Patient Information

Effective Date: June 1, 2024

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

Your health information is private, and no one without a legitimate need to know may have access to it. Elixir: A Wellness Collective (“Practice”) is required by law to maintain the privacy of your health information and to provide you with a notice of its legal duties and privacy practices. In the unlikely event that your health information becomes unsecured, Practice will provide you with prompt notification. Practice will not use or disclose your health information except as described in this Notice of Privacy Practices (“Notice”). This Notice applies to all the medical records generated during your treatment at Practice.

Marketing. Provided we do not receive any payment for making these communications, we may contact you to give you information about products or services related to your treatment, case management or care coordination, or to direct or recommend other treatments, therapies, health care providers or settings of care that may be of interest to you. We may similarly describe products or services provided by this practice and tell you which health plans this practice participates in. We may also encourage you to maintain a healthy lifestyle and get recommended tests, participate in a disease management program, provide you with small gifts, tell you about government sponsored health programs or encourage you to purchase a product or service when we see you, for which we may be paid. Finally, we may receive compensation which covers our cost of reminding you to take and refill your medication, or otherwise communicate about a drug or biologic that is currently prescribed for you. We will not otherwise use or disclose your medical information for marketing purposes or accept any payment for other marketing communications without your prior written authorization. The authorization will disclose whether we receive any compensation for any marketing activity you authorize, and we will stop any future marketing activity to the extent you revoke that authorization.

EXAMPLES OF DISCLOSURE FOR TREATMENT, PAYMENT AND HEALTH OPERATIONS
The following categories describe the ways that Practice may use and disclose your health information:

Treatment: Practice will use your health information in the provision and coordination of your healthcare. We may disclose all or any portion of your medical record information to your physician, consulting physician(s), nurses and other healthcare providers who have a legitimate need for such information in the care and continued treatment of the patient. For example, a healthcare provider treating you for an injury can ask another healthcare provider about your overall health condition.

Payment: Practice may release medical information about you for the purposes of determining coverage, billing, claims management, medical data processing and reimbursement. The information may be released to an insurance company, third-party payor or other entity (or their authorized representatives) involved in the payment of your medical bill and may include copies or excerpts of your medical record that are necessary for payment of your account. For example, to the extent Practice bills for services it provides to you, a bill sent to a third-party payor may include information that identifies you, your diagnosis, the procedures, and supplies used.

Routine Healthcare Operations: Practice may use and disclose your medical information during routine health care operations to run our practice, improve your care, and contact you when necessary. For example, we can use your health information to manage your treatment and services.

Business Associates: Practice may use and disclose certain health information about you to its business associates. A business associate is an individual or entity under contract with Practice to perform or assist Practice in a function or activity that necessitates the use or disclosure of medical information. Examples of business associates include but are not limited to, a copy service used by the Clinic to copy medical records, consultants, independent contractors, accountants, lawyers, medical transcriptionists, and thirdparty billing companies. Practice requires the business associate to protect the confidentiality of your medical information. In addition, Practice requires any subcontractor of Practice’s business associate to protect the confidentiality of your medical information.

Regulatory Agencies: Practice may disclose your medical information to public health or legal authorities charged with preventing or controlling disease, injury or disability. For example, billing practices may be audited by the State Auditor and records are subject to review by the Secretary of Health and Human Services and his/her authorized representatives.

Workers’ Compensation: Practice may release medical information about you for workers’ compensation or similar programs that provide benefits for work-related injuries or illnesses

Military Veterans: Practice may disclose your medical information as required by military command authorities if you are a member of the armed forces
Inmates: If you are an inmate of a correctional institution or under the custody of a law enforcement officer, Practice may release your medical information to the correctional institution or law enforcement official.

Organ and Tissue Donation Requests: Medical information can be shared with organ procurement organizations.

Medical Examiner or Funeral Director: Medical information can be shared with a coroner, medical examiner, or funeral director when an individual dies.
Required by Law: Practice will disclose medical information about you when required to do so by law, for example, responding to lawsuits and legal actions.
Other Uses: Any other uses and disclosures will be made only with your written authorization.
 

