Root Cause Integrative Medicine

Notice of Privacy Practices (HIPAA)

Effective April 14, 2003 revised federal regulations restrict the use and disclosure of your private health information (PHI) by our practice and other organizations. It has been, and continues to be the policy of our practice to protect the privacy of your patient health information and to comply with any regulations regarding the use and disclosure of patient information. The following summarizes the new law and under what circumstances it may be disclosed.

Permitted Disclosures
Our practice is permitted to use and disclose your PHI for treatment, payment, and for health operation purposes. These uses include sharing your PHI with other health care providers for confirmation of diagnosis, using your PHI to accurately bill services we provide to you, providing your PHI to your insurance company for reimbursement, to remind you of appointments, and as part of our quality improvement program.

We are also permitted to disclose your PHI in compliance with guidelines outlined by law and when required to do so by various government agencies. We may also disclose your PHI, with your consent, to family members, relatives, or close friends, when the information we disclose is relevant to the individual’s involvement with your care, or is required to assist in your health care (e.g. pick up your prescriptions or other documents, notes for follow up care and instructions, etc.)

We will disclose your PHI when we refer you to other physicians or healthcare providers. Finally, we reserve the right to change the privacy practice described in this notice as may be permitted or required by law and to make such change effective for all protected health information.

Restricted Disclosures
You have the right to request restrictions on certain uses and disclosures of your PHI and to request portions of the PHI be amended. However, our practice is not obligated to agree to requested restrictions or to amend your PHI in the manner you request. You also have the right to inspect and receive a copy of your PHI, but may pay a reasonable charge for labor and costs associated with copying and printing your PHI. Finally, you have the right to receive an accounting of disclosure of your health information.

Authorization
Our practice will make other uses and disclosures of your protected health information only after obtaining your written authorization. If you authorize a use not contained in this notice, you may revoke your authorization at any time by notifying us in writing that you want to revoke your authorization.

I give authorization for payment of insurance benefits to be made directly to Root Cause Integrative Medicine, and any assisting physicians for services rendered, and that I am responsible for any unpaid portion after my insurance has processed the claim. I understand payment is due at the time of service for private pay, coinsurance, co-pay, or deductible (if applicable), and that I may receive a separate bill for labs or radiology from another entity. I authorize treatment of the below listed patient by a provider at Root Cause Integrative Medicine. I agree that a photocopy of this agreement shall be as valid as the original. 

Please list names of family, medical offices, physicians, and any others whom you give permission for Root Cause Integrative Medicine to speak with concerning your medical care:

First Name   Last Name

First Name   Last Name 

First Name   Last Name   

First Name   Last Name