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Pediatric-NewPatientIntake

Name: Date:

Address:

City: State: ZipCode:

Phone(home): cell:____________________________other:___________________

E-mailaddress:______________________________________________________Age:___________________________

DateofBirth: ____________________________________________

Live:qAloneqw/Partnerqw/Parentsqw/ChildrenqOtherfamilyqFriends

Occupation:qWorkqUnemployedqDisabledqRetiredqVolunteerqStudent

CurrentOccupation:___________________________________#ofHoursWork/Volunteer________________________

Ifretired,disabledorunemployed,listlastoccupation:______________________________________________________

Nextofkinoremergencycontact:

Relationship: Phone:

Address:

Howdidyouhearaboutourclinic?______________________________________________________________________

Areyouunderthecurrentcareofaphysician?qYesqNoIfso,withwhom:

Ifnotreceivinghealthcare,whendidyoulastreceivehealthcare?_____________________________________________

Whatis/wasthereason?

Doyoucurrentlyhaveanycontagiousdiseases?qYesqNoPleaselist:

Doyouhaveanyallergies?qYesqNoPleaselist:

Whatareyourmostimportanthealthconcernsandwhattreatmentshavebeenused?

1. treatmentsused

2. treatmentsused

3. treatmentsused

Whatservice(s)areyouherefortoday?__________________________________________________

IgivetheprofessionalsatRNMpermissiontoassistinmycare.IunderstandthatsuchprofessionalsmayincludeRNMemployees,members,andindependentcontractors.IagreetoindemnifyandholdharmlessRNM,itsofficers,members,independentcontractors,directors,andemployeesfromanyandalldamagesand/orliabilityarisingoutoforrelatedtoservicesrendered.IalsounderstandthatifIdonotgivea24-hournoticeforanappointmentcancellationorifIdonotshowfortheappointment,Iwillbechargedaninsufficientnoticefee.

_____________________________________________________________/__________/__________

SIGNATURE DATE

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Name:__________________________________________________________Date:___/___/______

DOB:______/______/_______Height:_____’_____”Weight:_____lbs.___Male___Female

BloodType:______________!Unknown

Parent(s)Name:_______________________________________________________________________

Is thereanyother informationaboutyour child’shealth thatyou’d likeus toknow?Please include if thisinformationcanbediscussedinfrontofyourchild.____________________________________________

_______________________________________________________________________________________

GOALS

Whatisyourprimaryconcernforyourchild’shealth?________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Whatadditionalconcernswouldyouliketoaddress?________________________________________

_____________________________________________________________________________________

Whatledyoutochoosingthisclinic?______________________________________________________

_____________________________________________________________________________________

Whatdoyouknowaboutusandhowwework?_____________________________________________

_____________________________________________________________________________________

Whatexpectationsdoyouhavefortoday’svisitatourclinic?

_____________________________________________________________________________________

_____________________________________________________________________________________

Whatlong-termexpectationsdoyouhaveforworkingwithourclinic?_________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Atthispresenttime,howcommittedareyoutoaddressingtheunderlyingcausesofyourchild’ssignsandsymptomsthatmayrelatetotheirlifestyle?(0=notcommittedand10=completelycommitted)Pleasecircle.

0 1 2 3 4 5 6 7 8 9 10

MEDICALHISTORY

Whoisyourchild’spediatrician?_________________________________Phone:_____-_____-______

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Listallprescriptionmedicationsyourchildiscurrentlytaking(withdoses)___________________

___________________________________________________________________

Listallherbs/vitaminsyourchildiscurrentlytaking(withdoses)________________________________

_____________________________________________________________________________________

Listallallergies(food/environmental/drug)!NoneKnown___________________________________

_____________________________________________________________________________________

Listanddateallsurgeries,hospitalizationsandmajoraccidents________________________________

_____________________________________________________________________________________

Hasyourchildeverexperienced,beendiagnosedorreceivedtreatmentforthefollowing?(Checkallthatapply)

