shawn s. soszka, nd, msom, lac · 2018-06-28 · 7215 se 13th ave, portland, or 97202 (503)...

© 2015 Evergreen Integrative Medicine, LLC Beeson Wellness Center 7215 SE 13th Ave, Portland, OR 97202 (503) 238-7025

Instructions for Dr. Soszka’s New Patient Intake

Firstly, I’d like welcome you to our clinic and to thank you for choosing to seek healthcare with me. I strive to

provide the most comprehensive healthcare possible, seeking out the root cause of your health concerns. When

we are able to remove this cause, the process of healing occurs and the return of vibrant health follows.

This intake form is quite extensive, I recommend giving yourself 20 to 40 minutes depending the on your health

history. I use this form for both naturopathic and acupuncture patients as the nature of my practice tends to

blend the two disciplines interchangeably.

Ways to complete this intake:

This intake form is a fillable PDF form which allows you to complete the intake on your electronic device of

choice. Please use adobe acrobat and NOT your web browser to complete these forms as you will not be able to save your forms!! I’ve provided instructions on how to save this form below. Please note, this form can be

printed and com-pleted by hand if you wish.

If you are using the most current version of Adobe Reader, you will be able to complete the entire intake on your

computer and can even digitally sign the privacy policy on the last page without the need to print any of these

forms! Learn more about signing PDFs

Returning the intake form:

The preferred method is to email the forms to me at [email protected]. We recommend completing and submitting the form to the clinic at least 24 hours prior to your appointment. However, if it is more convenient you may fax this form to (888) 302-5652, or mail (or drop off) the forms to the clinic address below.

You have three options for returning the intake form. Email, Fax, or Mail/Drop off.

Thank you again for the time and effort you have put into completing these forms. I review all of the information

you provide within the intake, so I may have holistic overview of your current state of wellbeing and the

influencing factors on your health.

Shawn S. Soszka, ND, MSOM, LAc

http://helpx.adobe.com/reader/using/sign-pdfs.html

© 2015 Evergreen Integrative Medicine, LLC www.drsoszka.com

Dr. Shawn Soszka Beeson Wellness Center

7125 SE 13th Ave, Portland, OR 97202

New Patient Information: Name: Date:

Address:

City: State: Zip:

Telephone# (main): (Alternate):

Email Address:

Date of Birth: Gender: Male Female Transgender

Emergency Contact

Next of Kin or other to reach in an emergency:

Relationship: Phone:

Are You Using Medical Insurance? Yes No

If you are using insurance, it is important that you verify that your policy covers naturopathic and/or acupuncture care. Dr. Soszka has an insurance verification form you can use to confirm benefits. Please note, Medicare does not cover naturopathic medicine.

How did you hear about Dr. Soszka at this clinic?

Would you like to receive Dr. Soszka’s e-newsletter with health articles and other important news?

Yes No




Dr. Soszka’s Office Policies You must agree with our office policies before treatment. Please check the boxes below at each section to indicate that you have read, understood and agreed.

1. Patients are responsible for all fees incurred during the treatment period. We are happy to bill your insurance plan when we can, however it is your responsibility to understand your plan details and verify your benefits.

Prior to your visit, please complete our insurance verification form (on our website and in this packet). Your insurance card and ID must be presented at time of service.

If you insurance plan denies payment, it is your responsibility. You will be billed all deductibles and co-insurances fees. Timely payment is required. If you would like to pay in installments prior to receiving your bill (there can be a long delay with billing) please inform Dr. Soszka.

2. Cancellation Policy: You are required to give 48 hours’ notice to cancel or reschedule an appointment or you will be billed a $25 charge.Your appointment is reserved just for you. Late cancellations and no shows effect Dr. Soszka’s livelihood.

In rare instances, you may be ill or have an emergency, and we may waive the fee. On rare occasions, Dr. Soszka will be ill or in an emergency, and we ask for your understanding in rescheduling the appointment.

