methods of diagnosis and treatment, the Integrative Medicine Services have both benefits and risks.

Potential Benefits: Potential benefits may include restoration of health, mental well-being 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.

Potential Risks: Herbs, dietary supplements, and homeopathic remedies are generally considered safe. However, they may lack therapeutic effect or could cause allergic reactions or unpleasant side effects which could possibly range from mild to severe. The interactions between different herbs and between herbs and medications are also not always thoroughly understood. While unlikely, and while the Collaborative Natural Health Partners doctors are educated in herbal medicine including such interactions, it is possible to have an adverse reaction or experience a reduction or increase in the effect of other medications when taking herbs. These can have serious consequences for some medications, such as for the control of high blood pressure or blood sugar. Homeopathic medicines can potentially cause aggravation or worsening of current or pre-existing symptoms. There may also be other potential risks which may be discussed and clarified in separate consents specifically applicable to such treatments. For example: Potential risks of acupuncture include bruising, bleeding, numbness or tingling near the needling sites, and rarely nerve damage or infection. Potential risks of cupping include bruising and scarring.

I am aware that unforeseeable complications could occur, and that while the Collaborative Natural Health Partners doctors will make every reasonable effort to screen for contraindications to care, I do not expect them to be able to anticipate all possible risks and complications, and I wish to rely on them to exercise their professional judgment in recommending treatments that they feel, based on the facts then known, are in my best interest.

Following Doctor Instructions: I understand that for my safety, it is extremely important that I follow the instructions I receive with respect to dosing and administration of herbs, homeopathic medicines, nutritional supplements, and prescription medications. I understand that taking more than prescribed/recommended or self-treating with additional supplements or medications can be dangerous.

Complete Medical History: I understand that some treatments may be inappropriate and unsafe if I have certain health conditions or take certain medications or supplements, whether prescribed or over-the-counter. For this and other reasons, I understand that it is vital that I truthfully and accurately disclose all health information requested by my doctor as well as keep my doctor updated as to any changes, including any new treatments or procedures I am undergoing. I understand that failure to do so may negatively affect the safety of any treatments I receive, and there shall be no liability on the part of my doctor or Collaborative Natural Health Partners LLC should I fail to do so.

Notice Regarding Pregnancy and Breastfeeding: I understand that some treatments could present a risk during pregnancy and breastfeeding, and I agree to notify my Collaborative Natural Health Partners doctor immediately if I am pregnant, become pregnant, am planning to become pregnant in the next three months or if I am breastfeeding.

By voluntarily signing below, I certify that:  I have read the foregoing Informed Consent for Treatment, or someone has read it to me.  I understand the potential risks, benefits and alternatives, and I have had the opportunity to ask questions, and my questions have been answered. I hereby voluntarily consent and agree to receive Integrative Medicine Services with the Collaborative Natural Health Partners doctors, and I intend this Informed Consent to cover the entire course of my care with Collaborative Natural Health Partners. I understand that I am free to withdraw my consent and to discontinue participation in the Integrative Medicine Services at any time.

FINANCIAL AND CANCELLATION POLICIES AND
FINANCIAL RESPONSIBILITY AGREEMENT

We require all patients to maintain a credit card on file to hold your scheduled appointments and for other charges to your account including appointment fees, co-payments, and co-deductibles. This card will be used if you miss, cancel, or reschedule an appointment without proper 24 hour (M-F) notice, for your appointment fees and/or co-pays and co-deductibles after your appointment is over if another form of payment is not provided, and 30 days after your insurance carrier provides an EOB if you owe any remaining balance (if you have not paid within that time). You can also use this card on file for any purchases from our dispensary. Please complete the credit card authorization provided.

Fees: The current fee schedule is outlined below and also on the Collaborative Natural Health Partners website but is subject to change. Fees are the same for in-person and telemedicine appointments. Fees for appointments do not include the cost of any laboratory testing or supplements.  Review of lab tests requires a scheduled visit with your Collaborative Natural Health Partners doctor at the normal appointment rates.                                                 

Payment:

·        We accept cash, check, all major credit cards, as well as HSA and FSA cards. All self-pay fees and co-pays are due in-full at the time of service; all co-insurance payments and deductible payments are due upon receipt of invoice. If payment is not made via another method, your credit card on file will be charged. We will charge your credit card on file 30 days after your insurance carrier provides an EOB if you owe any remaining balance. Checks should be made payable to: Collaborative Natural Health Partners, LLC. An additional $50.00 fee will be charged for any check returned for insufficient funds or otherwise dishonored.

