HIPAA Privacy

Patient Consent for Use and Disclosure of Protected Health Information

I hereby give my consent for NATUROPATHIC LONGEVITY CENTRE to use and disclose protected health information (PHI) about me to carry out treatment, payment and health care operations (TPO). (The Notice of Privacy Practices provided by NATUROPATHIC LONGEVITY CENTRE describes such uses and disclosures more completely.)

I have the right to review the Notice of Privacy Practices prior to signing this consent. NATUROPATHIC LONGEVITY CENTRE 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 Naturopathic Longevity Centre, 8700 E Vista Bonita Dr, Ste 124, Scottsdale, AZ 85255.

With this consent, NATUROPATHIC LONGEVITY CENTRE 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, NATUROPATHIC LONGEVITY CENTRE 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, NATUROPATHIC LONGEVITY CENTRE 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 NATUROPATHIC LONGEVITY CENTRE 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 NATUROPATHIC LONGEVITY CENTRE 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, NATUROPATHIC LONGEVITY CENTRE may decline to provide treatment to me.

Financial Policy & Health Insurance

We would like to take a moment to welcome you to our office and assure you that you will receive the very best of care available for your condition. In order to familiarize you with the financial policy of this office we would like to explain how your medical bills will be handled.

Payments: We are a cash-based practice. All services are payable in full either in advance (if paid online) or at the time of your appointment. You will be informed of the estimated cost of your appointment at the time of scheduling.

Payment Methods: We accept cash, checks, and major US debit and credit cards.

Insurance: We do not bill any insurance carriers. As a courtesy, we will provide you with a Superbill for each visit to submit on your own behalf. You may also download PDF versions of your Superbills, Transaction Reports, and Treatment Sheets from your Patient Portal. All insurance submissions are the patient’s sole responsibility. If you have Naturopathic Physician coverage, reimbursement is usually considered out of network and will reflect as such. We cannot guarantee that your insurance will reimburse you for any of our services. If this is a concern for you, please contact your insurance provider before scheduling your appointment to clarify your coverage.

Voluntary Termination of Care: You may suspend or terminate your care at any time.

Disclaimer

As the patient, it is in your best interest to know and understand your insurance plan benefits. It is important that you know your responsibility for any deductible, co-insurance, or co-pay amounts prior to your office visit. Regardless of your individual insurance coverage or type, you are ultimately responsible for all charges. You are required to provide all information necessary so we can process your claim in a timely and efficient manner. If your insurance coverage changes during the course of your treatment, you must notify us immediately of that change and provide all information necessary. Verification of coverage is not a guarantee of payment. Bethel Naturopathic Medical, LLC is not responsible for any mis-quotes of benefits. Your patient responsibility will be processed according to the explanation of benefits received from your insurance company. Please know that we are here to help you if you have any questions.

Once again we welcome you to our office, and will be glad to answer any further questions that you might have.

I have read and agree to the above.

Cancellation Policy

Thank you for choosing us as your naturopathic healthcare providers. When you schedule an appointment with us this appointment time is set aside especially for you and is not available to other patients. Therefore, it is important that you let your practitioner know as soon as possible if you will be unable to come to your scheduled appointment. This allows us to make this time available to other patients.

We require 48 hours notice if you need to cancel or reschedule your appointment. If you do not provide adequate notice, you will be charged a $50 fee for the missed appointment.

Late Appointments: Late appointments create challenges for other scheduled patients. Arriving 15 minutes late may result in a cancelled appointment for which we will charge a $50 missed appointment fee. If you know you are going to be late, please let us know, and we will try our best to accommodate.

I, the undersigned, have read and understand the above cancellation policy.

Prescriptions

Naturopathic Longevity Centre and the physicians within have the authority to write prescriptions for drugs in Categories 3N and 3-5. It is common for certain therapies to require custom prescriptions formulated in a compounding pharmacy. It is the right of the patient to select/direct which pharmacy they wish the prescribing physician to use to fill their medications.

Communications

Communications: Our office confirms appointments via text 2 days prior to your appointment. If you prefer another means of communication, please indicate below how would you prefer to receive confirmation. NLC may also send information regarding upcoming events or specials through email or text. Please Opt-in or Opt-out of marketing communication in the appropriate section below.