Nutrition Patient Forms
New Nutrition Patient Forms
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More Nutrition Forms
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Symptom Survey Form
Symptom Survey Form - Fillable
Toxicity Questionnaire
Yeast Questionnaire
Thiamine Questionnaire
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HIPAA
Notice of Privacy Policy
Protecting the privacy of your personal health information is important to us. Disclosure of your protected health information without authorization is strictly limited to defined situations that include emergency care, quality insurance activities, public health, research and law enforcement activities. Any other disclosure for the purposes of treatment payment or practice operations will be made only after obtaining your consent. You may request restrictions on your disclosures. You may inspect and receive copies of your records within 30 days of your request. You may request to view changes to your records. In the future, you may contact you for appointment reminders, announcements, and to inform you about our practice and its staff. I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPPA) I have certain rights to privacy regarding my protected health information. I understand this information can be used to: conduct, plan and direct my treatment and follow up with multiple providers that may be treating me, obtain payment from third party payers and conduct normal health care operations such as quality assessments and physician’s certifications. The complete HIPPA manual is in the waiting room for my review. I have read and understand your Notice of Privacy Practices. A more complete description may be requested.
Protecting the privacy of your personal health information is important to us. Disclosure of your protected health information without authorization is strictly limited to defined situations that include emergency care, quality insurance activities, public health, research and law enforcement activities. Any other disclosure for the purposes of treatment payment or practice operations will be made only after obtaining your consent. You may request restrictions on your disclosures. You may inspect and receive copies of your records within 30 days of your request. You may request to view changes to your records. In the future, you may contact you for appointment reminders, announcements, and to inform you about our practice and its staff. I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPPA) I have certain rights to privacy regarding my protected health information. I understand this information can be used to: conduct, plan and direct my treatment and follow up with multiple providers that may be treating me, obtain payment from third party payers and conduct normal health care operations such as quality assessments and physician’s certifications. The complete HIPPA manual is in the waiting room for my review. I have read and understand your Notice of Privacy Practices. A more complete description may be requested.
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"It is the body that is the hero, not science, not antibiotics...not machines or new devices...The task of the physician today is what it has always been, to help the body do what it has learned so well to do on its own during its unending struggle for survival-to heal itself."
"It is the body, not the medicine that is the hero"