! RheumaticFever !Measles! ChickenPox !GermanMeasles! Scarletfever !Mumps! Shingles !Diptheria! Asthma !Eczema! AustismSpectrumDisorder !Sadness/Depression! Sorethroat/infectionfrequency_____________ !EarInfectionsfrequency______________! #ofColdsperyear___________ !EBV(mononucleosis)! LymeDisease !CMV(cytomegalovirus)! Other_________________________________________________________________________________

__________________________________________________________________________________________

Hasyourchildhadanyofthefollowingtests?(Checkallthatapply)

! Electroencephalogram(EEG) when?_________where?______________________________________! PsychologicalEvaluation when?_________where?______________________________________! HearingTests when?_________where?______________________________________! Speech/LanguageTests when?_________where?______________________________________! EyeExam when?_________where?______________________________________

Has your child had any of the following immunizations? (Check all that apply & circle any that causedadversereactions)

! Polio !Tetanus !Measles/Mumps/Rubella !Pertussis ! Diphtheria !Influenza !HepB !HPV ! ChickenPox !Hib !Rotavirus

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How was your child born? Vaginal or Cesarean section? Any complications? (premature, overdue, etc.)_____________________________________________________________________________________

_____________________________________________________________________________________

Wasyourchildbreastfed?!Y!NIfso,howlong?_______Formula?_______Milktype?________

Hasyourchildreachedallage-appropriatemilestones?(e.g.crawling,walking,talking,teething)____

_____________________________________________________________________________________

Whenwasthelasttimeyourchildhadafever?Whatwasthecauseandtemperaturereading?______

_____________________________________________________________________________________

TOXICEXPOSURES

Hasyourchildeverlivedinasmokinghousehold? YN

Hasyourchildeverhadexposurestolead,pesticides,mercury,chemicals,etc? YN

Ifyes,whatandwhen?_________________________________________________________________

FAMILYHISTORY

Pleaselistalldiseasesandindicatefamilialrelation(parents,grandparentsandsiblingsonly)_______

_____________________________________________________________________________________

_____________________________________________________________________________________

MOTHER’SHEALTHDURINGPREGNANCY

Bleeding YN Nausea YNHypertension YN Diabetes YNPhysicaloremotionaltrauma YN Thyroidproblems YNIllnesses YN Ifyes,what?______________________________________Medications YN Ifyes,what?______________________________________Cigarettes,alcohol,drugconsumption YN Ifyes,what?______________________________________Mother’sageatbirth?____________

DIET

Doesyourchildfollowaspecificdiet? YN Ifyes,pleasecircle

Vegetarian Vegan Paleolithic Anti-inflammatory Blood-type Atkins

Low-fat/lowcalorie Gluten-free Dairy-free Other_____________________________

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Pleasedescribeyourchild’sdietasaccuratelyaspossible

Breakfast_____________________________________________________________________________

Lunch________________________________________________________________________________

Dinner_______________________________________________________________________________

Snacks_______________________________________________________________________________

Beverages____________________________________________________________________________

Does your child have a well balanced diet? Are there certain foods that your child does not eat?_____________________________________________________________________________________

Howisyourchild’sappetite?Dotheyskipmealsregularlyorneedmultiplesnacksbetweenmeals?

_____________________________________________________________________________________

Aretherecertainfoodsthatyourchildcravesmorethanothers?_______________________________

_____________________________________________________________________________________

Whatnutritionalgoalsdoyouhaveforyourchild?___________________________________________

_____________________________________________________________________________________

PHYSICALACTIVITY

Pleaseexplainyourchild’susualenergylevel?______________________________________________

_____________________________________________________________________________________

Atwhatpartofthedayistheirenergylevelhighest?_________________________________________

Atwhatpartofthedayistheirenergylevellowest?_________________________________________

Whatdoesyourchilddoforphysicalactivity/howoftendotheydothis?________________________

_____________________________________________________________________________________

Doesyourchildparticipateinanysports?Whichones?_______________________________________

_____________________________________________________________________________________

MENTAL/EMOTIONAL

Does your child seem more emotional than their siblings and /or other children? How so?_____________________________________________________________________________________

_____________________________________________________________________________________

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How does your child play with others? Do they join groups easily or prefer to play on their own?_____________________________________________________________________________________