PATIENT INFORMATION RIGHTS
Although all records concerning your treatment obtained at Practice are the property of Practice, you have the following rights concerning your medical information:

Right to Confidential Communications: You have the right to receive confidential communications of your medical information by alternative means or at alternative locations. For example, you may request that Practice contact you only at work or by mail.

Right to Inspect and Copy: You have the right to inspect and copy your medical information.

Right to Amend: You have the right to amend your medical information. Any request for amendment should be submitted to Practice in writing, stating a reason in support of the amendment.

Right to an Accounting: You have the right to obtain an accounting of the disclosures of your medical information made during the preceding six (6) year period.

Right to Request Restrictions: You have the right to request restrictions on certain uses and disclosures of your medical information. Practice is not required to honor your request except where: (i) the disclosure is for the purpose of carrying out payment or healthcare operations and is not otherwise required by law, and (ii) the medical information pertains solely to a healthcare item or service for which you, or person other than the health plan on your behalf, has paid Practice in full.

Right to Receive a Paper Copy: You have the right to receive a paper copy of this Notice.

Right to Receive Electronic Copies: You have the right to receive electronic copies of your medical information.

Right to 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.

Right to Revoke Authorization: You have the right to revoke your authorization to use or disclose your medical information, except to the extent that action has already been taken in reliance on your authorization. A request to exercise any of these rights must be submitted, in writing, to Practice at 2146 NE 4th St. Suite 160, Bend OR 97701, or by contacting Practice at 541-306-4471.
 

FOR MORE INFORMATION OR TO REPORT A PROBLEM

If you have questions and would like additional information, you may contact our office at 541-306-4471. If you believe your privacy rights have been violated, you may file a complaint with us by calling 541- 306-4471 and with the U.S. Department of Health and Human Services Office for Civil Rights by calling 1-800-368-1019, visiting https://ocrportal.hhs.gov/ocr/smartscreen/main.jsf, emailing OCRMail@hhs.gov, or sending a letter to:

Centralized Case Management Operations
U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Room 509F HHH Bldg.
Washington, D.C. 20201
We will not retaliate against you for filing a complaint. 

CHANGES TO THIS NOTICE

Practice will abide by the terms of the Notice currently in effect. Practice reserves the right to change the terms of its Notice and to make the new Notice provisions effective for all health information that it maintains. An updated version of the Notice may be obtained at Practice.

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I certify that I have received a copy of Elixir: A Wellness Collective’s (“Practice”) Notice of Privacy Practices. The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that might occur in my treatment, payment of my bills or in the performance of Practice’s health care operations. The Notice of Privacy Practices also describes my rights and Practice’s duties with respect to my protected health information. The Notice of Privacy Practices is also posted in the Front Desk area and on Practice’s website at www.elixirbend.com.

Elixir: A Wellness Collective reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised Notice of Privacy Practices by calling the office and requesting a revised copy be sent in the mail, asking for one at the time of my next appointment, or accessing Practice’s website.

These Office Policies are issued on behalf of Elixir: A Wellness Collective. Elixir is the administrator and facilitator of the provider treating you, but not a medical provider itself.

Payment Due at Time of Service: I am responsible as the patient or patient's guarantor for full payment of services rendered at time of service, and any agreed upon supplements or lab work. Fees are dependent on complexity of care needed, time, and services provided. Payment for non-covered services and insurance copayments, co-insurances, or amounts owed towards insurance deductibles are due at the time of service. Elixir provides discounted self-pay rates for those not utilizing insurance. We accept cash, HSA benefit cards, credit cards, checks and cash.

Insurance/Credit Card Policy: I understand that I will need to provide Elixir with current insurance and credit card information for billing purposes as outlined in our Credit Card Authorization policy. Should there be a change in my insurance coverage or credit card information I agree to update Elixir immediately.

Returned Check Fee: I understand that there will be a $35 fee for all returned checks and for stop payments.

