Embed Size (px)
Citation preview
IntroductoryPatient Information
2716 Old Rosebud RdSuite 230
Lexington, KY 40509
(859) 554-0485fax (859) 203-0484
OmniHealthOmniHealthHea�h redefined
TABLE OF CONTENTS
Patient Checklist
What to Expect at Omni Health
Practice Policies for Patients• Website• Medical Records• Consultations• Initial Visits• Consultation Fees• Confirmation and Cancellation of Appointments• Payment Options• Insurance Information• Phone Calls, Messages and Faxes• Prescription Refill Requests• Office Location• Places to Stay in Lexington• Local Recommended Restaurants
Directions to Omni Health
Frequently Asked Questions• What is your website address? And how can I order the supplements I need?• Do you think you can help me with my health problem?• Can all the tests I need be done at Omni Health?• Will I see other practitioners at Omni Health?• Do you take insurance?• What credit cards do you accept?• Is Dr. Jandes a primary care physician?• Do I have to see the doctor in person for my medical consultation?• Whom do I contact with the following concerns?• Where are you located?
Important Patient Information• Appointments• Lab Tests• Billing/Insurance• Primary Care Physicians
Notice of Possible Medicare Denial
Authorization for Release of Medical Records
Informed Consent Regarding Email or the Internet Use of Protected Personal Information
Informed Consent Regarding Telemedicine
Research Consent Agreement
HIPAA Compliance Consent
Credit Card Authorization Form
_______________________________________________________________________________1
__________________________________________________________________2
_____________________________________________________________________2__________________________________________________________________________________3
___________________________________________________________________________3_____________________________________________________________________________3
_______________________________________________________________________________3_________________________________________________________________________3
______________________________________________3__________________________________________________________________________4
______________________________________________________________________4___________________________________________________________4
_________________________________________________________________4____________________________________________________________________________5
_________________________________________________________________5___________________________________________________________5
_______________________________________________________________________5
_____________________________________________________________________6______________________6
_________________________________________6______________________________________________6
_________________________________________________7_____________________________________________________________________7
____________________________________________________________7________________________________________________________7
______________________________7_______________________________________________7
____________________________________________________________________7
____________________________________________________________________1____________________________________________________________________________1
_________________________________________________________________________________1__________________________________________________________________________1
____________________________________________________________________1
_______________________________________________________________2
______________________________________________________3
_______________4
________________________________________________________5
___________________________________________________________________6
_____________________________________________________________________7
__________________________________________________________________8
INTRODUCTORY INFORMATION
CONSENT FORMS
PRACTICE POLICIES_____________________________________________________________________1
________________________________________________________________________________6
Notice of Privacy Practices
Financial Policy
PATIENT CHECKLIST
DID YOU REMEMBER TO?
FILL OUT AND/OR SIGN THE FOLLOWING FORMS
Read all of the practice documents
Obtain your medical records and/ or test results from previously seen physicians and have them sent to us by one of the following methods:
FAX: (859) 203-0484
Email: [email protected]
Mail: Omni Health
2716 Old Rosebud Rd
Suite 230
Lexington, KY 40509
Provide your preferred shipping/mailing address; if listing a P.O. Box please indicate a street address for receiving packages, UPS, or FED EX.
Provide us with your pharmacy name, address, phone and FAX number.
Important Patient Information
Notice of Medicare Denial
Authorization for Release of Medical Information
Informed Consent Regarding Email or the Internet Use Of Protected Personal Information
Informed Consent Regarding Telemedicine
Research Consent Agreement
HIPAA Compliance Consent
Credit Card Authorization Form
Health Assessment: Click here to open
Medical Symptom Questionnaire: Click here to open
Toxic Exposure Questionnaire: Click here to open
Diet & Lifestyle Journal: Click here to open
Thank you
1
must arrive at least 7 days prior to your appointment date.
Dear Patient
Welcome to Omni Health. We look forward to meeting you!
WHAT TO EXPECT AT OMNI HEALTH
(10 minutes)
(80 - 100 minute appointment)
Welcome to Omni Health Picture for medical chartRegistration for Supplement accounts
Reception Area – 2nd FloorPlease arrive 10 minutes before your appointment time
ADMINISTRATION OFFICE: - Check In
MD CONSULTATION: Anastasia Jandes, MD, PharmD
Review of Health AssessmentMedical AssessmentInitial Treatment PlanLab Test RecommendationNutrition & Lifestyle Assessment & Initial Nutrition Lifestyle PlanHow to obtain prescribed nutritional supplements
2
OmniHealthOmniHealthHea�h redefined
PRACTICE POLICIES FOR PATIENTS
WEBSITE
MEDICAL RECORDS
CONSULTATIONS
CONSULTATION FEES
CONFIRMATION AND CANCELLATION OF APPOINTMENTS
3
Our goal at Omni Health is to provide you with the highest level of personalized care. We are committed to helping you achieve optimal health.
