Welcome! We're so glad you're here. This comprehensive intake form helps us understand your unique health journey so we can create a personalized plan just for you. Please complete all sections to the best of your ability.
CLIENT INTAKE FORM CONSENT
Notice of Privacy Practices Short Form
Our practice is committed to educating our patients about healthcare issues that affect them. As a result, we are providing you with general information about the Privacy Rules, federal regulation of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) along with a brief overview of our new Notice of Privacy. Our practice is complying with HIPAA’s regulations.
What is HIPAA and how does the Privacy Rule affect you? When the Health Insurance Portability and Accountability Act (HIPAA) was passed in August of 1996 this gave the federal government the ability to mandate how healthcare plans, providers, and clearinghouses store and send a patient’s personal information as it relates to healthcare. The Privacy Rule was created to protect your rights as a patient of our practice and we are required by law to be compliant with this regulation on April 14, 2003. Under the Privacy Rule, you are guaranteed access to your medical records, allowed control over how your protected health information is used and disclosed, and allowed to take action if your privacy is compromised by following the practice’s policy. Our practice is dedicated to maintaining the privacy of your personal information.
What is individually identifiable health information (IIHI)? Any health information you provide, including your mailing address. Information that is created and retained by our practice or received by another healthcare provider that relates to treatment, payment, and/or that identifies you as an individual.
What is the Notice of Privacy Practice? Our practice has an official Notice of Privacy Practice posted in our waiting room informing our patients about their rights surrounding the protection of your IIHI and our obligations concerning the use and disclosure of your IIHI. This notice applies to all records created or retained by our practice. We can update our Notice of Privacy Practices at any time. It will be posted in our waiting room and you can ask for a copy of the current notice at any time.
The following categories describe the different ways in which we may use and disclose your IIHI:
Treatment Appointment Reminders Release of information to family/friends
Payment Treatment Options Disclosures Required by Law
Healthcare Operations Health-related benefits & services
The following categories describe unique situations in which we may use or disclose your identifiable health information:
Public risks Health oversight activities Lawsuits Law enforcement
Deceased patient’s Organ and tissue donation Serious health threats/safety Research
What are your rights concerning your Individually Identifiable Health Information (IIHI)?
You have rights regarding the IIHI that we maintain about you. In our Notice of Privacy you can view the policies and procedures you will need to follow for the areas listed below:
1. Confidential communication 2. Requesting restrictions
3. Inspection and copies 4. Amendment
5. Accounting of Disclosures 6. Right to a paper copy of this notice
7. Right to file a complaint 8. Right to provide an authorization for other uses
If you have any questions regarding this notice or our health information privacy policies, please contact: Pembroke Holistic Center 954-501-2208.
Pembroke Holistic Center Appointment Policy
Our goal is to provide quality individualized medical care in a timely manner. "No-shows" and late cancellations inconvenience those individuals who need access to medical care in a timely manner. We would like to remind you of our office policy regarding appointments. This policy enables us to better utilize available appointments for our patients in need of medical care.
Cancellation of an Appointment
In order to be respectful of the medical needs of other patients, please be courteous and call the office promptly if you are unable to show up for an appointment. If it is necessary to cancel your scheduled appointment, we require that you call at least 24 hours in advance. Appointments are in high demand, and your early cancellation will give another person the possibility to have access to timely medical care.
How to Cancel Your Appointment
To cancel appointments, please call 954-501-2208. If you do not reach the receptionist, you may leave a detailed message on our voicemail or with our answering service. If you would like to reschedule your appointment, please leave your phone number. We will return your call and give you the next available appointment time.
No Show Policy
A "no-show" is someone who misses an appointment without canceling it in an adequate manner. A failure to be present at the time of a scheduled appointment will be recorded in your medical record as a "no-show." Your first missed appointment, there is no charge. For subsequent missed appointments a $25 fee will be billed to your account. Patients who habitually miss appointments may be discharged from the practice.
Consent and Release of Liability
Thank you for choosing Pembroke Holistic Center for your healthcare needs. In order to facilitate your request, it is important that you read and understand the following conditions
You are required to advise your physician of any medical conditions, including pregnancy, which may prevent you from receiving Natural Medicine.
You are required to inform your physician if at any time during your Natural Medicine treatment you experience any pain or discomfort.
Pembroke Holistic Center reserves the right to terminate or refuse its services for inappropriate behaviors. This is an elective service. Pembroke Holistic Center will not file insurance claims on your behalf for this service. You are required to pay for this service by cash, check, or credit card when receiving the Natural Medicine treatment. You may independently submit a claim to your insurance carrier for reimbursement if you choose to do so. Our office will provide you with the necessary documentation.
You are advised that all records pertaining to your Natural Medicine treatment will be kept confidential and will not be released by Pembroke Holistic Center without your written consent unless otherwise required by law.
Except for negligent or intentional acts or omissions of Pembroke Holistic Center, you on behalf of yourself, your successors, heirs and assigns hereby release Gloria Moreira, MMSc, L.Ac., and Pembroke Holistic Center, and their related entities, and the trustees, directors, officers, employees, medical staff members, agents or contractors, of each, in their personal or representative capacities, of and from any and all liability for any claims or demands for harm, damages, judgments, verdicts, settlements, or otherwise, arising from any injury or damage resulting from the Natural Medicine treatment.
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I hereby state that, to the best of my knowledge, my answers to the above questions are correct.
I agree and consent to assessment and treatment. I understand that my personal health information will be collected. I understand that all information that I provide will be kept confidential unless required by law. I understand and consent that my medical information may be shared by the various care providers involved in my care and treatment. I further understand everything that I have read above. By submitting this form, you have agreed to this privacy policy.
I have read and agree to the terms, statements & policies above.
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