_____________________________________________________________________________________

Does your child show a lack of interest in participating in activities or doing everyday things? If so, howoften?___________________________________________________________________________

_____________________________________________________________________________________

Doesyourchildhaveanysignificantfears?Dotheyhavenightterrors?___________________________

_____________________________________________________________________________________

Doesyourchildhaveanyissueswithsleep?________________________________________________

_____________________________________________________________________________________

Doesyourchildhaveproblemswithwettingthebed?Ifso,howoften?_________________________

_____________________________________________________________________________________

LIFESTYLE

What types of daily or weekly lifestyle habits/activities do you feel support or strengthen your child’shealth?______________________________________________________________________________

_____________________________________________________________________________________

What obstacles or challenges do you potentially anticipate that may undermine your child’s health andfollowingthroughontheirtreatment?_________________________________________________

_____________________________________________________________________________________

Whodoyouknowthatwillsincerelysupportyouandyourchildconsistentlywiththelifestylechangesyourchildwillbemakingtoregaintheirhealthandvitality?___________________________________

_____________________________________________________________________________________

Whatdoesyourchildlovedoing;whatbringsthemjoy?______________________________________

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REVIEWOFSYMPTOMS

Pleasecircleallthatapply

Hives Burningurine Bloodyurine Eczema Hairloss

Crieseasily Bleedinggums Heartmurmur Nervous/anxiety Dizzyspells

Nosebleeds Vomitingspells Sleepproblems Asthma Frequenturination

Acne Anemia Nightsweats Highfevers Allergies/runnynose

Jaundice Sensitivetolight Chronicrash Stomachaches Difficultylearning

Diarrhea HearingLoss Easybruising Sorethroats Sadness

Flatfeet Noappetite Body/breathodor Constipation/diarrhea Cough

Nightmares Frequentcolds Bleedingtendency Unusualfears Behaviorproblems

Wheezing Jointpain Excessivefatigue Other(explainbelow)

APPOINTMENT&CANCELLATIONPOLICY

Newpatientvisitsare90to120minutesindurationandreturnvisitsareusually60minutes.Ifyouareunabletomakeanappointmentyouwillneedtoprovideatleasta24-hournotice.Thisallowsustomeettheneedsofotherpatientswhoneedanappointment.Duetothis,follow-upappointmentsthatarecancelledwithoutprovidinga24-hournoticewillbechargeda$75insufficientnoticefee,newpatientappointmentsthatarecancelledwithoutprovidinga24-hournoticewillbechargeda$100 insufficientnotice fee.We charge your credit cardon file if youdonot call and cancel your appointmentwithin thetimeframesbelow.Notificationallowsthepractitionerstoseeotherclientswhoneedtobecaredforthatday.

COMMUNICATINGWITHRICHMONDNATURALMEDICINEANDYOURPRACTITIONER

EmailPolicy

Werecognizethatmanyofourclientsprefertouseemailasaquickandeasywaytocommunicatewithahealthcareprovider.Wewouldliketoofferthisasamethodtocommunicateforbusinessandhealthcarematters.Youmaycontactyourpractitionerbyemailatthefollowingaddress:patients@richmondnaturalmed.com.Herearesomepointswewouldlikeourclientstobeawareofregardingemailcommunications:

1) Thistypeofcommunicationisnotalwayssecureorconfidentialsotohelpensureyourprivacya. Pleasedonotsendmedicalemailsfromyourworkemailaccountb. Please do not send information which you do not want shared; as email is never a

guaranteedsecurecommunicationtool.2) Allmedicalemailcommunicationsmaybekeptinyourchartaspartofyourmedicalrecord.3) Employees of Richmond Natural Medicine other than your provider, such as other health care

providersandsupportstaff,mayhaveaccesstoyoure-mailaddressande-mailcontent.4) Wewilldoourbesttoreplytoemailswithin48hours,butthereisalwaysachancethatanemailis

not properly sent or received. If you do not hear fromuswithin 2-3 days, please follow upwithanotheremailorbytelephone.

5) In cases where an email response would not be appropriate or sufficient, you may be asked toscheduleaphoneorin-officeappointmenttoensurethatyourconcernsgetproperlyaddressed.

