Liability, Privacy, Policies, and Consent for Treatment
GrassRoots Functional Medicine PLLC. (GrassRoots), is A Functional Medicine Practice that provides consultations on multiple health issues. Nurse Practitioner (NP) Osgood is glad to work collaboratively with your Primary Care Physician and provide his expertise to help manage any specific aspects of your health, but the current practice structure does not allow for him to be available for the level of acuity necessary for urgent care or primary care services. It is the recommendation that all patients seen at GrassRoots Functional Medicine maintain an active relationship with a Primary Care Physician.
The new patient intake forms are very detailed and comprehensive, and they are one of our most important assessment tools. Expect to spend between 30 minutes and 1 hour filling out the questionnaires.
Because your visit is so comprehensive, we request that you complete your new patient forms 48 hours prior to your arrival so that NP Osgood can review them before your visit.
Having these forms 48 hours in advance will allow NP Osgood to help optimize your health more efficiently and enhance the quality of your care. If the medical questionnaires have not been received at least 48 hours prior to your initial appointment, it may take NP Osgood up to 30 minutes of your appointment time to review your chart.
Information about GrassRoots Functional Medicine PLLC, a Functional Medicine Practice is available through the website: www.GrassRootsFM.com.
Please expect to spend 80 minutes with NP Osgood during your first visit. He will review your Intake Form, perform a physical exam, and partner with you to develop a plan to achieve your highest health potential.
MEDICAL RECORDS FROM OTHER DOCTORS/CLINICS/HOSPITALS:
Medical records can only be released with your authorization. A medical records release form is enclosed in this packet for your use. It is your responsibility to obtain previous medical records from other physicians or health care providers that you wish NP Osgood to review. Please contact your physician or other health care provider to obtain these records and make sure that we have received them at least 48 hours prior to your initial appointment. Your medical records should be faxed to 1-(603) 856-0372.
CANCELLATION AND RESCHEDULING OF APPOINTMENTS:
There is a 48-hour (2 business days) cancellation and rescheduling policy. Your appointment must be cancelled or rescheduled at least 48 hours (2 business days) prior to your consultation time or you will be charged for the complete fee for your scheduled appointment time. You may cancel your appointment by calling the office 1(888) 644-7668 or emailing firstname.lastname@example.org.
LATE ARRIVAL APPOINTMENTS:
We are committed to being on time with patient appointments. On your appointment date, please plan to arrive at least 15 minutes ahead of time to ensure that you find the GrassRoots Functional Medicine office. If you arrive late to your patient visit, your appointment will end at the scheduled time and you will be charged for the length of the originally scheduled visit.
NP Osgood may use standard lab testing and advanced lab testing when evaluating your health. Some labs that involve stool, urine, or saliva samples are done by you in your home. You will be given all lab kits and step-by-step instructions for at home test at the time of your consult. Once all of the final lab results are received, we will go over them at your follow-up visits.
Medical insurance is not accepted at GrassRoots Functional Medicine. GrassRoots Functional Medicine cannot assist you with claim resolution. You will be provided with a billing summary that you can submit to your insurance carrier.
Office hours vary according to NP Osgood's schedule, but the office will be open generally from 8:30 a.m. to 5:00 p.m. Monday through Thursday and 8:30 a.m. to 12:00 pm on Friday.
PHONE CALLS AND MESSAGES:
- Phone messages left will be responded to within 24 hours (during business hours).
- To reach the office, please call 1(888) 644-7668
- When leaving a message, please be brief and include the following information:
- Full name, spell your last name, and date of birth
- Reason for call
- Phone number(s)
- E-mail address (if desired)
AFTER HOUR ISSUES:
GrassRoots Functional Medicine is a consulting clinic. If you experience health complications or concerns that require immediate assistance outside of business hours, follow up with your primary care physician, an Urgent Care facility, or an emergency room. Please be aware that GrassRoots Functional Medicine is not equipped to manage life-threatening emergencies. If you are experiencing an emergency, you should call 911 or report to the nearest emergency room.
GrassRoots Functional Medicine is a fee-for-service clinic and payment is expected at the time of your appointment.
We accept credit cards, checks, and cash. On the day of your scheduled appointment, all charges for consultations, laboratory testing and nutritional supplements will be itemized and payment is due on the day of service.
A fee schedule is available on our website. If you have any questions about fees or charges, please do not hesitate to contact GrassRoots Functional Medicine before your appointment or ask NP Osgood during your visit.
We refill medications that NP Osgood has prescribed as long as certain guidelines are followed. We ask that you contact your pharmacy and have them fax over the medication refill request. Our fax number is (603) 856-0372. Please request refills prior to exhausting your existing supply of prescription medications. Assuming the request is safe and appropriate, we will attempt to refill your prescription the same day, but it may take up to 72 hours. Please also be aware that GrassRoots Functional Medicine CANNOT refill prescriptions or prescribe new medications after hours, on weekends, or on holidays.
