HIPAA Patient Consent Form Patient Consent for Use and Disclosure of Protected Health Information
I hereby give my consent for Bee Your Healing Home to use and disclose protected health information (PHI) about me to carry out treatment, payment and health care operations (TPO).
I have the right to review the Notice of Privacy Practices prior to signing this consent. Bee Your Healing Home reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to BYHH.
With this consent, Bee Your Healing Home may call my home or other alternative location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any calls pertaining to my clinical care, including laboratory test results, among others.
With this consent, Bee Your Healing Home may mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements as long as they are marked “Personal and Confidential.”
With this consent, Bee Your Healing Home may e-mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements. I have the right to request that Bee Your Healing Home restrict how it uses or discloses my PHI to carry out TPO. The practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.
By signing this form, I am consenting to allow Bee Your Healing Home to use and disclose my PHI to carry out TPO.
I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, Bee Your Healing Home may decline to provide treatment to me.
Signature of Patient _______________________________
Print Patient’s Name______________________________ ______________________
Preventative Holistic Options for Optimal Health and Wellbeing
NAME (LAST, FIRST, MI)
DATE OF BIRTH
SOCIAL SECURITY NUMBER ‐‐
HOME TELEPHONE NUMBER ()
CELL TELEPHONE NUMBER ()
HOME ADDRESS CITY STATE ZIP CODE
OFFICE TELEPHONE NUMBER ()
EMPLOYER ADDRESS CITY STATE ZIP CODE
IN CASE OF EMERGENCY, CONTACT PERSON AND TELEPHONE NUMBER
May we leave messages at the telephone numbers listed above? Household Members Names:
How did you hear about our practice?
Phone: ( )
I hereby certify that the above information is true.
I accept responsibility for all charges to this or subsequent treatment.
I understand that BYHH does not medically manage patients via the telephone. Therefore, no lab results will be given to a patient over the telephone.
Signature of Patient :
I understand that Rose Pizzi, NP, is not acting as my primary care provider. I understand that even though she may address issues affecting my general health, the practice is focused on a complementary, holistic or integrative approach to medicine. It is in my best interest to also have a primary care physician to ensure that I am fully informed about all available conventional means to address any medical conditions I may have.
This is also important because Rose Pizzis’ practice is exclusively office-based and is not affiliated with a hospital. If I become so ill that I require hospitalization, it is vital that I have a primary care provider with hospital admitting privileges familiar with my health problems and history. I understand that Rose Pizzi does not provide emergency, on-call assistance. Even should Rose Pizzi provide treatment for a condition, I understand this assistance does not mean she is taking primary responsibility for managing that condition, but is complementing the care I receive from my primary care provider. I understand that in addition to a primary care provider, it may be in my best interest to see appropriate specialists, such as a cardiologist. Rose Pizzi is an Adult NP and does not see any patient's under the age of 18yo.
I also understand that it is my responsibility on an ongoing basis to inform Ms.Pizzi of the name of and contact information for my primary care provider and treating specialists, of any diagnoses I have received, and of any treatments I have had or am now undergoing for current conditions. I also understand that it is important for me to let my primary care provider know about any recommendations/treatments performed by Ms. Pizzi, in order to ensure that my care is properly coordinated.
My primary care provider is:
I am also being treated for I am also being treated for
Name: Address: City, State, Zip: Phone:
Patient Name Printed:
Thank you for choosing Bee Your Healing Home. We are committed to your successful treatment. Please understand that full payment of your bill is very important for our financial survival and to avoid the “assembly line” visits so common in health care today.
We ask for the payment at the time of service. Like any sensible business, we accept cash, personal check, Visa, MasterCard.
Our practices services are not usually covered by Medicare, Medicaid, or Private insurances. The rate of reimbursement will depend on your insurance plan, your annual deductible and level of co-insurance for out-of-network providers. Based on this, we cannot guarantee insurance coverage, nor does the office bill insurance directly. We highly recommend that you contact your insurance company to determine whether they cover integrative medical services as part of your plan or as a special benefit for your condition, and what level of coverage is allowed for out-of-network services. Since BYHH does not participate with any insurance plans, its services might be covered only as an out-of-network benefit.
Our practice is committed to providing the best treatment for our patients while charging “usual and customary” fees for our area. We do conduct surveys of area rates and find we are ‘mid-range’. You are responsible for payment regardless of any insurance company’s arbitrary determination of usual and customary rates. Medicare patients may participate in a free consult, an in some free educational sessions throughout the year.