EmailBillingPolicyWe recognize that formany clients, a quickmedical question is sometimes easier to send through email.Wewould like to continue towelcome your questions thisway, but due to an increasing volume of emails of thisnature,andtheamountoftimepractitionersarespendingonemailpatientcare,wehaveimplementedanemail

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billing policy. Youmay be billed for time spent responding to your email inquiries related to your health caredependingonthecomplexityofandtimespentrespondingtoyourinquiry.

TimewillNOTbebilledfor:

1. Schedulingquestions2. Billingquestions3. Supplementrefills4. Clarificationofyourmostrecenttreatmentplan

Ifyouwouldliketosendusahealthupdatethatdoesnotrequireareplypleasetype“NoReplyNecessary”inthesubject lineof theemail. Thiswill ensureyouwill notbebilled. Weappreciate your consideration in followingthesepolicies.Ifyouhaveanyquestionsorconcerns,pleasecontactusatyourconvenience.

PhonePolicyAtRichmondNaturalMedicine,wehavefoundthatfollowupscanbeeffectivelymanagedoverthephone,allowingustotakeonmanylongdistancepatients.Wedoask,however,thatyoucomeinforyourinitialvisit.Theinitialintakeisatimeforgatheringpertinentinformationthatwillbeusefulthroughoutthecourseoftreatment,thereforebeingthereinpersonisanimportantfactorinreceivingthebestcarepossible.Also,meetingyoufacetofaceallowsustheopportunitytogettoknowyouasawholeperson,andallowsyoutogetafeelofhowwepractice.Appropriatelytimedfollowupsareveryimportanttoyourhealingprocess,andwewouldlovetobeinformedofsignificanthealthchanges,or ifyougetacutely ill so thatwecanadjustyoursupportplanasyourhealthneedschange.Phoneconsultationscanbeveryuseful in thisway,asyoudonothave tocome to theoffice fora lastminuteappointmentorifyou’renotfeelingwellenoughtotravel.

PhoneBillingPolicyYourpractitionerspendsanequalamountoftimeandeffortonyourcareoverthephoneastheydoduringin-officeappointments,andthereforephoneconsultationswillbebilledatournormalfollowuprate.Yourpractitionermaycallyouforaquickcheckinafteryoubeginanewremedyormakechangestoyoursupportplan.Youwillnotbebilledfortheseshort(5-10min)phoneconsultations,howeverifthecallendsuprequiringadditionaltimeorextensivedecisionmaking,youmaybebilledfortheconsultationoraskedtoscheduleafollowupappointmentatalaterdate.

Beloware a few thingswehave foundnecessary toprovide themost effective care forour clients, particularlythosewhoarelongdistanceorfollowingupbyphone:

1. You will need to have a local physician to perform examinations and manage prescriptionmedications that are needed during the course of seeing your practitioner at Richmond NaturalMedicine.

2. It is ideal ifyouhaveaclose familymemberor friendwho iswillingandabletospeakwithusonoccasion.Thishelpsusgatherobservationaldetailsaboutyoursymptomsthatmaybemissedinaphoneconsultation. It’salsohelpful if thisperson iswillingandabletocontactusonyourbehalfshouldacircumstancearisewhenyoumaybeunabletodoso.

3. Weaskthatyouincludeusinallmedicaldecision-makingsuchasstarting/stoppingothertherapiesthatmayaffecttheprogressofourtherapies.

CONSENTTOTREATMENTIamtheparentorlegalguardianofthechilddescribedabove,andIamauthorizedtoconsentonbehalfofthischild.AsusedbelowinthisConsenttoTreatment,“I”meansboththeparent/legalguardianandthechild.

