Our promise to you: Our mission is to empower you to learn the patterns of behavior that inform your wellness choices. We promise to listen carefully, think deeply and kindle insight into directions (therapies, treatments, services) that will nourish sustainable health. We promise to be considerate about your time and thoughtful regarding your finances. We thank you for allowing us to journey with you on this path to transformation and look forward to growing with you!
We ask in return for your authenticity and courage to step outside of usual thinking and behavioral patterns. A key component of success is the willingness to incorporate diet, lifestyle and relationship changes. We ask you to be honest with what are realistic changes to begin with, and to wholeheartedly embrace the possibility that your health and life can look and feel exactly how you want it to, although this requires both effort and time and there are no guarantees from our clinic or providers that this will happen.
Our practice is dedicated to maintaining the privacy of your individually identifiable health information (also called protected health information, or PHI). In conducting our business, we will create records regarding you and the treatment and services we provide to you. We are required by law to maintain the confidentiality of health information that identifies you. We also are required by law to provide you with this notice of our legal duties and the privacy practices that we maintain in our practice concerning your PHI. By federal and state law, we must follow the terms of the Notice of Privacy Practices that we have in effect.
I acknowledge that I have been provided a copy of and have read and understand Dr. Keesha’s HIPAA Privacy Notice containing a complete description of my rights, and the permitted uses and disclosures, under HIPAA. While Dr. Keesha has reserved the right to change the terms of its Privacy Notice, copies of the Privacy Notice as amended are available from Dr. Keesha.
You have the right to revoke this authorization, in writing, at any time, except to the extent that Dr. Keesha has taken action in reliance on it. A revocation is effective upon receipt by Dr. Keesha of a written request to revoke and a copy of the executed authorization form to be revoked.
In addition to the allowable disclosures described in the Statement of Privacy Practices, I hereby specifically authorize disclosure of my protected health care information to the person indicated below:
Having come to Dr. Keesha for evaluation or treatment, I (or my authorized representative on my behalf) hereby consent to and authorize Dr. Keesha medical providers and other staff members involved in my care to administer such diagnostic procedures, treatment or both as they may consider advisable to maintain my health and to assess and to evaluate and treat my injury or illness. I understand that the provider responsible for my care has the responsibility to explain to me the purpose, the benefits and the most common risks involved in the diagnosis and treatment of my illness or injury, as well as alternative available courses of treatment, and I understand that I have the right to refuse any suggested examination, test or treatment.
Right to Refuse Treatment: In giving my general consent to treatment, I understand that I retain the right to refuse any particular examination, test, procedure, treatment, therapy or medication recommended or deemed medically necessary by my individual treating health care providers. I also understand that the practice of medicine is not an exact science and that no guarantees have been made to me as to the results of my evaluation and/or treatment.
This questionnaire gives an indication of your toxicity and inflammation levels based on common signs and symptoms. Periodically, you may be asked to submit this questionnaire again to examine progress during and after treatments.
Interpreting your Grand Total score:
Check all the symptoms that are of concern to you at this time that you want to discuss with the practitioner. On the comments line, please indicate if any checked symptoms are current or past and describe any area in which you have experienced a severe episode and indicate if that episode was in previous 6 months or prior to 6 months ago.
Please take a few minutes to go inside of yourself to answer these last questions so that we may better design a program to fit your unique needs. Thank you for your careful consideration. It is very much appreciated.
Our office is dedicated to protect the privacy rights of our patients and the confidential information entrusted to us. The commitment of each employee to ensure that your health information is never compromised is a principal concept of our practice. We may, from time to time, amend our privacy policies and practices but will always inform you of any changes that might affect your rights.
Protecting Your Personal Healthcare Information
Collection Protected Health Information
We will only request personal information needed to provide our standard of quality integrative medical care, implement payment activities, conduct normal medical practice operations and comply with the law. This may include your name, address, telephone numbers, social security number, employment data, medical history, health records, etc. While most of the information will be collected from you, we may obtain information from third parties if it is deemed necessary. Regardless of the source, your personal information will always be protected to the full extent of the law.
Disclosure of our Protected Health Information
As stated above, we may disclose information as required by law. We are obligated to provide information to law enforcement and governmental officials under certain circumstances. We will not use your information for marketing purposes without your written consent. We may use and/or disclose your health information to communicate reminders about your appointments including voicemail messages, answering machines and emails.
You have a right to request copies of your healthcare information; to request copies in a variety of formats; and to request a list of instances in which we, or our business associates have disclosed your protected information for uses other than stated above. All such requests must be in writing. We may charge for your copies in an amount allowed by law. If you believe your rights have been violated, we urge you to notify us immediately. You can also notify the U.S. Department of Health and Human Services.
We value you for being a patient at Dr. Keesha. Please let us know if you have any questions concerning your privacy rights and the protection of your personal health information.
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