It is important to read all the enclosed information carefully and mail, email, or fax all medical assessment forms to our office at least 7 days prior to your appointment. This will allow us to help solve your problems more efficiently and enhance the quality of your care. If your forms are late or not completed, it may take up to 30 minutes of your appointment time to review your records.
Information about Omni Health is available through our website: https://theomnihealth.com
Medical records can only be released with your authorization. A medical records release form is enclosed for your use. You are responsible for obtaining previous medical records from other physicians or health care providers. Please contact your physician or other health care provider to obtain these records. Your records should be faxed to 859-203-0484. You can also email them to [email protected], or express mail them to Omni Health, 2716 Old Rosebud Rd, Suite 230, Lexington, KY 40509. Please reference the consent form regarding email or internet use of protected personal information to understand the risks of using email to transmit sensitive information.
Your initial visit will be an 80-minute medical consultation with Dr. Jandes. Nutritional therapy and laboratory/ diagnostic testing are integral components of your treatment plan. Test results are used to design your personal health care program as well as uncover the root causes of your medical condition. Nutritional supplements are often recommended and we will help you select and find the highest quality products.
• Initial MD consultation 80-minutes: $800• Follow-up MD Consultations: $350/hr
There is a 72 hour cancellation policy. Your appointment must be canceled at least 72 hours prior to your scheduled consultation or your initial deposit will be forfeited. You may cancel your appointment by calling the office. If calling after hours, please leave a message.
Our office accepts cash or credit cards (MasterCard, Visa, Discover, American Express) for services rendered. When you schedule the initial visit, we request a credit card on file to hold the appointment for you. No charges will be applied to your credit card unless you miss or cancel an appointment without proper notice. On the day of your scheduled appointment, all charges for consultations (medical and nutritional) as well as laboratory testing will be itemized and reviewed with you. Payment is due on the day of service.
Follow-up phone consultations will be billed to your credit card on file unless you provide other payment information and instructions prior to your appointment.
Omni Health does not accept insurance and we cannot assist you with claim resolution. In addition, we are not Medicare providers. You will be provided with a billing summary which you can submit to your insurance carrier.
1. Our office hours are Monday 9 am to 5 pm EST, by appointment only. We do not accept walk-ins.2. To reach Omni Health please call or text (859) 554-0485 or email [email protected]. Our fax number is (859) 203-0484.4. If you call or text after hours, our office staff will return your call or text on the next business day.5. If you have a medical emergency, call 911 or go directly to the nearest emergency room.6. When leaving a message, please be brief and include the following information:
a. Full name, spell your last name, and date of birthb. Reason for callc. Best time to be called backd. Phone number(s)e. Email address (if desired)
7. When sending a text message, please do not include any medically sensitive information
PAYMENT OPTIONS
INSURANCE INFORMATION
PHONE CALLS, MESSAGES, & FAXES
PRESCRIPTION REFILL REQUESTSIt may take up to 72 hours to process a prescription refill. Please plan ahead to avoid any interruptions
in your medications. Prescription refills can be faxed to our office by your pharmacy. Our fax number is 859-203-0484.
4
Our office is located in the Hamburg Place area of Lexington, Kentucky. Our reception area is on the second floor. The building is handicapped accessible and there is an elevator.
OFFICE LOCATION
PLACES TO STAY IN LEXINGTON (in no specific order)
LOCAL RECOMMENDED RESTAURANTS IN LEXINGTON (in no specific order)
1. Residence Inn Lexington South/Hamburg Place: (844) 631-05952. Holiday Inn Lexington - Hamburg: (859) 687-70083. Homewood Suites by Hilton Lexington - Hamburg Place: (855) 605-03204. 21c Museum Hotel Lexington, Downtown: (859) 534-96205. DoubleTree Suites by Hilton Hotel Lexington, Richmond Rd: 855-605-03186. Marriott Griffin Gate, New Town Pike: (859) 231-51007. The Kentucky Castle, near airport: (859) 256-0322
1. Malone’s, Hamburg: (859) 264-80232. CoreLife Eatery, The Summit: (859) 687-79753. First Watch, Hamburg Place: (859) 263-47374. Vinaigrette Salad Kitchen, Hamburg Place: (859) 935-90455. Louie’s Wine Dive & Chevy Chase Kitchen, Chevy Chase: (859) 523-79006. Kentucky Native Cafe, Downtown: (859) 281-17187. Carson’s Food And Drink, Downtown: (859) 309-30398. Corto Lima, Downtown: (859) 317-87969. Coles 735 Main, Downtown: (859) 266-900010. Grillfish, Downtown: (859) 469-867311. Le Deauville, Downtown: (859) 246-099912. Saul Good, Hamburg Place: (859) 317-9200
5
6
CAN ALL THE TESTS I NEED BE DONE AT OMNI HEALTH?
DO YOU THINK YOU CAN HELP ME WITH MY HEALTH PROBLEM?
WHAT IS YOUR WEBSITE ADDRESS? AND HOW CAN I ORDER THE SUPPLEMENTS I NEED?