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IagreetoabidebytheguidelinesofRichmondNaturalMedicine,LLC(“RNM”).IunderstandthattheCommonwealthofVirginiadoesnotlicenseorotherwiserecognizenaturopathicmedicaldoctors.Therefore,neitherDr.Allen,JoyBlack,Dr.Bloomingdale,Dr.Casey,Dr.Hollon,LindsayKluge,Dr.Lundberg,Dr.ReckersnoranyothernaturopathicdoctorparticipatinginmycareatRNMarepermittedtodiagnoseortreatagivendiagnosisofadisease/illness.Theroleofmynaturopathicdoctorissupportive,adjunctiveandconsultativeinnaturetoassistinmyhealthandwell-being.Ifurtherunderstandthatmynaturopathicdoctormayworkwithotherphysiciansorhealthcareproviders.Ifurtherunderstand,ifIneedadditionalassistanceormedicalcare,Iwillbereferredtootherswithinthecommunity.

Iherebyrequestandconsenttotheperformanceofnaturopathiccareandrelatedproceduresonmebythenaturopathicdoctorand/oranyRNMpersonnelauthorizedbythenaturopathicdoctor.IfurtherunderstandmynaturopathiccaremaybeperformedbyDr.Allen,JoyBlack,Dr.Bloomingdale,Dr.Casey,Dr.Hollon,LindsayKluge,Dr.Lundberg,Dr.Reckers,and/oranyothernaturopathicdoctorwhomaycareformeorconsultwithmenoworinthefutureatRNM.IhavehadanopportunitytodiscusswithDr.Allen,JoyBlack,Dr.Bloomingdale,Dr.Casey,Dr.Hollon,LindsayKluge,Dr.Lundberg,Dr.Reckersand/orotherRNMpersonnelthenatureandpurposeofnaturopathiccareandrelatedprocedures.IunderstandthatresultsarenotguaranteedandthatneitherRNM,Dr.Allen,JoyBlack,Dr.Bloomingdale,Dr.Casey,Dr.Hollon,LindsayKluge,Dr.Lundberg,Dr.Reckers,oranyotherRNMpersonnelwarrantorguaranteeanyresultoroutcome.

Inagreementwithfederalandstatelaw,IagreetoallowRNMtodeliverthenecessarycaretomeinordertoprovidecontinuityofcareandtreatment.RNMand/ormynaturopathicdoctormayobtainfromanysourceandexamineanduse,ordiscussanddisclose,mymedicalrecordsandinformationtoRNMpersonnelandagents,otherhealthcareproviders,medicalrecordsauditors,professionalcommittees,careevaluatorsandgovernmentalagencies.Thisinformationcaninclude,butisnotlimitedto:medicalhistory,examinations,diagnoses,treatmentsanypsychiatric,drugandalcoholabuseorgenetictestinginformation,orHIVorAIDSinformation.Thisconsenttoreleaseandobtaininformationisvaliduntilrevoked.Imayrevokethisconsentinwritingatanytime,exceptwithregardtodisclosuresthathavealreadybeenmadeinrelianceonsuchconsent.

Ihaveread,orhavehadreadtome,theaboveconsent.Ihavealsohadanopportunitytoaskquestionsaboutitscontents,andbysigningbelow,Iagreetothetreatmentrecommendedbymynaturopathicdoctor.Iintendthisconsentformtocovertheentirecourseoftreatmentformypresentcondition(s)andforanycondition(s)forwhichIseektreatmentatRNM.IunderstandRNM’sfee,appointment,andcancellationpoliciesaswell.

____________________________________________________________________________________Signatureofindividualorguardian Date____________________________________________________________________________________RNMRepresentative Date