- If you would like to schedule an appointment or cancel an appointment, have lab kit questions or administrative questions, please email email@example.com
- If you have a medical question for NP Osgood please submit that through the Secure Messages page. Please note that it can take NP Osgood up to 72 hours to respond to messages.
- If you would like to order supplements, please send a portal message or an email to: firstname.lastname@example.org.
FUNCTIONAL MEDICINE AGREEMENT:
NP Osgood utilizes lifestyle and dietary interventions as part of the treatment plan. He will also make recommendations for specific nutritional supplements and may prescribe medications when it is in your best interest. It is important that you actively participate in your healthcare plan. Functional Medicine is not the most common way that healthcare issues are handled in a conventional medical practice, thus it is not necessarily the standard of care.
Functional Medicine is based on science from the medical literature. However, it is considered complementary and alternative medicine. To comply with state medical board regulations, GrassRoots must ensure patients are informed of this and consent to treatment.
I have read and understand the office policy of GrassRoots Functional Medicine.
Informed Consent Regarding Email or the Internet Use of Protected Personal Information
GrassRoots Functional Medicine PLLC., a Functional Medicine Practice, provides patients the opportunity to communicate by e-mail. Transmitting confidential health information by e-mail; however, has a number of risks, both general and specific, that should be considered before using e-mail.
- General e-mail risks are the following: e-mail can be immediately broadcast worldwide and be received by many intended and unintended recipients; recipients can forward e-mail to other recipients without the original sender's permission, or knowledge; users can easily misaddress an e-mail; e-mail is easier to falsify than handwritten, or signed documents; backup copies of e-mail may exist even after the sender, or recipient has deleted his/her history.
- Specific e-mail risks are the following: e-mail containing information pertaining to diagnosis and/or treatment must be included in the protected personal health information; all individuals who have access to the protected personal health information will have access to the e-mail messages; patients who send, or receive e-mail from their place of employment risk having their employer read their e-mail.
- It is the policy of GrassRoots Functional Medicine PLLC., a Functional Medicine Practice, that all email messages sent, or received, which concern the diagnosis, or treatment, of the patient will be a part of that patient's protected personal health information and will treat such email messages, or internet communications, with the same degree of confidentiality as afforded other portions of the protected personal health information. GrassRoots Functional Medicine PLLC., a Functional Medicine Practice, will use reasonable means to protect the security and confidentiality of e-mail, or internet communication. Because of the risks outlined above, we cannot; however, guarantee the security and confidentiality of e-mail, or internet communications.
- Patients must consent to the use of e-mail for confidential medical information after having been informed of the above risks. Consent to the use of e-mail includes agreement with the following conditions:
- All e-mail to, or from, patients concerning diagnosis and/or treatment will be made a part of the protected personal health information. As a part of the protected personal health information, other individuals, GrassRoots Functional Medicine PLLC., a Functional Medicine Practice, nurse practitioners, nurses, other healthcare practitioners, insurance coordinators, and upon written authorization other healthcare providers and insurers will have access to e-mail messages contained in protected personal health information.
- GrassRoots Functional Medicine PLLC., a Functional Medicine Practice, may forward email messages within the practice as necessary for diagnosis and treatment. GrassRoots Functional Medicine PLLC., a Functional Medicine Practice, will not; however, forward the e-mail outside the practice without the consent of the patient as required by law.
- GrassRoots Functional Medicine PLLC., a Functional Medicine Practice, will endeavor to read e-email promptly, but can provide no assurance that the recipient of the particular e-mail will read the e-mail message promptly. Therefore, e-mail must not be used in a medical emergency.
- It is the responsibility of the sender to determine whether the intended recipient received the e-mail and when the recipient will respond.
- Because some medical information is so sensitive that unauthorized disclosure can be very damaging, e-mail should not be used for communications concerning diagnosis, or treatment of AIDS/HIV infection; other sexually transmissible, or communicable diseases, such as syphilis, gonorrhea, herpes, and the like; Behavioral health, Mental health, or developmental disability; or alcohol and drug abuse.
- GrassRoots Functional Medicine PLLC., a Functional Medicine Practice, cannot guarantee that electronic communications will be private. However, we will take reasonable steps to protect the confidentiality of the e-mail, or internet communication, but GrassRoots Functional Medicine PLLC., a Functional Medicine Practice, PLLC is not liable for improper disclosure of confidential information not caused by its employee's gross negligence, or wanton misconduct.
- If consent is given for the use of e-mail, it is the responsibility of the patient to inform GrassRoots Functional Medicine PLLC., a Functional Medicine Practice, of any type of information you do not want to be sent by e-mail.