Dr. Jandes uses a root-cause based systems approach to assessing and treating your health care concerns. Perhaps you have experienced being examined by your doctor, having blood tests done, x-rays, or other diagnostic tests taken, only for your doctor to report back that “all your tests are normal.” Yet, both you and your doctor know that you are sick. Unfortunately, this experience is all too common.
Most physicians were trained to look only in specific places for the answers, using the same familiar labs or diagnostic tests. Yet, many causes of illness cannot be found in these places. The usual tests do not look for food allergies, hidden infections, environmental toxins, mold exposures, nutritional deficiencies, metabolic imbalances, and the relationship all body systems have with each other. Additionally, gene testing can uncover underlying genetic predispositions that can be modified through diet, lifestyle, supplements, or medications.
Dr. Jandes has helped pioneer the use of such testing to help her patients prevent illness and recover from many chronic and difficult-to-treat conditions. She is highly skilled in evaluating, assessing, and treating chronic problems such as fibromyalgia, fatigue syndromes, autoimmune diseases, inflammatory disorders, mood and behavior disorders, memory problems, Parkinson’s disease and other chronic, complex conditions. We also focus on the prevention and treatment of heart disease, diabetes, dementia, hormonal imbalances, and digestive disorders.
Information about Omni Health can be found at theomnihealth.com. During your first visit, we will set you up with several accounts that will enable you to order your pharmaceutical-grade supplements online. Our team has researched the highest quality products available that meet independently verified standards of effectiveness, quality, and purity.
Tests are not performed at Omni Health, but we work with many different laboratories across the country. Many of the lab tests can be collected at a location close to your house and oftentimes these tests can be done in the comfort of your own home. Some testing is done through conventional laboratories and others are only available through specialty laboratories. During your medical consultation, Dr. Jandes will determine which tests are needed and then a staff member will review testing recommendations, instructions (ex. fasting or non-fasting, etc.), and costs. Some testing can be performed at home with test kits to collect urine, saliva, or stool. Others may require you to go to a local laboratory to have blood drawn. In all cases, we will assist you in coordinating initial and follow-up testing.
Occasionally, we may recommend certain tests that must be performed at a third party facility (i.e. heart scans, cardiac stress tests, bone density, sleep studies, etc.) In those instances, we can provide you with an order that you can take to a facility near your home or we can schedule an appointment to have them done near our office.
FREQUENTLY ASKED QUESTIONS
Nutritional therapy is a vital component of your treatment plan. During your initial medical consultation, you will also meet with our nutritional health coach, Mark Jandes. He will work closely with Dr. Jandes to provide recommendations based on your health concerns and tailor your diet based on medical evaluation and test results.
Omni Health does not accept insurance or Medicare; we do not file insurance claims on your behalf; nor do we assist with claim resolution. However, we will provide a detailed receipt of services performed for you to submit to your insurance carriers. For assistance with your reimbursement you may want to contactwww.phd-or-services.com. We expect payment in full by check, cash or credit card due at the time services are provided.
We accept the following credit cards: Visa, MasterCard, American Express, and Discover. It is important to maintain an active credit card on file with our office for billing of follow-up consultations, laboratory testing, and other services.
Dr. Jandes is trained as a primary care physician but she does not provide acute care services. Our practitioners will work closely with you as consultants and coaches in preventive, nutritional, and functional medicine to help you address the roots of chronic health problems. Dr. Jandes can confer with your primary care doctor if required.
Patients have the option of seeing Dr. Jandes in person or through a HIPAA compliant video telemedicine application for their medical consultations.
Omni Health is located in beautiful Lexington, Kentucky, the ‘Horse Capital of the World.’ Lexington Bluegrass International Airport (LEX) is about 20 minutes, Louisville International Airport (SDF) is about 75 minutes and Cincinnati / Northern Kentucky (CVG) is about 75 minutes from our office.
Our phone number is: (859) 554-0485. Text messages are welcome and even preferred for questions that do not contain medically sensitive information.
All questions and concerns can be communicated via email to:
WILL I SEE OTHER PRACTITIONERS AT OMNI HEALTH?
DO YOU TAKE INSURANCE?
WHAT CREDIT CARDS DO YOU ACCEPT?
IS DR. JANDES A PRIMARY CARE PHYSICIAN?
DO I HAVE TO SEE DR. JANDES IN PERSON FOR MY MEDICAL CONSULTATION?
WHOM DO I CONTACT?
WHERE ARE YOU LOCATED?
7
Administration: Practice Manager, ([email protected])
Lab Results: Lab, ([email protected])
Patient Concerns: Office ([email protected])
Prescription Refills/Questions: Office ([email protected])
Medical Records: Medical Records ([email protected])
Consent Forms2716 Old Rosebud Rd
Suite 230Lexington, KY 40509
(859) 554-0485fax (859) 203-0484
OmniHealthOmniHealthHea�h redefined
1
IMPORTANT PATIENT INFORMATION
APPOINTMENTS
LAB TESTS
BILLING INSURANCE
PRIMARY CARE PHYSICIAN
• There is a 72 business hour cancellation policy (please see cancellation policy on page 3 of the ‘Introductory Patient Information’ packet).