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PaymentPolicy

RichmondNaturalMedicinestrivestoensureaclearunderstandingofyourfinancialresponsibilitywithrespecttotheservicesweprovide.Thesepoliciesapplytoallproceduresandproducts.Payments:Paymentforservicesrenderedisdueatthetimeofservice.Weacceptcash,Visa,MasterCard,DiscoverandAmericanExpress.Wealsoacceptpaymentbycheckanddebitcards.Weholdacreditcardnumberonfiletosecureyourappointmentandtosecurenecessaryfeesforbreachofourcancellationpolicy.RichmondNaturalMedicinewillsendclientsaccountstocollectionsforbalancesnotpaidaftertwofailedattemptstocollectonbalancespastdueby60daysormore.Paymentplansareofferedatmanagement’sdiscretion.Wereservetherighttorequirepaymentforservicestobemadeatorbeforethetimeofservice.Outstandingbalances:Wemayrefusetoseepatientswhohavelargebalancesorarenotmakingregularpaymentsontheirbalance.Ifyouhaveanunpaidbalanceattheendofabillingcycle,wemayapplya$5latepaymentfeetoyouraccount.Ifyoumakeapaymentanditisinsufficienttopayboththelatepaymentchargeandtheprincipleamountdue,weapplyyourpaymenttothelatepaymentfeedueandthenweapplytheremainingamounttotheprincipal.Intheeventthatyouraccountisplacedforcollection,acollectionfeewillbeaddedtoyouraccount,alongwithanyattorneyfeesand/orcourtcoststhatmaybenecessaryforrecoveryoftheoutstandingbalance.Intheeventofan“insufficientfund”check,therewillbea$25insufficientfundschargeaddedtothebalancedue.Cancellations:Wechargeyourcreditcardonfileifyoudonotcallandcancelyourappointmentwithinthetimeframeslistedbelow.Notificationallowsthepractitionerstoseeotherclientswhoneedtobecaredforthatday.NewClientandFollow-upappointments:Follow-upappointmentsthatarecancelledwithoutprovidinga24-hournoticewillbechargeda$75insufficientnoticefee,newpatientappointmentsthatarecancelledwithoutprovidinga24-hournoticewillbechargeda$100insufficientnoticefee.Failuretoshowforanappointmentwillalsoresultinachargetoyourcreditcard.Dependents:Youareresponsibleforpaymentofservicesrenderedtoyourdependentsonyouraccount.IauthorizeRichmondNaturalMedicinetokeepmysignatureonfileandtochargemycreditcard(heldinoursecuresystem)for:1.Chargesassociatedwithappointmentsthatarenotcancelledwithinthetimeframeslistedabove.2.Chargesassociatedwithpaymentarrangements.Contactmanagementtomakepaymentarrangements.AttestationStatement:Ihaveread,understand,andagreetotheaboveRichmondNaturalMedicinePaymentPolicy.Iunderstandthatchargesaremyresponsibility.IacknowledgethatthesepoliciesdonotobligateRichmondNaturalMedicinetoextendcredit.____________________________________________PrintNameofPatient(OrParent/Guardian)__________________________________________________________________SignatureofPatient(OrParent/Guardian) Date

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NoticeofPrivacyPractices

Thisnotice,andtheaccompanyingPracticesRegardingDisclosureofClientHealthInformation,describehowhealthinformationaboutyoumaybeusedanddisclosed,andhowyoucangetaccesstoyourhealthinformation.Copiesaregiventoallindividualsreceivingcare.Pleasereviewthisinformationcarefully.

Understandingyourhealthrecord:ArecordismadeeachtimeyoucometoRichmondNaturalMedicineforatreatmentorconsultation.Yoursymptoms,thepractitioner’sassessment,andaplanofservicesarerecorded.Thisrecordformsthebasisforplanningyourcareandtreatment/consultationatfuturevisits,andalsoservesasameansofcommunicationamongotherhealthprofessionalswhomaycontributetoyourcare.Understandingwhatinformationisretainedinyourrecordandhowthatinformationmaybeusedwillassistyoutoensureitisaccurateandmakeinformeddecisionsaboutwho,what,when,where,andwhyothersmaybeallowedaccesstoyourhealthinformation.

Understandingyourhealthinformationrights:YourhealthrecordisthephysicalpropertyofRichmondNaturalMedicine,butthecontentisaboutyou,andthereforebelongstoyou.Youhavetherighttorevieworobtainapapercopyofyourhealthrecord.Youhavetherighttorequestrestrictions,toauthorizedisclosureoftherecordtoothers,andbegivenanaccountofthosedisclosures.Otherthanactivitythathasalreadyoccurred,youmayrevokeanyfurtherauthorizationstouseordiscloseyourhealthinformation.