1. We appreciate the value of your time, you can expect us to be on time for you. We will appreciate the same courtesy. If you do not come in for your appointment, it deprives another patient of that time slot. Therefore, there will be a $65 charge if you cannot keep your appointment, and have not informed us at least 24 hours prior to the scheduled time
2. Return check fee: $25;
3.Patient whose accounts are in arrears will be asked to bring these accounts current prior to receiving additional services.
Thank you for taking time to review our Financial Policy. Our entire staff is familiar with our policy and anyone you speak with will make every effort to clarify any question you may have concerning your account.
I have read the Financial Policy. I understand and agree to this Financial Policy
Signature_____________________________________________________ Date _____/_____/______
Our Financial Policy
I understand that care I receive from Rose Pizzi, ANP- BC, may be non-traditional or non-conventional. Such services are commonly referred to as complementary or alternative medicine (ACM or CAM), holistic care, or integrative medicine. This can include a variety of innovative medical treatments as well as acupuncture, nutritional and herbal consultation, and mind-body approaches to care. Many of these services may not be recognized as standard medical practice, generally accepted by the medical community, or approved by the Food and Drug Administration or other regulatory agencies. While many of these approaches have long been practiced, they may still be considered investigational or experimental. I am seeking care from Rose Pizzi NP, in order to benefit from her special training in integrative medicine and receive advice and treatment about such care.
Nutritional and Herbal Guidance: Consultations may include discussion of diet, dietary supplements, and herbal or botanical products. While herbs and botanical products are generally available over-the-counter and considered safe based upon their long history of use, many of them have not been widely tested. There is some risk that these products could prove harmful, particularly if I am allergic to them, which in rare circumstances could lead to serious consequences. I understand that interactions between herbs, and between herbs and drugs, are not yet well known. While unlikely, I could have an adverse reaction or experience a reduction or increase in the effect of other medications. This can have serious consequences for some medications, such as for high blood pressure or blood sugar. I will advise Ms.Pizzi and my other health care providers what herbs I am taking. I agree to notify Ms. Pizzi, if I experience any interactions or adverse experiences or reactions; if they are not serious, I will contact her to ask for her assistance. If a reaction is serious, I agree to seek emergency care first before notifying Ms. Pizzi.
Recommendations could include fasting and other forms of detoxification. While this is generally safe, some people may experience a healing process, which may be a short period in which symptoms increase, or a period of a flu-like illness during which there could be some mild fever, chills, dizziness, loss of appetite, etc. Such an experience, while unpleasant, can signal that the body is effectively detoxifying or undergoing a healing effort.
Mind/Body Medicine: Mind/body medicine is an emerging medical view intended to improve patient well-being by improving lifestyle, capacity to function in a meaningful and effective way, and reversing the impacts of stress. Because stress and emotional states may play an important role in my medical conditions, Ms. Pizzi may assist me in recognizing more successful approaches to lifestyle and mind/body approaches such as meditation, massage, or other stress management techniques.
Energy Medicine: Energy medicine is a controversial approach to healing that has a long traditional history across many cultures, for which there is some evidence of having a healing benefit. It is a “hands off” approach in which the practitioner channels life energy for healing benefit, intended to affect the balance and flow of energy in a manner that might be thought of as similar to acupuncture, but without needles. It may be ineffective or it is possible that it could temporarily aggravate symptoms.
I understand that while these approaches can provide an important complement to my health care, I should ensure, by discussing my health needs with Rose Pizzi ANP-BC, and my primary care providers, that appropriate mainstream care is provided. I understand that Ms.Pizzi will discuss potential therapies that she recommends, and I agree to accept the risks explained to me about these procedures by agreeing to undertake these treatments.
I have read and understand the nature of the services provided by Ms.Pizzi., I represent that I am seeking treatment in order to further my own health and for no other reason. I agree to take a responsible role in improving my own health and discuss advice and suggestions of Ms.Pizzi as presented in a treatment plan. I acknowledge that if I do not follow the treatment plan as provided, I may not receive the full benefit of the treatments proposed by Ms.Pizzi and I accept responsibility for less than satisfactory results. I am aware that I may withdraw this consent and discontinue following the recommendations at any time.
Signature of Patient
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**Note: The content of this website is provided for general informational purposes only and is not intended as, nor should it be considered a substitute for, professional medical advice. Do not use the information on this website for diagnosing or treating any medical or health condition. If you have or suspect you have a medical problem, promptly contact your professional healthcare provider.
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