• A 50% deposit is required at the time of booking; failure to provide sufficient cancellation notice as outlined above will result in a complete loss of your deposit.
• As a courtesy, you will receive an email (and a text if you consent to receiving text messages from us)to confirm the appointment prior to your scheduled time; ultimately it is your responsibility to keepthe scheduled appointment or reschedule.
• Initial Evaluation (may last up to 2 hours): $800.00
• Additional follow-up appointments to review lab results or treatment programs: $350.00/hr
• After your initial and/or follow-up consultations, lab tests and/or diagnostic tests may be ordered.
• Testing recommendations and cost(s) per test will be reviewed.
• Lab tests are performed “fasting’: which means nothing except water 10 hours before your visit.
• Some lab tests take up to 6 weeks to be finalized. The results will be mailed or emailed to you whenthey are finalized. If your follow-up appointment was not booked at the time of your initial visit,then you should contact the office to schedule a follow-up appointment.
• We do not accept insurance and we cannot assist you with claim resolution. We will provide you with abilling summary which you can submit to your insurance carrier or HSA account.
• Payment for the office visit, video call, or phone consultation is expected at time of service. We accept cash (office location only) or credit cards. All credit card payments will be processed the same day of the visit, video call, or phone call.
• Please note that Dr. Jandes is not your primary care physician. We recommend that you have a primary care physician at home.
Patient Signature: Date:
OmniHealthOmniHealthHea�h redefined
NOTICE OF POSSIBLE MEDICARE DENIALICF
Medicare will only pay for services determined to be reasonable and necessary under Section 1862 (a) (1) of Medicare Law. If a particular service is considered not acceptable and unnecessary under Medicare standards, Medicare will deny payment for those excluded services.
Dr. Jandes is not a Medicare provider; therefore, your payment is due at the time services are provided. Any claims submitted will have to be sent to Medicare by the patient; payment reimbursement is not guaranteed and is subject to Medicare eligibility/reimbursement rules and regulations.
My physician, and/or staff have informed me that he or she believes services provided will likely be denied by Medicare for reasons stated above.
NOTICE OF POSSIBLE MEDICARE DENIAL
MEDICARE NOTICE
PATIENT ACKNOWLEDGMENT
Name:
Signature:
Date:
2
All Medicare patients must sign this form!
3
AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS
Please send records to our HIPAA compliant secure fax line: (859) 203-0484You may also email records to: [email protected]
Name of Facility or Person: ______________________________________________________________________
Address: ______________________________________________________________________________________
Telephone Number: __________________________ Fax Number: __________________________
ICF
THE PURPOSE FOR THIS RELEASEYou are hereby authorized to furnish and release to Omni Health all information from my medical,
psychological, and other health records, with no limitation placed on history of illness or diagnostic or therapeutic information, including the furnishing of photocopies of all written documents pertinent thereto.
In addition to the above general authorization to release my protected health information, I further authorize release of the following information if it is contained in those records:
N/ANoYesGenetic Testing:
N/ANoYesCommunicable disease related information, including AIDS or ARC diagnosis and/or HIV or HTLA-III test results or treatment:
N/ANoYesAlcohol or Drug Abuse:
Note: With respect to drug and alcohol abuse treatment information, or records regarding communicable disease related information, the information is from confidential records which are protected by state or federal laws that prohibit further disclosure with the specific written consent of the person to whom they pertain, or as otherwise permitted by law. A general authorization for the release of the protected health information is not sufficient for this purpose.
This authorization can be revoked in writing at any time except to the extent that disclosure made in good faith has already occurred in reliance on this authorization.
I hereby release Omni Health, its employees, agents, managing members, and the attending physician(s) from legal responsibility or liability for the release of the above information to the extent authorized. A copy of this authorization shall be as valid as the original.
I understand that there may be a fee for this service depending on the number of pages photocopied. However, no such fee will be charged if these records are requested for continuing medical care.
*PLEASE INCLUDE A COPY OF YOUR DRIVERS LICENSE OR PASSPORT ALONG WITH THE COMPLETED AND SIGNED FORM*
Name:
Signature:
DOB:
Date:
please print
4
Omni Health provides patients the opportunity to communicate with their physicians, health care providers, and administrative staff by e-mail, text message, or the internet; however, transmitting confidential protected health information (PHI) electronically through these means has a number of risks, both general and specific, that should be considered before proceeding.
Any further use of e-mail, text messaging, or internet communication 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, text messaging, or internet may be withdrawn at any time by e-mail or written communication to Omni Health.
I have read this form carefully and understand the risks and responsibilities associated with the use of e-mail and text messaging. I agree to assume all risks associated with the use of e-mail and text messaging.