Ourresponsibility:RichmondNaturalMedicineisrequiredtomaintaintheprivacyofyourhealthinformationandtoprovideyouwiththisnoticeofourprivacypractices.We’rerequiredtofollowthetermsofthisnoticeandtonotifyyouifweareunabletograntyourrequesttodiscloseorrestrictdisclosureofyourhealthinformationtoothers.RichmondNaturalMedicinereservestherighttochangeitspracticesandpromisestomakeagoodfaithefforttonotifyyouofanychanges.Otherthanforthereasonsdescribedinthisnotice,RichmondNaturalMedicineagreesnottouseordiscloseyourhealthinformationwithoutyourconsent.

Contactinformation:RichmondNaturalMedicine2201WestBroadSt.Suite107Richmond,VA23220804-977-2634

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PracticesRegardingDisclosureofClientHealthInformation

Yourhealthinformationwillberoutinelyusedfortreatment/consultation,payment,andquality-monitoring,andyourconsent,ortheopportunitytoagreeorobject,isnotrequiredintheseinstances:

Treatment/Consultation:InformationobtainedbyyourpractitioneratRichmondNaturalMedicinewillbeenteredinourrecordandusedtoplantheservicesprovidedyou.Yourhealthinformationmaybesharedwithothersinvolvedinyourcareorprovidingconsultationaboutyourservices.Yourpractitioner’sownexpectationandthoseofothersinvolvedinyourcaremayalsoberecorded.

Payment:YourrecordwillbeusedtoreceivepaymentforservicesrenderedbyRichmondNaturalMedicine.Abillmaybesenttoeitheryouorreceiveddirectlyuponservicesrendered.

QualityMonitoring:RichmondNaturalMedicinewilluseyourhealthinformationtoassessthecareyoureceivedandcomparetheoutcomeofyourcaretoothers.Yourinformationmaybereviewedforriskmanagementorqualityimprovementpurposesinoureffortstocontinuallyimprovethequalityandeffectivenessofthecareandservicesprovided.

Inaddition,thefollowingdisclosuresarerequiredbylawanddonotrequireyourconsent:

FoodandDrugAdministration(FDA):ThisofficeisrequiredbylawtodisclosehealthinformationtotheFDArelatedtoanyadverseeffectsoffood,supplements,products,andproductdefectsforsurveillancetoenableproductrecalls,repairs,orreplacements.

PublicHealth:Thisofficeisrequiredbylawtodisclosehealthinformationtopublichealthand/orlegalauthoritiestoavertaseriousthreattohealthorsafety,toreportcommunicabledisease,injury,ordisability,ortocomplywithmandatedreportingrequirementsfortrackingofbirthandmorbidity.

LawEnforcement:Asrequiredunderstateorfederallaw,yourhealthinformationwillbedisclosedtoappropriatehealthoversightagencies,publichealthauthorities,lawenforcementofficials,orattorneys:(1)Inresponsetoavalidsubpoena;(2)Intheeventthatastaffmemberofbusinessassociateofthisofficebelievesingoodfaiththatoneormoreclients,workers,orthegeneralpublicareendangeredduetosuspectedunlawfulconductofapractitionerorviolationsofprofessionalorclinicalstandards;(3)Whenaclientisasuspectedvictimofabuse,neglectordomesticviolence.

ItisRichmondNaturalMedicine’practicetoconsiderthefollowingasroutineusesanddisclosuresforwhichspecificauthorizationwillnotberequested.Youhavetherighttorequestrestrictionsontheseuses.Otherwise,RichmondNaturalMedicinewillrequestyourauthorizationwheneverdisclosureofpersonalhealthinformationisnecessarytopartiesotherthanthosereferencedhere:

BusinessAssociates:Someoralloryourhealthinformationmaybesubjecttodisclosurethroughcontractsforservicestoassistthisofficeinprovidinghealthcare.Toprotectyourhealthinformation,werequiretheseBusinessAssociatestofollowthesamestandardsheldbythisofficethroughtermsdetailedinawrittenagreement.

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CommunicationswithFamily:Usingbestjudgment,afamilymember,closepersonalfriendidentifiedbyyou,personalrepresentative,orotherpersonsresponsibleforyourcaremaybenotifiedorgiveninformationaboutyourcaretoassisttheminenhancingyourwell-beingortoconfirmyourwhereabouts.