·        If payment is not made or if there is a chargeback or billing dispute, you understand that Collaborative Natural Health Partners is authorized to provide the credit card company with a copy of this signed form any necessary information including services provided to you to obtain payment. Delinquent accounts may be turned over to a collection agency, and all expenses incurred in collecting a delinquent account are the patient's responsibility.

Out-of-Network Insurance: Deductibles, co-payments, and co-insurance are part of your agreement with your insurance company. Co-payments will be collected at the time of your appointment. If you have not met your deductible for the year, you will be required to pay for the visit in full.

·        After collecting a copy of your insurance card, we verify your current insurance coverage. Our verification is not a guarantee of payment by your carrier. If your insurance company does not pay for your visits, payment will be your responsibility. You are financially responsible for any co-insurance or deductible if applicable and we will send you an invoice.

·        Please understand that it is your responsibility to know your insurance coverage and benefits at the time of your visit.

·        Pursuant to HIPAA and as set forth in our Notice of Privacy Practices, we are permitted to share your information with your insurance company for purposes of seeking payment. If you do not want information shared with your insurance company, you can notify us, but you must pay our self-pay rate in-full at the time of service.

No Medicare:

·        At this time, Medicare does not cover naturopathic medicine services and our osteopathic physicians have opted-out of Medicare. Therefore, we cannot bill Medicare for any services.

·        Some medicare advantage plans may have coverage. Please contact your insurance company to confirm coverage.

Lab Tests:

·        We attempt to utilize lab companies in in your insurance network. However, this is not always possible.

·        Fees for lab tests are handled between the patient and lab. Insurance coverage for other labs will depend on your individual insurance plan and if you have met your deductible. We cannot guarantee what your insurance may cover or what your out-of-pocket costs may be. If you have commercial insurance (PPO), the lab will bill your insurance company, and if your insurance does not cover the cost of the labs, the lab company will bill you for the remainder that wasn’t covered.  It is the patient’s responsibility to understand their insurance coverage. To prevent the stress of unexpected bills, if you wish to use your insurance for lab testing, we recommend you contact your insurance company to have a good understanding of your lab benefits prior to completing any lab tests. If you have questions, we can provide you with a list of recommended labs and you can contact your insurance company for clarification.

24-Hour Cancellation, Rescheduling and Missed Appointment Policy: When you book an appointment, that time is reserved especially for you. Therefore, we ask that you call a at least 24 hours in advance to reschedule or cancel your appointment. Monday appointments must be cancelled by 5pm the Friday before. A $50 late-cancellation/no-show fee will be charged to your credit card on file if you do not show up to your appointment or if you cancel without the required 24 hour notice. This fee is not covered by your insurance and will be billed to you directly.

Late Arrival Policy: We are committed to being on time with patients’ appointments. If you arrive late to your appointment, your appointment will end at the scheduled time, and you will be charged for the full length of the originally scheduled appointment.

FINANCIAL RESPONSIBILITY AGREEMENT

1.       By signing below, I agree that I have read, understand, and agree to the terms of the Collaborative Natural Health Partners Financial and Cancellation Policies, and accept full financial responsibility for all balances on my account.

2.       I understand and agree that I will be financially responsible for any and all charges for services not paid by my insurance for my visits. This includes any naturopathic medical service or visit, preventive exam or physical, lab testing, and any other screening service or diagnostic testing ordered for me by Collaborative Natural Health Partners.

3.       I understand and agree it is my responsibility (and not the responsibility of Collaborative Natural Health Partners) to know if my insurance will pay for my medical service or visit, preventive exam or physical, lab testing, and any other screening service or diagnostic testing.

4.       I understand and agree it is my responsibility to know if my insurance has any deductible, co-payment, co-insurance, out-of-network amounts, usual and customary limit, or any other type of benefit limitation for the services I receive, and I agree to make full payment whenever required.

5.       I understand that Collaborative Natural Health Partners will charge a $50.00 fee if I do not show up for my appointment or if I cancel without a 24 hour notice (or by 5pm the Friday before for Monday appointments).

6.       I, the undersigned, hereby authorize and direct my insurance carrier to pay directly to Collaborative Natural Health Partners LLC all insurance benefits, if any, due to me under my insurance plan. I further agree to pay the balance of the charges not paid by my insurance to Collaborative Natural Health Partners. Any balance that is not paid within 30 days will also be my responsibility. I hereby authorize the release of any information necessary to secure payment of benefits. I also authorize the use of this signature on all insurance submissions. If the patient is a minor, I as a legal guardian give consent for treatment for current and future services rendered. I have received Collaborative Natural Health Partners’ Notice of Privacy Practices and I have been provided an opportunity to review it.