- It is the responsibility of the patient to protect their password, or other means of access to e-mail sent, or received from GrassRoots Functional Medicine PLLC., a Functional Medicine Practice, to protect confidentiality. GrassRoots Functional Medicine PLLC., a Functional Medicine Practice, PLLC is not liable for breaches of confidentiality caused by the patient.
Any further use of e-mail initiated by the patient that discusses diagnosis, or treatment, constitutes informed consent to the foregoing. I understand that my consent to the use of e-mail may be withdrawn at any time by e-mail, or written communication, to GrassRoots Functional Medicine PLLC., a Functional Medicine Practice. I have read this form carefully and understand the risks and responsibilities associated with the use of e- mail. I agree to assume all risks associated with the use of e-mail.
Financial Liability Information
GrassRoots Functional Medicine and its practitioners are committed to practicing medicine in a professional and financially responsible manner. We realize that there are situations that may affect the timing of your payment. In such cases, payment arrangements may be made by contacting GrassRoots Functional Medicine before your visit. Keep in mind, however, that it is your responsibility to contact our office to make such arrangements, and requests are not necessarily a guarantee that a payment plan will be created for your particular situation.
Agreement to Pay:
Subject to foregoing terms and conditions stated above, I acknowledge that by signing below agree to be personally liable for all medical services charged by GrassRoots Functional Medicine, including any necessary lab work that GrassRoots Functional Medicine provides.
I have also read and understand the above statements.
General Consent for Treatment
I, knowing from discussions with NP Osgood that I require certain diagnostic tests and/or medical treatment, do hereby voluntarily consent to such procedures and care under the general and specific instructions of GrassRoots Functional Medicine, its health practitioners and/or practitioner designees as is necessary in his/her judgment.
I also acknowledge that the practice of medicine is not an exact science and that no guarantees have been made to me as to the result of treatments or examination.
Notice of Privacy Practice
THIS NOTICE DESCRIBES HOW PERSONAL HEALTHCARE INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU ACQUIRE ACCESS TO YOUR PERSONAL HEALTH CARE INFORMATION. PLEASE REVIEW IT CAREFULLY.
GrassRoots Functional Medicine PLLC., a Functional Medicine Practice, ("GrassRoots Functional Medicine") is committed to protecting your personal healthcare information. Each time you visit us, GrassRoots Functional Medicine's staff creates and/or updates medical records containing your personal healthcare information. You have legal rights that can limit the disclosure of your medical information. However, there are also some situations in which this information may/must be disclosed to third parties. This document outlines your rights and those categories of situations in which your information may be legally disclosed. They include the following disclosures of your medical information:
Medical Treatment GrassRoots Functional Medicine may disclose medical information about you to facilitate your medical treatment and services. This disclosure could be to doctors, nurses, technicians, or other personnel involved with your medical treatment. For example, a specialist may need to know if GrassRoots Functional Medicine has ordered specific treatments or tests prior to you being seen. This is important because the sharing of information among practitioners is important for the efficiency and effectiveness of your medical treatment.
Health Care Operations. We may disclose protected health care information to ensure that GrassRoots Functional Medicine and its staff are providing medical services appropriately and that patients are receiving quality care. GrassRoots Functional Medicine, for example, may use your health care information to evaluate performance of its staff or to determine if additional medical services need to be offered. However, such internal uses, shall be maintained confidentially by and among GrassRoots Functional Medicine's staff and/or consultants or agents who are bound by similar duties to maintain confidentiality.
Treatment Alternatives. We may disclose medical information about you to recommend possible treatment options or alternatives that may interest you.
People Involved in Your Care. We may release medical information about you to a friend or family member who is involved in your care. These individuals, however, will be limited to those described in your Release of Medical Records, or as otherwise consented to by you.
As Required By Law. We will disclose medical information about you when required to do so by federal, state, or local law.
To Avert Serious Threat to Safety or Health. It may be necessary to disclose medical information about you to prevent serious threat to your health and safety or the health and human safety of the public or another person.
Organ and Tissue Donation. If you are an organ donor, we may release medical information to organizations that handle tissue transplantation, or as necessary to facilitate organ or tissue harvesting.
Military Personnel and Veterans. We may release medical information to military commanding authorities if you are a member of the armed forces and our disclosure is required by law.
Workers' Compensation Beneficiaries. We may release medical information about you for workers' compensation or similar injury compensation programs as required by law.
Risks to Public Health. We may disclose medical information about you for public health purposes. Such disclosures may be for reasons including:
- The prevention or control of disease, injury or disability;
- The reporting of births or deaths;
- The reporting of child abuse or neglect;
- The reporting of reactions to medications or medical treatments;
- The notification of patients affected by product recalls;
- The reporting of any patients who have been exposed to a disease or may be at risk for contracting or spreading a disease or condition.