Consent

IconsenttotheuseordisclosureofmyprotectedhealthinformationbyRNMforthepurposeofanalyzing,diagnosingorprovidingtreatmenttome,obtainingpaymentformyhealthcarebillsortoconducthealthcareoperationsofRNM.Iunderstandthatanalysis,diagnosisortreatmentofmebyRNMmaybeconditioneduponmyconsentasevidencedbymysignaturebelow.IunderstandIhavetherighttorequestarestrictionastohowmyprotectedhealthinformationisusedordisclosedtocarryouttreatment,paymentorhealthcareoperationsofthepractice.RNMisnotrequiredtoagreetotherestrictionsthatImayrequest.However,ifRNMagreestoarestrictionthatIrequest,therestrictionisbindingonRNM.Ihavetherighttorevokethisconsent,inwriting,atanytime,excepttotheextentthatRNMhastakenactioninrelianceonthisConsent.My"protectedhealthinformation"meanshealthinformation,includingmydemographicinformation,collectedfrommeandcreatedorreceivedbymyphysician,anotherhealthcareprovider,ahealthplan,myemployerorahealthcareclearinghouse.Thisprotectedhealthinformationrelatestomypast,presentorfuturephysicalormentalhealthorconditionandidentifiesme,orthereisareasonablebasistobelievetheinformationmayidentifyme.IhavebeenprovidedwithacopyoftheNoticeofPrivacyPracticesofRNMandunderstandthatIhavearightthatNotice'sNoticeofPrivacyPracticespriortosigningthisdocument.TheNoticeofPrivacyPracticesdescribesthetypesofusesanddisclosuresofmyprotectedhealthinformationthatwilloccurinmytreatment,paymentofmybillsorintheperformanceofhealthcareoperationsofRNM.TheNoticeofPrivacyPracticesforRNMisalsoavailableatthefrontdeskat2201WestBroadSt.Suite107,RichmondVA.ThisNoticeofPrivacyPracticesalsodescribesmyrightsanddutiesofRNMwithrespecttomyprotectedhealthinformation. RNMreservestherighttochangetheprivacypracticesthataredescribedintheNoticeofPrivacyPractices.ImayobtainarevisednoticeofprivacypracticesbycallingtheofficeofRNMandrequestingarevisedcopybesentinthemailoraskingforoneatthetimeofmynextappointment.

Signatureofindividualorguardian Date

____________________________________________

PrintName

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HIPAAPrivacyAuthorizationForm

ThisformisrequiredbytheHealthInsurancePortabilityandAccountabilityAct(HIPAA),

Section45C.F.R.Parts160and164Authorization

I,________________________________,authorizeRichmondNaturalMedicine(RNM)touseanddisclosetheprotectedhealthanddemographicinformationtotheindividualsworkingwithintheestablishment.Also,thisauthorizationexpireswillexpireoneyearfromtoday’sdate:____/___/____.

Youhavethefollowingrights:

1.Ihavearighttorefusesignthisauthorization.2.Ihavearighttoreceiveanoticeaboutmyprivacypolicies.3.Ihavearighttorequestandaccessmymedicalinformation.4.Ihavearighttolimittheusesanddisclosureofmymedicalinformation.5.ThismedicalinformationwillonlybeusedbythepersonIauthorizetoreceivethisinformationhealthcareandhealthconsultationorotherpurposeImayauthorize.6.IunderstandthatIhavearighttowithdrawthisauthorization,inwriting,atanytimeduringmycare.Iacknowledgethatawithdrawalisnoteffectivetotheextentthatanypersonorentityhasalreadyactedinrelianceonmyauthorization.

☐Idonotgiveanyone(family,caregiver,friends)accesstomymedicalinformationrelatedtomycare

☐Idogivethefollowingindividualsaccesstomymedicalinformationrelatedtomycare:

Name(s):___________________________________________________________

Expirationofaccess:__________________________________________________

____________________________________________________________________Signatureofpatientorpersonalrepresentative

_____________________________________________________________________Printednameofpatientorpersonalrepresentative

Date____/____/______