Late Cancellation / No Show Policy: I acknowledge that, if I do not provide 48 hours notice to cancel an appointment or fail to show up for a scheduled appointment, I will be charged a Late Cancel/No Show Fee equal to $100 for Naturopathic Physician and Nurse Practitioner visits and $45 for Chiropractic, Acupuncture, Health Coaching, and Massage Therapy visits. If you arrive more than five minutes late to an appointment, you may be asked to reschedule and will be subject to the late cancellation fee. Emergencies will be taken into consideration.

PacificSource Community Solutions & Open Card Late Cancellation / No Show Policy: Scheduled appointments must be canceled or rescheduled 48 hours prior to the appointment time. Any patient who fails to arrive for a scheduled appointment without canceling at least 48 hours prior is considered a no-show or late cancellation. After an established patient with a PacificSource Community Solutions or OHP plan has two no-show or late cancellation appointments, their provider holds the discretion to discharge the patient from their care or place them on a same day scheduling plan. Being discharged would mean the patient would no longer be able to schedule appointments with the practitioner. An appropriate referral would be given. A same day scheduling plan indicates the patient will only be permitted to book same day appointments if the provider’s schedule permits.

Prescription Refill Policy: Elixir requires 3 business days to respond to all medication refill requests. It is recommended that you contact your pharmacy to initiate refill requests at least one week prior to running out of your current prescription to prevent any lapses in medication availability.

No Returns/Refunds: Once purchased, supplements cannot be returned. This applies to any product, open or unopened. Please let us know if you are on a budget and we will gladly prioritize your treatment options or look for less costly alternatives.

Credit Card Processing: Elixir gladly accepts all major credit cards. If you choose to pay with a credit card a 4% processing fee will be applied to the total amount of your bill to cover merchant services fees associated with credit card transactions.

Communication Policy: I understand and agree that e-mail communications (outside of the secure patient portal), facsimile, and cell phone are not guaranteed to be encrypted, secure or confidential methods of communications. I agree that all e-mail communications made outside of the patient portal are made at my risk. I understand that use of electronic communication outside of the secure patient portal has inherent limitations, including possible breach of privacy or confidentiality, difficulty in validating the identity of the parties, and possible delays in response.

I understand that portal communications with my practitioner are only for non-urgent clarifications. Requesting lab orders, acute concerns, prescription changes, or modifications to my current plan require a visit. I understand that I have the following options; Schedule a 15 minute acute appointment, pay a Portal Consultation Fee of $50.00, or wait until my next visit. Providers at Elixir strive to respond to portal messages within 1-3 business days.

Lab Results: Per the Cures Act put into effect on April 1, 2021 all labs will be made viewable on the portal upon receipt by Elixir. Please feel confident that our policy is to reach out to patients with any critical lab values. Elixir encourages you to discuss these results with your practitioner at your scheduled follow-up prior to beginning any new or modified treatment.

Responsibility to Maintain Separate Primary Care Physician. Medical providers associated with Elixir may consult with, but do not replace care currently provided by other physicians, such as an internist, gynecologist, cardiologist, gastroenterologist, pediatrician (in the case of children), oncologist or other specialty care provider. I understand the possibility of a referral to a specialist for my condition(s) if I have not already consulted with an appropriate specialist. Medical providers associated with Elixir do not admit patients to the hospital or treat hospitalized patients.

Elixir does not function as a primary care practice. Rather, Elixir acts as an extension of a patient’s medical team in working on root cause resolution. As a condition of receiving services from Elixir, all patients must maintain a relationship with an outside physician to act as a primary care provider and to provide emergency and urgent care. If you encounter a medical emergency and are not able to obtain care from your primary care physician(s), you are advised to contact 911 or report to a hospital emergency department as appropriate.

Insurance Benefit Verifications: I am solely responsible as the patient or patient's guarantor to contact my insurance provider to learn my coverage benefits. Insurance benefits will be verified as a courtesy in office as well. I acknowledge that if an insurance company has given inaccurate information, they may not honor the benefits that were quoted. I understand that Elixir is not liable for any representations made by me, Elixir, or any other third-party regarding insurance benefits.