INFORMED CONSENT REGARDING THE USE OF EMAIL, TEXT-MESSAGING, OR THE INTERNET TO COMMUNICATE PROTECTED HEALTH INFORMATION
ICF
Risks:General e-mail/text risks are the following: messages can be immediately broadcast worldwide and be received by many intended and unintended recipients; recipients can forward messages to other recipients without the original sender(s) permission or knowledge; users can easily misaddress an message; e-mail/text is easier to falsify than handwritten or signed documents; backup copies of e-mail/text may exist even after the sender or the recipient has deleted his/her copy.
Specific e-mail/text risks are the following: messages containing information pertaining to diagnosis and/or treatment must be included in the protected health information; all individuals who have access to the protected health information will have access to the e-mail/text 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 Omni Health to refrain from using text messaging for communicating protected health information. All e-mail messages sent or received which concern the diagnosis or treatment of a patient will be a part of that patient’s protected health information and will treat such e-mail messages or internet communications with the same degree of confidentiality as afforded other portions of the protected health information. Omni Health 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, text, or internet communication.
Patients must consent to the use of e-mail or text 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 messages 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, such as Omni Health physicians, nurses, other health care practitioners, insurance coordinators and upon written authorization other health care providers and insurers will have access to messages contained in protected personal health information.
Omni Health may forward messages within the practice as necessary for diagnosis and treatment. Omni Health will not, however, forward the message outside the practice without the consent of the patient as required by law.
Omni Health will endeavor to read messages promptly, but can provide no assurance that the recipient of a particular message will read the message promptly. Therefore, e-mail and text must not be used in a medical emergency.
It is the responsibility of the sender to determine whether the intended recipient received the message and when the recipient will respond.
Because some medical information is so sensitive that unauthorized discloser can be very damaging, e-mail and text messaging 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.
Omni Health cannot guarantee that electronic communications will be private, however, we will take reasonable steps to protect the confidentiality of the e-mail, text, or internet communication. Omni Health 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 or text messaging, it is the responsibility of the patient to inform Omni Health of any types of information you do not want to be sent by e-mail or text message.
It is the responsibility of the patient to protect their password or other means of access to e-mail sent or received from Omni Health to protect confidentiality. Omni Health is not liable for breaches of confidentiality caused by the patient.
a.
b.
1.
2.
3.
a.
b.
c.
d.
e.
f.
g.
h.
Name:
Signature:
Date:
INFORMED CONSENT REGARDING TELEMEDICINETelemedicine involves the use of electronic communications to enable healthcare providers at different locations to share
individual patient medical information for the purpose of improving patient care. Providers may include primary care practitioners, specialists, and/or sub-specialists. The information may be used for diagnosis, therapy, follow-up and/or education, and may include any of the following:
• Patient medical records• Medical images• Live two-way audio and video• Output data from medical devices and sound and video files
Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.
Responsibility for the patient care should remain with the patient’s local clinician, if you have one, as does the patient’s medical record.
• Improved access to medical care by enabling a patient to remain in his/her local healthcare site(i.e. home) while the physician consults and obtains test results at distant/other sites.
• More efficient medical evaluation and management.• Obtaining expertise of a specialist.
As with any medical procedure, there are potential risks associated with the use of telemedicine. These risks include, but may not be limited to:
• In rare cases, the consultant may determine that the transmitted information is of inadequate quality, thus necessitating a face-to-face meeting with the patient, or at least a rescheduled video consult;
• Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment;• In very rare instances, security protocols could fail, causing a breach of privacy of personal medical
information;• In rare cases, a lack of access to complete medical records may result in adverse drug interactions or
allergic reactions or other judgment errors;
I have read and understand the information provided above regarding telemedicine, have discussed it with my physician or such Omni Health staff as may be designated, and all of my questions have been answered to my satisfaction.
I have read this document carefully, and understand the risks and benefits of the teleconferencing consultation and have had my questions regarding the procedure explained and I hereby give my informed consent to participate in a telemedicine visit under the terms described herein.
1. I understand that the laws that protect privacy and the confidentiality of medical information also apply totelemedicine, and that no information obtained in the use of telemedicine, which identifies me, will be disclosed to researchers or other entities without my written consent.
2. I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care atany time, without affecting my right to future care or treatment.
3. I understand the alternatives to telemedicine consultation as they have been explained to me, and in choosingto participate in a telemedicine consultation, I understand that some parts of the exam involving physical tests may be conducted by individuals at my location, or at a testing facility, at the direction of the consulting healthcare provider.
4. I understand that telemedicine may involve electronic communication of my personal medical information toother medical practitioners who may be located in other areas, including out of state.
5. I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured.
6. I understand that my healthcare information may be shared with other individuals for scheduling and billingpurposes. Others may also be present during the consultation other than my healthcare provider and consulting healthcare provider in order to operate the video equipment. The above mentioned people will all maintain confidentiality of the information obtained. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history/physical examination that are personally sensitive to me; (2) ask non-medical personnel to leave the telemedicine examination room; and/or (3) terminate the consultation at any time.
