THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW CAREFULLY.
The Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential. This Act gives you, the patient, significant new rights to understand and control how your health information is used. HIPAA provides penalties for covered entities that misuse personal health information.
As required by HIPAA, we have prepared this explanation of how we are required to maintain the privacy of you health information and how we may disclose your health information.
We may use and disclose your medical records only for each of the following purposes: treatment, payment and health care operations.
Treatment means providing, coordinating, or managing health care and related services by one or more health care providers. An example of this would include a physical examination.Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities, and utilization review. An example of this would be sending a bill for your visit to an insurance company for payment.Health Care Operations include the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis, and customer service. An example would be an internal quality assessment review.
We may also create and distribute de-identified health information by removing all references to individually identifiable information.
We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.
Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization.
You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to the Privacy Officer:
We are required by law to maintain the privacy of your protected health information and to provide you with notice of our legal duties and privacy practices with respect to protected health information.
This notice is effective as of June 10, 2002, and we are required to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right to change the terms of our Notice of Privacy Practices and to make the new notice provisions effective for all protected health information that we maintain. We will post and you may request a written copy of a revised Notice of Privacy Practices from this office.
You have recourse if you feel that your privacy protections have been violated. You have the right to file a formal, written complaint with our office or with the Department of Health and Human Services, Office of Civil Rights, about violations of the provisions of this notice or the policies or procedures of our office. We will not retaliate against you for filing a complaint.
Please contact us for more information, by asking to speak to our Privacy Officer or for written inquiries, note “Attention Privacy Officer.”
For more information about HIPAA or to file a complaint:
The U.S. Department of Health and Human Services
Office of Civil Rights
200 Independence Ave. S.W.
Washington D.C. 20201
Toll Free: 1-877-696-6775
• Office Visits: Fees for appointments are determined by many factors including time spent, procedures performed and complexity of your health care needs. We can give an estimate for each visit upon patient request. Late patients will be charged for the full price of the original appointment duration.
o INSURANCE: We are out-of-network with all insurance companies. All visits must be paid for in full at the time you are seen. Some lab orders and prescriptions may be eligible for insurance coverage. Any noncovered services or any non-covered fees are the patient’s responsibility. You may be eligible for out-of network reimbursement for visits or other services. Please request a “coded bill” at your visit to submit to your insurance company for possible patient reimbursement. Each person’s insurance policy is different from the next; please check with your insurance company to ask about out-of-network Zeimbursement.
Laboratory Testing: All eligible laboratory tests will be billed to the patients’ insurance company by the laboratory or billed to the patient if you do not carry insurance. Any remainder balance not covered by the insurance company is the sole responsibility of the patient. Some labs ordered may require patient payment and may not be eligible for insurance payment.
E-Mails: Fees may apply. The doctor is available by e-mail for simple clarification of the treatment plan or updates on health status. To ensure privacy and confidentiality laws, e-mail correspondence must be conducted through our Patient Portal. Please call to gain access to the patient portal. E-mail is not to be used for the purpose of case management. The doctor will not have your case information in front of her while replying to your e-mail so be sure to include all pertinent information in your e-mailcorrespondence. If your questions or health needs exceed a simple e-mail reply, we will ask you to make an appointment for an in office visit to address your healthcare needs. Please allow 24-48 hours (during business hours/days only) to receive your e-mail reply.
Phone Consultations: Phone consultations with the physician are available and will have a fee attached. This fee is not chargedin the following cases: when you require clarification of your treatment plan and when the doctor has asked you to call. The office will respond to your inquiry within 24-48 business hours. If the office has not responded within 24 - 48 hours, please call the office again.
Copies/Administrative Fees: Copies of patient chart notes or any request that incurs an expense to the clinic will be charged to the client. Fees will be variable depending on the extent of the request. $25.00 minimum per request.
Appointment cancellations: Any no-show appointments or appointments cancelled without 24 hours notice will be billed the full appointment fee. These fees will be the patients’ responsibility (not billable to insurance).
PAYMENTPayment is due at the time of service for office visits and pharmacy products. Dr. Bowen accepts checks, cash, credit card (Visa, Mastercard and Discover) and money orders. Invoices and receipts are available by request.
Returned Check Fee: There is a $25 fee for each returned check.
Returned Prescriptions: You may return unopened prescriptions purchased from Dr. Bowen, within thirty days of purchase for a refund except for the following items: any acidophilus products, suppositories, compounded hormones and amino acids, and specially ordered or assembled items.
All fees are subject to change and patients will be kept abreast of these changes. If you have any questions regarding these guidelines please feel free to ask.
CONSENT FOR TREATMENT
GENERAL INFORMATION: Dr. Bowen incorporates a wide variety of clinical tools in her practice. Most patients will receive a combination of treatment methods drawing from her varied background in nutrition, counseling, herbal medicine and other naturopathic medicine approaches. Diagnosis and treatment may include methods from any or all of the following treatment approaches: Naturopathic Medicine, Physical Medicine, Homeopathy, Lifestyle and Nutritional Counseling as well as referrals to other skilled clinicians.
METHODS, PROCEDURES AND THERAPEUTIC APPROACHES:
Dr. Bowen may perform any of the following procedures as necessary to give proper diagnosis, determine treatment approaches or otherwise address your health concerns:• General Diagnostic Procedures: including but not limited to: blood collection, imaging orders (ultrasound, xray, MRI, CT), lab analysis of blood, urine and stool, general physical exam, neurological and musculoskeletal assessments. Most of these procedures will be performed outside of the clinic.• Counseling: Compassionate and reflective listening, coaching in healthy lifestyle changes, nutrition and exercise.• Topical Treatments and Prepping: prepping skin for puncture with alcohol, iodine or other antiseptic agents.• Herbs and Natural Medicines: prescription of vitamins, minerals, and dietary supplements to achieve therapeutic goals; prescription and / or application of herbs in capsules, powders, teas, tinctures, plasters, pastes, suppositories, creams, salves, etc.; as well as highly dilute homeopathic remedies, intramuscular vitamin injections.• Soft Tissue Manipulation: use of massage, neuro-muscular techniques, muscle energy stretching and visceral manipulation.• Thermal Therapies: includes the use of hydrotherapy and applications of heat and cold.• Minor Office Procedures: such as laceration care and cerumen removal.• Pharmaceutical prescriptions: of herbs, nutrients, hormones and antimicrobials when necessary
POTENTIAL RISKS: Pain, discomfort, blistering, discolorations, infection, burns, loss of consciousness or deep tissue injury from needle insertions, topical procedures, heat or frictional therapies, electromagnetic and hydrotherapies; allergic reactions to prescribed herbs or supplements; soft tissue or bone injury from physical manipulations; and aggravation of pre-existing symptoms.
POTENTIAL BENEFITS: Restoration of health and the body’s maximal functional capacity; relief of pain and symptoms of disease, assistance in injury and disease recovery, and prevention of disease or its progression.
NOTICE TO PREGNANT WOMEN: All female patients must alert the doctor if they know or suspect that they are pregnant, since some of the therapies used could present a risk to the pregnancy. A treatment intended to inducelabor requires a letter from a primary care provider authorizing or recommending such a treatment.
I understand that I may ask questions regarding my treatment before signing this form and that I am free to withdraw my consent and to discontinue participation in these procedures at any time. With this knowledge, I voluntarily consent to the above procedures, realizing that no guarantees have been given to me by Dr. Bowen, regarding cure or improvement of my condition. I understand that a record will be kept of the health services provided to me. This record will be kept confidential and will not be released to others unless so directed by my representative or me or otherwise permitted or required by law.