 

Collaborative Natural Health Partners requires a credit card on file to hold your scheduled appointments. Your credit card will be charged the $50 Late Cancellation/No-Show Fee for any cancellations and scheduling changes with less than 24 hours (one business day, M-F) notice and missed appointments; for your appointment fees and/or co-pays after your appointment is over if another form of payment is not provided; for any remaining balances you owe 30 days after your insurance carrier provides an EOB (if you have not paid within that time); and for any other fees listed in our Financial and Cancellation Policies.

Please complete the information below. Thank you in advance.

Please sign below to acknowledge and agree to the following:

• I have read, understand, and agree to the terms of the Collaborative Natural Health Partners Financial and Cancellation Policies, and I accept full financial responsibility for services rendered at time of service.
• I understand my credit card will be charged if cancellations or scheduling changes are not made with at least 24 hours (one business day) prior notice before my scheduled appointment or if I do not show up to an appointment.
• I authorize Collaborative Natural Health Partners to charge my credit card as set forth in the Financial and Cancellation Policies, and I understand that my information will be saved for future transactions on my account. 

INFORMED CONSENT FOR TELEMEDICINE

The purpose of this form is to obtain your informed consent for telemedicine appointments with the providers of Collaborative Natural Health Partners. This Informed Consent for Telemedicine is intended as an addition to the informed consent for treatment and does not change the terms of that informed consent.

Telemedicine involves the use of electronic communications to enable the doctor at a different location from the patient to share medical information with that patient. The information may be used for diagnosis, treatment, follow-up, and/or education. During a telemedicine appointment, your Collaborative Natural Health Partners doctor will be providing care to you via live two-way audiovisual electronic communications or telephone (audio-only communications) instead of in-person.

Because the providers of Collaborative Natural Health Partners are licensed in the State of Connecticut, you must be located in the State of Connecticut during a telemedicine appointment.

The interactive video connection and electronic communication system used by Collaborative Natural Health Partners for telemedicine consultations is HIPAA-compliant and designed to protect the confidentiality of patient data.

Expected benefits of a telemedicine consultation include:

· The doctors can provide care to patients located in other regions of Connecticut without patients having to travel to the office.

· Patients don’t need to travel to the office for all appointments allowing for more efficient medical evaluation and management.

Potential risks associated with the use of telemedicine include, but are not limited to:

· There is the potential that conditions that could be diagnosed with an in-person visit may go undetected in a remote encounter especially because a full physical exam cannot be performed.

· The video connection may not work, or it may stop working during the consultation, or there may be other technical difficulties or failures during the consultation.

· The video picture or information transmitted may not be clear enough to be useful for the consultation or to allow for appropriate care. This may cause a delay in medical evaluation and treatment.

· Security protocols may fail, causing a breach of privacy of personal medical information and/or unauthorized access to the video connection during the consultation.

· Certain treatments that can be provided in-person may not be able to provided via telemedicine.

By signing this Informed Consent to Telemedicine, you acknowledge and confirm that you understand and agree to the following with respect to telemedicine services:

1. I understand that telemedicine consultations do not replace in-person visits in all cases, and I will need to receive in-person care for in-person physical examinations and other diagnostic and screening procedures.

2. I understand it is up to my Collaborative Natural Health Partners doctor to determine whether or not my specific clinical needs are appropriate for a telemedicine consultation. I understand that I may be required to discontinue the telemedicine consultation and to see my doctor in person, if possible, or a licensed provider in my area if my Collaborative Natural Health Partners doctor determines in his/her best judgment that I need to receive an in-person physical examination or that the videoconferencing connections are not adequate for the situation or to provide appropriate care for any reason.

3. I understand that the federal and state laws that protect the privacy and confidentiality of health information also apply to telemedicine and all medical reports resulting from the telemedicine consultation are part of my medical record. I understand that there will be no recording of any of the online sessions and that all information disclosed within telemedicine sessions and in the written records pertaining to those sessions are confidential and will not be revealed to anyone without my written consent, except where disclosure is required or authorized by law

4. I understand that I am responsible for information security on my device, including but not limited to, a computer, tablet, or phone. I also understand that I am responsible for using this technology in a private location so that others cannot hear my conversation.