EXPECTED BENEFITS
POSSIBLE RISKS
BY SIGNING, YOU ACKNOWLEDGE THAT YOU UNDERSTAND AND AGREE WITH THE FOLLOWING:
SIGNATURE
Name:
Signature:
Date:
ICF
5
ICF
6
RESEARCH CONSENT AGREEMENT
Patient’s Name: _________________________________________________________________________________
Patient’s Address: _______________________________________________________________________________
_______________________________________________________________________________________________
You are being asked to provide your consent for Omni Health to use information from your medical records in research studies, the goal of which is to improve the practices of the functional medicine approach. No personal identifying information will be used in the study. The Principal Investigator of these research studies is Anastasia Jandes, MD, PharmD.
If you consent to the use of your medical records in these research studies, your personal information will be kept confidential to the extent permitted by law and will not be released without your written permission except as described in this paragraph. In all study forms, you will be identified only by a randomly selected patient number. Your name will not be reported in any publication; only the data obtained as a result of the use of your medical records in these studies will be made public.
Your decision as to whether or not to consent to the use of your medical records is completely voluntary ( of your free will). If you decide not to consent to the use of your medical records it will not affect the care you receive.
If you decide to consent to the use of your medical records in connection with these studies, you may withdraw consent at any time without affecting the care you receive. You should contact the Principal Investigator and let her know about your decision if you decide to withdraw consent.
EXPECTED BENEFITS
AGREEMENT TO PARTICIPATE
I have read the description of the research studies and general conditions, have have discussed it with my physician or such Omni Health staff as may be designated, and all of my questions have been answered to my satisfaction. I hereby give my consent to Omni Health to use my medical records as described herein in connection with the research studies described herein. I will receive a copy of this Consent Form.
Print Name of Patient / Legal Representative
Signature of Patient / Legal Representative Date:
Name of Person Obtaining Consent
HIPAA COMPLIANCE CONSENT FORM
Name:
Signature:
Date:
The Department of Health and Human Services has established a “Privacy Rule” to help ensure that personal health care information is protected for privacy. The privacy Rule was also created in order to provide a standard for certain health care providers to obtain their patient’s consent for uses and disclosures of health information about the patient to carry out treatment, payment, or health care operations.
As our patient, we want you to know that we respect the privacy of your personal medical records and will do all we can to secure and protect that privacy. We strive to always take reasonable precautions to protect your privacy. When it is appropriate and necessary, we provide the minimum necessary information to only those we feel are in need of your health care information and information about treatment, payment or health care operations, in order to provide health care that is in your best interest.
We also want you to know that we support your full access to your personal medical records. We may have indirect treatment relationships with you (such as laboratories that only interact with physicians and not patients), and may have to disclose personal health information for purposes of treatment, payment, or health care operations. These entities are most often not required to obtain patient consent.
You may refuse to consent to the use or disclosure of your personal health information, but this must be in writing. Under this law, we have the right to refuse to treat you should you choose to refuse to disclose your Personal Health Information (PHI). If you choose to give consent in this document, at some future time you may request to refuse all or part of your PHI. You may not revoke actions that have already been taken which relied on this or a previously signed consent.
If you have any objections to this form, please ask to speak to one of our staff members regarding HIPAA compliance. You have the right to request restrictions and revoke consent in writing after you have reviewed our privacy notice, which have been provided to you.
ICF
7
8
CREDIT CARD AUTHORIZATION FORM
Cardholder’s Signature: __________________________________________
Patient Name: ___________________________________________________
Address: __________________________________________________________________________________________________
Email: __________________________________________________________________________________________________
Date: ______________________________
DOB: ________________________________
PATIENT INFORMATION
CREDIT CARD INFORMATION
I authorize Omni Health to automatically bill the card(s) as “card on file” under the specification listed above:
Please complete this form to authorize Omni Health to charge your credit card for services rendered at the time of your visit. All requested information is required. Upon approval, we will automatically bill your credit card for services rendered and your total charges will appear on your monthly credit card statement.
Credit card number: _____________________________
Expiration (mm/yy): ______________________________
CID: ____________________________________________
Card type: Visa MasterCard Amex Discover
Name on Card: _________________________________
PRIMARY CARD
Credit card number: _____________________________
Expiration (mm/yy): ______________________________
CID: ____________________________________________
Card type: Visa MasterCard Amex Discover
Name on Card: _________________________________
SECONDARY CARD (if primary is Discover)
Billing Zip Code: _________________________________Billing Zip Code: _________________________________
*Note: If Discover is your primary card, please provide another card (i.e., MasterCard or Visa) for transactions (i.e., supplement orders, lab orders, etc.) that we may need to process. Some companies do not accept Discover.