Insurance Billing: I understand that insurance billing is provided as a courtesy and that I am responsible for all claims unpaid by my insurance company. I agree to be billed for any amount not paid by my insurance. Our providers are in-network with a limited number of insurance companies. I understand that Elixir does not bill out of network benefits or secondary insurance plans. I acknowledge my insurance provider may or may not cover the cost of the office visit fee or procedures and does not typically cover the cost of any natural medicine products.

Medicare Non-Participating Policy: If I am eligible for Medicare, then I agree to sign an Advanced Beneficiary Notice of Non-Coverage designated by Elixir. This form states that neither I or Elixir will bill Medicare for payment. Chiropractic adjustments are an exception. Elixir will collect the fees designated by Medicare for non-participating chiropractic physicians at the time of service and submit a claim to Medicare. This does not include non-covered services such as initial office visits, re-exam office visits, physical therapy, labs, imaging, or supplements.

Collection of Fees: I acknowledge that I am financially responsible for all charges. If it becomes necessary to effect collections of any amount owed on this or subsequent visits, the undersigned agrees to pay for all costs and expenses, including reasonable attorney fees. I hereby authorize Elixir to release information necessary to secure payment.

Acceptable Use Policy: I agree to comply with Elixir's acceptable use guidelines, which we may change from time to time. We reserve the right to discontinue service due to, but not limited to: non-payment; abandonment or non-responsiveness; abusive and/or disrespectful behavior/language towards our team. Appropriate referrals will be given as needed to ensure appropriate transition of care.

CONSENT FOR TELEHEALTH COMMUNICATION

I understand that telemedicine is the use of electronic information and communication technologies by a healthcare provider used to deliver services to an individual when he/she is located at a different location or site than I am.

I am seeking the telemedicine consultation services of Elixir for my own purposes and not on behalf of any third party.

I understand that I am a participant in the decision-making process and I am free to decline services or treatments at any time. 

I retain the option to withhold or withdraw consent at any time without affecting my right to future care or treatment.

I acknowledge that my provider may, in his or her sole discretion, determine whether the nature of my consultation is inappropriate for telemedicine, and may require me to come in for an in-person consultation.

I agree to bring to the attention of Elixir, if, at any time, I have any lack of understanding of such risks, benefits and alternatives, and need further explanation to have a full understanding before giving consent to any treatment or services.

The purpose of this form is to obtain your consent for the use of telemedicine consultations with your provider.  The purpose of the use of telemedicine consultations is to assist in the care and services provided by Elixir. 
 

Telemedicine involves the use of audio and video electronic communications to interact with you, consult with your healthcare provider and/or review your medical information for the purpose of diagnosis, treatment, follow-up and/or educational purposes.

The benefits of telemedicine include having access to medical specialists and additional medical information and education without having to travel outside of your home or local health care community. Additional benefits are that patients may be diagnosed and treated earlier which can contribute to improved outcomes and less costly treatments. Potential risks of telemedicine include that because of your specific medical condition, or due to technical problems, a face-to-face consultation still may be necessary after the telemedicine appointment.

Elixir has taken the following steps to ensure the privacy of the telemedicine consultation: 

• We use only HIPAA compliant software through our Electronic Medical Record (EMR) software and teleconferencing software.
• We have taken steps to encrypt data stored on local devices;
• We use password protected screen savers; and
• We use other reliable authentication techniques and safeguards, both electronically and physically, to reduce the likelihood of patient data or privacy breaches.

In rare instances, technology failure may lead to the loss of information provided through telemedicine consultations. Additionally, in rare instances, security protocols could fail causing a breach of patient privacy. In rare cases, a lack of access to complete and/or accurate medical records or information may result in adverse drug reactions, allergic reactions, or other judgment errors. You agree to hold your provider and Elixir harmless from any such information loss, and any resulting judgments or decisions, due to technological failures outside of their agency or control. The quality of transmitted data may also affect the quality of the services provided via the telemedicine consultation. The alternative to telemedicine consultation is a face-to-face visit with a physician.

I understand insurance billing for Tele-Health appointments requires face to face connection and it is my responsibility to ensure a stable internet connection while also being in a quiet distraction-free environment. I will not conduct Tele-Health visits while driving. I acknowledge, if I am not in a quiet distraction-free environment with a stable internet connection, my appointment will be cancelled and I will be subject to the Late Cancel Fee of $100. 