5. I understand there is a risk of technical failures during the telemedicine encounter including difficulties with internet connectivity, hardware, software, equipment, and/or services supplied by a third party, and that these technical failures are beyond the control of Collaborative Natural Health Partners. I understand Collaborative Natural Health Partners cannot make any guarantee that such services will work as expected, and I agree to hold Collaborative Natural Health Partners harmless for delays in evaluation or for information lost due to such technical failures.

6. I understand that alternatives to telemedicine consultation, such as in-person services are available to me, and in choosing to participate in a telemedicine consultation some naturopathic medical services may not be available.

7. Specifically with respect to Connecticut: I understand that my primary care provider may obtain a copy of my records of my telemedicine encounter. (Conn. Gen. Stat. Ann. § 19a-906).

By signing this Informed Consent for Telemedicine, I confirm and agree that: I have read this informed consent form, or someone has read it to me.  I understand the contents of this form including the risks and benefits of telemedicine consultation and my questions have been answered. I hereby give my informed consent to participate in telemedicine consultations with the naturopathic doctors of Louts Integrative Healthcare, and I intend this informed consent to cover the entire course of my care with Collaborative Natural Health Partners.

 

Notice of Privacy Practices

THIS NOTICE IS REQUIRED BY LAW AND DESCRIBES HOW PROTECTED HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.  PLEASE REVIEW IT CAREFULLY.

Collaborative Natural Health Partners LLC (“we,” “our” or “us”) is dedicated to providing service with respect for your personal information. Protecting your privacy and healthcare information is fundamental in the course of our relationship.

This Notice tells you about the ways we may collect, store, use and disclose your protected health information and your rights concerning your protected health information. “Protected health information” is information about you that can reasonably be used to identify you and that relates to your past, present or future physical or mental health or condition, the provision of health care to you or the payment for that care.

Federal and state laws require us to provide you with this Notice about your rights and our legal duties and privacy practices with respect to your protected health information. We must follow the terms of this Notice while it is still in effect. Some of the uses and disclosures described in this Notice may be limited in certain cases by applicable state laws that are more stringent than the federal standards.

Uses and Disclosures of Your Protected Health Information

We may use and disclose your protected health information for different purposes. The examples below are illustrations of the different types of uses and disclosures that we may make without obtaining your authorization. 

·        Treatment. We may use and disclose your protected health information for your treatment and to provide you with treatment-related health care services. For example, we may disclose protected health information to other doctors, naturopathic assistants, technicians, or other personnel, including people outside our office, who are involved in your medical care and need the information to provide you with medical care.

·        Payment. We may use and disclose your protected health information so that we may bill and receive payment from you, your insurance company, or a third party for the treatment and services you received. For example, we may give your health insurance carrier information so that they will pay for your treatment. However, if you pay for services yourself in full at the time of service (e.g., out-of-pocket and without any third-party contribution or billing), we will not disclose your health information to a health plan if you instruct us to not do so. Additionally, if you submit a superbill to your insurance carrier, insurance companies may require that copies of your applicable medical records be sent with respect to your request for reimbursement of services already provided to you and paid for.

·        Health Care Operations.   We may use and disclose your protected health information in order to perform various operational activities.

·        Appointment Reminders, Treatment Alternatives and Health Related Benefits and Services. We may use and disclose protected health information to contact you and to remind you that you have an appointment with us. We also may use and disclose protected health information to tell you about treatment alternatives or health-related services that may be of interest to you. We will not, however, send you communications about health-related or non-health-related products or services that are subsidized by a third party without your authorization.

Other Permitted or Required Disclosures

·     As Required by Law.  We must disclose protected health information about you when required to do so by law.

·     Public Health Activities.  We may disclose your protected health information to public health agencies for reasons such as preventing or controlling disease, injury, or disability.

·     Victims of Abuse, Neglect or Domestic Violence.  We may disclose your protected health information to government agencies about abuse, neglect, or domestic violence.

·     Health Oversight Activities.  We may disclose protected health information to government oversight agencies (e.g., state insurance departments) for activities authorized by law.

·     Business Associates. We may disclose protected health information to our business associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services. For example, we may use another company to perform billing services on our behalf. All of our business associates are obligated to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.

·     Judicial and Administrative Proceedings.  We may disclose protected health information in response to a court or administrative order.  We may also disclose protected health information about you in certain cases in response to a subpoena, discovery request or other lawful process.