Practice Policies
2716 Old Rosebud RdSuite 230
Lexington, KY 40509
(859) 554-0485fax (859) 203-0484
OmniHealthOmniHealthHea�h redefined
NOTICE OF PRIVACY PRACTICESNotice
1
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
YOUR RIGHTS
You have the right to: • Get a copy of your paper or electronic medical record
• Correct your paper or electronic medical record
• Request confidential communication
• Ask us to limit the information we share
• Get a list of those with whom we’ve shared your information
• Get a copy of this privacy notice
• Choose someone to act for you
• File a complaint if you believe your privacy rights have been violated
YOUR CHOICES
You have some choices in the way that we use and share information as we:
• Tell family and friends about your condition
• Provide disaster relief
• Include you in a hospital directory
• Provide mental health care
• Market our services and sell your information
• Raise funds
OUR USES AND DISCLOSURES
We may use and share your information as we:
• Treat you
• Run our organization
• Bill for your services
• Help with public health and safety issues
• Do research
• Comply with the law
• Respond to organ and tissue donation requests
• Work with a medical examiner or funeral director
• Address workers’ compensation, law enforcement, and other government requests
• Respond to lawsuits and legal actions
2
YOUR RIGHTS
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.
Get an electronic or paper copy of your medical record
• You can ask to see or get an electronic or paper copy of your medical record and other healthinformation we have about you. Ask us how to do this.
• We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
Ask us to correct your medical record
• You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
• We may say “no” to your request, but we’ll tell you why in writing within 60 days.
Request confidential communications
• You can ask us to contact you in a specific way (for example, home or office phone) or to sendmail to a different address.
• We will say “yes” to all reasonable requests.
Ask us to limit what we use or share
• You can ask us not to use or share certain health information for treatment, payment, or ouroperations. We are not required to agree to your request, and we may say “no” if it would affectyour care.
• If you pay for a service or health care item out-of-pocket in full, you can ask us not to share thatinformation for the purpose of payment or our operations with your health insurer. We will say“yes” unless a law requires us to share that information.
Get a list of those with whom we’ve shared information
• You can ask for a list (accounting) of the times we’ve shared your health information for six yearsprior to the date you ask, who we shared it with, and why.
• We will include all the disclosures except for those about treatment, payment, and healthcare operations, and certain other disclosures (such as any you asked us to make). We’ll provideone accounting a year for free but will charge a reasonable, cost-based fee if you ask for anotherone within 12 months
Get a copy of this privacy notice
• You can ask for a paper copy of this notice at any time, even if you have agreed to receive thenotice electronically. We will provide you with a paper copy promptly.
Choose someone to act for you• If you have given someone medical power of attorney or if someone is your legal guardian, that
person can exercise your rights and make choices about your health information.• We will make sure the person has this authority and can act for you before we take any action.
3
YOUR CHOICES
OUR USES AND DISCLOSURES
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.
In these cases, you have both the right and choice to tell us to:
• Share information with your family, close friends, or others involved in your care• Share information in a disaster relief situation• Include your information in a hospital directory
If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
In these cases we never share your information unless you give us written permission:
• Marketing purposes• Sale of your information• Most sharing of psychotherapy notes
In the case of fundraising:
• We may contact you for fundraising efforts, but you can tell us not to contact you again.
File a complaint if you feel your rights are violated
• You can complain if you feel we have violated your rights by contacting us using the information on page 1.
• You can file a complaint with the U.S. Department of Health and Human Services Office for CivilRights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/
• We will not retaliate against you for filing a complaint.
How do we typically use or share your health information?
We typically use or share your health information in the following ways:
Treat You
We can use your health information and share it with other professionals who are treating you.Example: A doctor treating you for an injury asks another doctor about your overall health condition.
Run our organization
We can use and share your health information to run our practice, improve your care, and contact you when necessary.Example: We use health information about you to manage your treatment and services.
Bill for your services
We can use and share your health information to bill and get payment from health plans or other entities. Example: We give information about you to your health insurance plan so it will pay for your services.
4
We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see:www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html
Help with public health and safety issues
We can share health information about you for certain situations such as: • Preventing disease• Helping with product recalls• Reporting adverse reactions to medications• Reporting suspected abuse, neglect, or domestic violence• Preventing or reducing a serious threat to anyone’s health or safety
Do research
We can use or share your information for health research.
Comply with the law
We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.
Respond to organ and tissue donation requests
We can share health information about you with organ procurement organizations.
Work with a medical examiner or funeral director
We can share health information with a coroner, medical examiner, or funeral director when an individual dies.
Address workers’ compensation, law enforcement, and other government requests
We can use or share health information about you:• For workers’ compensation claims• For law enforcement purposes or with a law enforcement official• With health oversight agencies for activities authorized by law• For special government functions such as military, national security, and presidential protective
services
Respond to lawsuits and legal actions
We can share health information about you in response to a court or administrative order, or in response to a subpoena.
HOW ELSE CAN WE USE OR SHARE YOUR HEALTH INFORMATION?
