The Privacy Notice includes a complete description of the uses and/or disclosures of my protected health information (“PHI”) necessary for Natural Health to provide treatment to me, and also necessary for Natural Health to obtain payment for that treatment and to carry out its health care operations. Natural Health explained to me that the Privacy Notice would be available to me in the future at my request and may receive a copy at any time after I have signed the Consent.
Natural Health reserves the right to change its privacy practices that are described in its Privacy Notice, in accordance with applicable law.
Natural Health’s “Notice of Privacy Practices” is also provided near the bulletin board in the reception area.
This Notice of Privacy Practices also describes my rights and the duties of this office with respect to my protected health information.
I understand that, and consent to, the following appointment reminders that will be used by the Practice: a) telephoning my home or business and leaving a message on my answering machine or with the individual answering the phone. Request for no reminder calls will be accepted.
Natural Health may use and/or disclose my PHI (which includes information about my health or condition and the treatment provided to me) in order for the Practice to treat me and obtain payment for that treatment, and as necessary for Natural Health to conduct its specific health care operations. I can request refusal of Natural Health to file my insurance, and realize I am responsible for the treatment cost.
I understand that this Consent is valid for seven years. I further understand that I have the right to revoke this Consent, in writing, at any time for all future transactions.
I understand that if I do not sign this consent or revoke consent at any time, Natural Health has the right to refuse to treat me.
I understand and consent to the following other types of correspondence from this office:
a.) A birthday card or greeting card may be mailed or emailed to me at the address I provided.
b.) I may receive periodic mailings of general health information in the form of a newsletter.
c.) I may receive E-mails periodically of general health information.
d.) Thank you notes may be sent for referring a new patient and your name may be posted on our waiting room thank you board.
I understand that the Healthcare Providers at Natural Health may discuss my conditions to refer to one another so they may help me improve.
I have read and understand the foregoing notice, and all of my questions have been answered to my full satisfaction in a way that I can understand.