·     Law Enforcement.  We may disclose protected health information under limited circumstances to a law enforcement official in response to a warrant or similar process; to identify or locate a suspect; or to provide information about the victim of a crime.

·     To Avert a Serious Threat to Health or Safety.  We may disclose protected health information about you, with some limitations, when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.

·     Special Government Functions.  We may disclose information as required by military authorities or to authorized federal officials for national security and intelligence activities.

·     Workers' Compensation.  We may disclose protected health information to the extent necessary to comply with state law for workers' compensation programs.

Other Uses or Disclosures With an Authorization: Other uses or disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law.  You may revoke an authorization at any time in writing, except to the extent that we have already taken action on the information disclosed or if we are permitted by law to use the information.

Your Rights Regarding your Protected Health Information

You may have certain rights regarding protected health information that we maintain about you.

·     Right To Access Your Protected Health Information.  You have the right to review or obtain copies of your protected health information records, with some limited exceptions. Your request to review and/or obtain a copy of your protected health information must be made in writing.  We may charge a fee for the costs of producing, copying and mailing your requested information, but we will tell you the cost in advance.

·     Right to Amend Your Protected Health Information.  If you feel that the protected health information that we maintain about you is incorrect or incomplete, you may request that we amend the information. Your request must be made in writing and must include the reason you are seeking a change. We may deny your request, if for example, you ask us to amend information that we did not create, or you ask us to amend a record that is already accurate and complete.  If we deny your request to amend, we will notify you in writing.  You then have the right to submit to us a written statement of disagreement with our decision and we have the right to rebut that statement.

·     Right to an Accounting of Disclosures.  You have the right to request an accounting of disclosures we have made of your protected health information. The list will not include our disclosures related to your treatment, our payment, or our health care operations, or disclosures made to you or with your authorization.  The list may also exclude certain other disclosures, such as for national security purposes.  Your request for an accounting of disclosures must be made in writing and must state a time period for which you want an accounting. 

·     Right to Request Restrictions on the Use and Disclosure of Your Protected Health Information.  You have the right to request that we restrict or limit how we use or disclose your protected health information for treatment, payment, or health care operations. We may not agree to your request. If we do agree, we will comply with your request unless the information is needed for an emergency.  Your request for a restriction must be made in writing.  In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit how we use or disclose your information, or both; and (3) to whom you want the restrictions to apply.

·     Right to Receive Confidential Communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you by mail or at work. To request confidential communication, you must make your request, in writing, to us. Your request must specify how or where you wish to be contacted. We will accommodate reasonable requests.

·     Right to a Paper Copy of This Notice.    You have a right at any time to request a paper copy of this Notice, even if you had previously agreed to receive an electronic copy.

As required by law, patient records will be kept for a period of at least seven (7) years after the date of the patient’s last visit, but not more than ten (10) years unless required by Connecticut law.

Health Information Security: Collaborative Natural Health Partners maintains physical, administrative and technical security measures to safeguard your protected health information and requires any staff to follow such security policies and procedures as well as limits access to health information about patients to those individuals who need it to perform their job responsibilities.

Changes to This Notice: We reserve the right to change the terms of this Notice at any time, effective for protected health information that we already have about you as well as any other information that we receive in the future.  We will provide you with a copy of the new Notice whenever we make a material change to the privacy practices described in this Notice.  Any time we make a material change to this Notice, the new Notice will contain the new effective date.  You may always obtain a copy of our current Notice by contacting us as indicated below or asking for a copy at the time of your next consultation.

Complaints: If you are concerned that we have violated your privacy rights, or you disagree with a decision we made about access to your records, you may file a complaint with us by contacting the person listed below.  You may also send a written complaint to the U.S. Department of Health and Human Services.  The person listed below can provide you with the appropriate address upon request.  We support your right to protect the privacy of your protected health information. We will not retaliate against you or penalize you for filing a complaint. 

If you have any questions or complaints, please contact:

Dr. Lauren Young, ND

Phone (860) 533-0179

 

Effective: February 2023

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

By signing below, I acknowledge that I have been presented with a copy of the Notice of Privacy Practices for Collaborative Natural Health Partners LLC detailing how my information may be used and disclosed as permitted under federal and state law and that I have read and understand such Notice.