5
OUR RESPONSIBILITIES
CHANGES TO THE TERMS OF THIS NOTICE
OTHER INSTRUCTIONS FOR NOTICE
• We are required by law to maintain the privacy and security of your protected health information. • We will let you know promptly if a breach occurs that may have compromised the privacy or
security of your information.• We must follow the duties and privacy practices described in this notice and give you a copy of it. • We will not use or share your information other than as described here unless you tell us we can in
writing. If you tell us we can, you may change your mind at any time. Let us know in writing if youchange your mind.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html
• Effective date January 01, 2019.• For questions about our privacy practices, please contact our privacy officer at (859) 554-0485 or
by email at [email protected].• We never market or sell your information to third parties.• We will never share any mental health or substance abuse treatment records without your written
permission.
We can change the terms of this notice, and the changes will apply to all information we have about you.
The new notice will be available upon request, in our office, and on our web site: https://theomnihealth.com
6
WHY WE CHARGE FOR FOLLOW-UP CONSULTATIONS
WHY WE DO NOT ACCEPT INSURANCESome of our patients have asked us why we do not bill insurance directly. While we fully understand
the financial challenge this presents to some patients we have chosen not to bill insurance directly for the following reasons:
When clinics bill insurance companies directly, the doctors are required to become participating providers. The doctors must sign a contract that allows the insurance company to determine which services they will and will not provide, and how much they can charge for those services. In general, insurance companies are not focused on any preventative or wellness services. They are heavily invested in the conventional model of health care that too often relies on drugs and surgical procedures. We are committed to the functional medicine model that addresses the underlying causes of your symptoms with specific nutritional and lifestyle recommendations as the primary intervention. We do use drugs to alleviate symptoms while we address the root cause of the problem, if necessary.
A participating provider must agree to accept the fees the insurance company establishes, regardless of whether the fees are reasonable or applicable to that practice. In general, these established fees cover the actual cost of the briefest (and we believe the lowest quality) care. Doctors who are participating providers are required to accept discounted fees for their services. Therefore, the clinic must write-off the difference, often as much as fifty percent or more of the doctor’s fee for service. Our office cost to provide high quality care is very high and involves significantly more time compared to the standard medical model, making this a very difficult situation. You may be aware but in today’s health care environment, the actual cost for doctors to provide services continues to rise, while the percentage of reasonable fees that insurance payments cover is declining.
Most doctors and clinics cope with the requirements of being participating providers by keeping their office visits very brief, so that they can see many patients within a given timeframe. When the clinic becomes unprofitable, it will need support from another institution. Most primary care medical clinics are not self-sustaining financially, and have had to merge with hospitals whose expensive high-tech surgical and diagnostic procedures are priced to keep the clinics afloat.
Ironically, some of our patients complain about their extremely brief office visits in other medical practices, while at the same time expressing frustration that we do not accept insurance. Unfortunately, we have found that we cannot stay in the insurance networks and provide the time-intensive, well-researched, expert care that you will get at Omni Health.
At Omni Health, we are passionate about what we do, and we feel that we have a calling to provide as many people as possible with the highest quality health care possible. Just as our services are unique to this region, our financial policies set us apart from mainstream medicine. We have prepared this handout to answer questions you or your family members may have about the rationale for our financial policies. If, after reading this, you still have questions, feel free to speak with our staff.
Some patients have asked why we charge for follow-up consultations regarding lab results and exams, as well as for telephone consultations.
In follow-up visits, our doctors spend significant time discussing your results with you. For example, it is relatively simple to inform a patient that her mammogram is negative; but it is entirely different to discuss the results of more complex functional evaluations and to recommend practical lifestyle and dietary strategies that may help to prevent breast cancer or turn off autoimmunity. We want you to understand that preventative health care takes considerable time and expertise on the part of the doctor, and someone has to pay for that time and expertise.
EXPLANATION OF OUR FINANCIAL POLICY
ABOUT THE CHARGES FOR OUR DOCTORSʼ SERVICES
WHY WE SELL NUTRITIONAL SUPPLEMENTS AND HOW WE PRICE THEM
Some patients may have the mistaken impression that our doctors take home the majority of the fees we charge for their services, and that the doctors have a great deal of leeway to offer discounts for those fees. In fact, our doctors take home only a fraction of the fees collected for services. This is because a clinic like ours requires trained staff and expensive professional continuing education. The majority of our fees support the overall mission of providing high quality, wellness-based, functional medicine care, not the doctors’ paychecks. Our doctors have chosen this work because it is their passion and their calling, and certainly not because it is a way to make a lucrative income. In fact, most medical doctors who choose to practice functional medicine know that their income will be substantially lower than it would be if they were practicing in a more conventional manner that is fully supported by the health care reimbursement system.
We recommend nutritional supplements as an adjunct to dietary and lifestyle modification. This approach is central to the well-researched and science-based practice of functional medicine, which all of our professional staff have studied. We sell therapeutic-quality nutritional supplements as a service to our patients. With a few exceptions, we do not sell nutritional products of similar quality to those that are widely available over the counter. We purchase high-quality nutritional products from the top nutritional research laboratories in North America and we price them to cover our costs of providing them, however, we keep our mark-ups as low as possible.
7