- The notification of the appropriate authorities if GrassRoots Functional Medicine or its medical staff believes a patient has been the victim of abuse, neglect, or domestic violence.
Government Healthcare Audits. We may disclose this information to a governmental agency for lawful audit activities. These audits include investigations, inspections, and licensure inspections that involve you and/or GrassRoots Functional Medicine's medical practice.
Lawsuits. If ordered, we may disclose medical information about you in response to a court or administrative order. We may also disclose information about you to a subpoena, discovery request, or other lawful process by someone else involved, but only if efforts have been made to tell you about the request or to obtain your consent or an order protecting the information requested.
Law Enforcement. We may release medical information if requested to do so by a law enforcement official. This may include the following situations:
- A court or administrative order;
- In situations in which we are called upon to identify or locate a suspect, fugitive, material witness, or missing persons;
- Investigations about a crime victim;
- Death that may have been the result of criminal conduct;
Coroners, Medical Examiners, and Funeral Directors. We may release medical information to a coroner or medical examiner in cases where it may be necessary to identify a deceased person, or determine cause of death.
National Security. We may release medical information about you to authorized federal officials for national security activities authorized by law. This may include medical information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state.
Inmates. If you are an inmate of a correctional facility or under the custody of law enforcement officials, we may release medical information about you to the correctional facility or official. This release is necessary for the correctional facility to provide you with the proper health care, to protect your health and safety or the health and safety of others, for the safety and security of the correctional facility.
Your Rights Regarding Your Medical Information.
You have the following rights with your medical information:
The Right to Inspect and Copy. You have a right to inspect your own protected healthcare information. This can be done by calling GrassRoots Functional Medicine and requesting to see your records. GrassRoots Functional Medicine's staff will set up a mutually agreeable time for you to come in and review your medical records. If you are requesting copies of your records you must give us 30 days to get them copied for you. In most circumstances, we can provide your medical records much sooner. It is our policy, however, to only copy the information done and ordered in our office. Medical records that another health care provider ordered or created must be requested from the medical provide who/that originally created them.
The Right to Amend.In some situations, you may feel that your records need to be amended. You may request us to amend our information in situations in which you feel that your medical information is incorrect or incomplete. You have the right to request an amendment as long as GrassRoots Functional Medicine maintains your records and they are medical records that GrassRoots Functional Medicine or its staff originally created. If you are requesting an amendment, we will provide you an amendment sheet to fill out the necessary information you believe should be amended. Your request, however, is no guarantee that GrassRoots Functional Medicine or its practitioners will agree to amend your medical records. You will have a chance to appeal any determination with which you disagree.
Disclosure Accounting. You have the right to request an accounting of the disclosures of your medical information that have been made. This is a list of disclosures that will have been made either from your medical history, or otherwise compiled during the course of receiving medical treatment.
Restriction Right. You have the right to restrict the disclosure of your medical information to third parties. You may also limit the medical information we disclose about you to someone involved in your care. GrassRoots Functional Medicine, however, not required to agree to your request in every circumstances. If we do agree with your request, we will comply unless the information is needed for emergency treatment or unless otherwise necessary to comply with state or federal law. To request restrictions you must make your preferences made know in writing, and you must detail have the medical information you want limited. These restrictions will be listed on your Release of Medical Records.
Right to Request Confidential Communication. You also have the right to request that GrassRoots Functional Medicine and its medical staff communicate medical information in any reasonable manner that you prescribe. For example, you can request that GrassRoots Functional Medicine contact you only at home. Like other prescribed limitation, however, you must request confidential communications in writing and include how we may contact you. We will try to accommodate all reasonable requests.
Right to Have a Copy of the Privacy Notice. You have the right to have a copy of this Privacy Practice Notice. You may ask us for this copy at any time.
Changes to This Notice. We reserve the right to change this notice. We further reserve the right to revise this policy without prior notice to you. We will post a copy of the current notice in the waiting room or contact you otherwise to give you notice of this change.
Complaints. If you believe that your privacy has been violated, then you may file a complaint with GrassRoots Functional Medicine's privacy officer or with the Secretary of the Department of Health and Human Services. To file a complaint with the privacy officer, please detail your complaint in writing to the office manager, or submit it to any of GrassRoots Functional Medicine practitioners for review.
Other Disclosures. Other disclosures of medical information not covered by this notice or the laws will be made only with your written permission. If you provide us with permission to use or disclose medical information about you, you may revoke such permission at any time in writing.
I have read and understand the above statements about Notice of Privacy Practice and filled out the accompanying Release of Medical Records authorizing the use and disclosure of my medical records.