 

I agree to be within the state lines of Oregon for all tele-health visits, unless otherwise specified by my provider.

Exceptions include: New York for Mackenzie Hartmann, NP and Jordan Sirtoli, NP who maintain New York licenses.

All laws concerning patient access to medical records and copies of medical records apply to telemedicine.  Dissemination of any patient identifiable images or information from the telemedicine consultation shall not occur without your consent.
 

All existing confidentiality protections under federal and state law apply to information used or disclosed during your telemedicine consultation. However, there are both mandatory and permissive exceptions to confidentiality, which may allow or require disclosure of information used or disclosed during the telemedicine consultation. You will be informed of any parties who will be present from the Elixir during your tele-health consultation, and will have the opportunity to exclude anyone from attending the consultation.

You may withhold or withdraw your consent to a telemedicine consultation at any time before and/or during the consultation without affecting your right to future care or treatment.
 

• I understand that I may expect anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured.
• I have had opportunities to ask questions and have had them answered to my satisfaction.
• I have read and fully understand the foregoing Telemedicine Consent, and I have all of the knowledge I currently desire.
• I agree and accept all of the terms above.  I am legally competent and have sufficient knowledge to give voluntary and informed consent. 

Do not sign this form unless you have read it and feel that you understand it. Ask any questions you might have before signing this form. Do not sign this form if you have taken medications which may impair your mental abilities or if you feel rushed or under pressure.

Please sign with mouse or finger:

 

Clear Signature

Elixir requires patients to have a current major credit or debit card on file to be charged for accumulated costs related to services, labs, and/or supplements after each appointment. If you have insurance, you will be charged your patient responsibility as determined by your insurance plan. Additionally, this authorization covers late cancellations and no-show fees as outlined in our office and financial policies. Should you accumulate a balance during treatment, further services will be put on hold until your balance has been paid.

Elixir submits claims to insurance carriers as a courtesy for our patients. We request authorization to bill your credit or debit card on file to cover amounts determined by your insurance to be your responsibility. This includes but is not limited to copays, co-insurances, amounts subject to a deductible, non-covered services, and denied claims. Upon receipt of an explanation of benefits from your insurance carrier, any unpaid portion of your claim will be billed to your credit or debit card on file. A receipt will be posted in your portal for your reference. In the event that your insurance does not cover a portion of services that exceeds $100.00, Elixir will contact you 7 days prior to charging the owed amount. Should insurance pay in full, your account will not be subject to any additional charges.

All credit card/debit card information will remain confidential and securely stored by Cerbo. Elixir will not store any banking account data. I, Name:   , hereby authorize Elixir to charge any and all outstanding balances (after insurance company reimbursement or denial, if applicable) to my credit/debit card. I understand that my information will be saved on file for future transactions on my account.

Do you now or have you ever had:

Please list what you had yesterday for:

Please enter all medicines you are taking into the Medications Tab of the Patient Portal.
 

For the following, please check the appropriate box:

•  Y= A condition you have now  
• N= Never had  
• P = Significant problem in the past

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform the clinic of any changes in my health/medical status. I also authorize the health care staff to perform the necessary services I may need.

Please sign with mouse or finger:

 

Clear Signature

The Toxicity and Symptom Screening Questionnaire identifies symptoms that help to identify the underlying causes of illness, and helps you track your progress over time. Rate each of the following symptoms based upon your health profile for the past 30 days. If you are completing this after your first time, then record your symptoms for the last 48 hours ONLY.

POINT SCALE

0 = I do not have this symptom
1 = Occasionally have it, effect is not severe
2 = Occasionally have it, effect is severe
3 = Frequently have it, effect is not severe
4 = Frequently have it, effect is severe
 

Care Team (Please fill in name if applicable)

Family History:

Place a check in the box for all that apply.

Nutrition & Lifestyle

What do you usually eat for the following meals on a typical day?

Please sign with mouse or finger:

CLEAR SIGNATURE

SUBMIT