Confidential Channel Communication

As required by the Health Information Portability and Accountability Act of 1996 (HIPAA), you have a right to request that communications concerning your personal health information be made through confidential channels.
Outside of appointments, we will generally communicate with you through the patient portal if needed. The purpose of this document is to let Collaborative Natural Health Partners know how and where to contact you if we need to contact you outside of the patient portal. We will not ask you why you are making your request and will make reasonable efforts to accommodate all reasonable requests. Some method of contact must be provided and, as appropriate, information as to how payment will be handled.

 E-mail Newsletter: In order to receive practice updates as well as health tips and information, we will sign you up for our office newsletter. We will never SPAM or share or distribute the mailing list, and you will have the option to opt-out and unsubscribe at any time within every e-mail you receive.

 

POLICY FOR DIVORCED OR SEPARATED PARENTS

*This form, and all other new patient forms must be signed by both parents if parents are divorced or separated. If this does not apply to your family, please skip to the end.

Collaborative Natural Health Partners is dedicated to our patients and providing quality medical care to your child(ren). Children of divorced or separated parents sometimes present our practice with unique challenges; therefore, the following policy has been established to avoid misunderstandings going forward. Please understand that our goal in presenting these guidelines is to provide the highest possible level of care for our patients. It is imperative that we care for your child(ren) in an open atmosphere where information is shared with both parents.
Information Sharing:
Under Connecticut law, both parents are entitled to information about their child(ren) unless a court order specifically bars a parent from such information. By law, a parent not granted custody of a minor child has the same right as the custodial parent to the child's academic, medical, hospital or other health records, unless otherwise ordered by the courts (CGS § 46b-56(e)). We expect both parents to communicate with each other regarding their child's health and medical history. It is not the responsibility of our office to provide information to each parent separately because the parents don't communicate with each other. Please know that our role is to be impartial and therefore we cannot take the side of one parent over the other.
Information on File:
The address listed first for your child(ren) should be the address at which the child resides. If parents share custody and the child resides at two different addresses, please list both addresses. Please don't eliminate the "other" parent by listing a stepparent instead, as this prevents us from keeping appropriate information on file when both parents are entitled to information about their child(ren).
Financial Responsibilities:
The parent that brings the child to our office for the appointment is responsible for paying for the visit in full at the time of service. The parent signing the Comprehensive Pediatrics Membership Agreement is responsible for paying for the monthly Membership Fees. A parent sometimes tells us that the "other" parent is responsible for the payment and that we should send a bill to that person. Both parents are responsible, and both should settle the payment details without our involvement. We do not provide duplicate statements nor are we responsible for notifying more than one parent of an account delinquency. Payment responsibility is a decision of the court and cannot be negotiated by us.
Please read and agree to the following so that we may provide care to your child(ren):
The Collaborative Natural Health Partners clinicians and office staff will not be put in the middle of domestic issues or disagreements over the phone or in the office.
Please make decisions regarding appointments and/or any office procedures or treatments PRIOR to visiting our practice.
“Joint Custody” means that each parent has equal access to the child’s medical records. Without a court order, we will not stop either parent from looking at their child’s chart or obtaining test results. If there is a dispute between the parents regarding custody, and a custody agreement has been reached, we will need to see documentation specifying the legal guardian.
Only in situations where there is a confirmed, documented Court Order will one of the parent’s be denied access to the minor child’s health records or visits at the office. Collaborative Natural Health Partners must have a copy of this Court Order on file in the minor child’s electronic chart.
If there is NOT a court order on file with our office, either parent or legal guardian can consent to any treatment during a visit. Either parent or legal guardian can schedule an appointment for their child, be present for the visit and/or obtain a copy of the visit summary.
It is both parents’ responsibility to communicate with each other about the patients’ care, office visit dates and any other pertinent information relevant to the patient. It is not the responsibility of Collaborative Natural Health Partners to communicate visit information to each custodial parent separately. Our clinicians will not call the non-attending parent following visits. Additionally, we will not call a parent to notify of an appointment scheduled by the other parent.
The responsibility of the bill for minors is with the parents or legal guardian. It is our policy to collect payment at the time of service from the parent or guardian who brings the child in for the appointment.
The parent or guardian who completes the financial and cancellation policies and signs the credit card authorization will be charged for all visits unless another valid form of payment is provided at the time of the visit.
We reserve the right to charge an administrative fee for copying records should the requests become excessive.
Should the issues that come between parents become disruptive to our practice or there is non-compliance with this policy, we reserve the right to discharge the family from the practice.
By signing this form, you agree to honor the above policy and understand that breaking this agreement may result in the discharge of your family from the Collaborative Natural Health Partners practice