3. Out of pocket prices may not be combined with any other discount.Our time of service payment prices are discounted for prompt (cash) payments, as such, you may not combine these prices with any other discounts. These are not the prices that we bill insurance companies, which reflect the added costs and delayed payments associated with interacting with the various medical insurance companies.

Thank you for completing this form. You may scheduled an appointment by calling (503) 238-7025.

Shawn Soszka, ND, LAc (Evergreen Integrative Medicine, LLC) Beeson Wellness Center

7125 SE 13th Ave, Portland, OR 97202 (P): 503-238-7025 | (F) 888-302-5652

Email: [email protected] Tax ID: 47-4255886 | Group NPI: 1407237175

Please complete this benefit check form with your insurance agency to help determine if you have benefits for our services. Please note that what the representative says is not a guarantee of payment. If you need assistance, contact us at (503) 238-7025.

Please record the plan information on your insurance card here:

Patient’s Name: ID or Member Number:

Group #: Date of Birth:

Insurance Carrier: Issuing State: Effective Date:

Are you the primary policy holder? Yes No If not, please provide the following information:

Name of Policy Holder: Date of Birth:

Relationship to you: Gender: Phone:

Address (If different from yours):

_

Please call the Member Phone number on the back of your card, to ask these questions:

Do I have benefits for naturopathic medicine and/or acupuncture? Yes No

If so, what services are covered?

Do I have to meet a deductible before my insurance contributes to the payment? Yes No

If so, what is my deductible?

What is my co-pay or co-insurance for each service? _______________________________________________________

What is the maximum # of visits or payment maximum, per year, per service?

__________________________________________________________________________________________________

Does this visit require preauthorization? Yes No

Is Dr. Soszka in-network on this insurance? Yes No

Are naturopathic physicians allowed to order blood tests? Yes No

Is Quest Diagnostics an in-network lab? Yes No | Is Labcorp an in-network lab? Yes No

When does my plan year begin and end? What is the representative's name who helped me?

___________________________________ ___________________________________________

mailto:[email protected]


Name: Date:

Occupation: Date of Birth: Gender:

Relationship Status: S M D W SEP Partner How would you rate your health (1 to 10 Scale):

List Current Health Conditions and Previous Treatments Used in the Past

1.

2.

3.

Past Treatment:

Past Treatment:

Past Treatment:

Y N Do you have a Primary Care Provider? If yes, list:

If no, are you seeking to establish primary care with Dr. Soszka? Y N

Y N Do you have any known contagious diseases at this time? If yes, explain:

Y N Have you tried alternative medicine before? If yes, describe:

(Women Only) Are you pregnant? Y N Not Sure

Y N Do you take blood thinners? If yes, list:

If yes, how often do you get your blood checked?

How long ago was your most recent blood work? Any abnormal labs?

Dr. Soszka’s New Patient Intake Naturopathic | Functional Medicine | Acupuncture

Check any of the following symptoms experienced DAILY (or nearly every day)?

Debilitating fatigue

Headaches

Dizziness

Shortness of breath

Panic attacks

Insomnia

Fecal Incontinence

Urinary Incontinence

Low Grade Fever

Nausea

Vomiting

Diarrhea

Chronic pain

Bleeding

Chest pain

Abnormal mammogram

Alcoholism/Addictions

Appendicitis

Autoimmune disease

Birth defects/Congenital diseases

Bleeding disorder

Cancer (Type: )

Celiac disease

Chronic sinus infections

Diabetes (Type 1 or 2)

Epilepsy/Seizure disorder

Fibromyalgia/Chronic pain syndrome

Food Poisoning/Traveler’s diarrhea

Gallbladder surgery/removal

Gout

Heart Attack

Heart Disease (CHF)

Hepatitis B, C, or D

High Cholesterol

HIV/AIDS

Kidney Stones

Mental Health Issues

Mononucleosis (Mono)

Multiple Sclerosis

Neuropathy

Pace maker

Osteoporosis

Rheumatoid arthritis

Stroke

Thyroid problems

Check any of the conditions you have or have had:


Current Medications ( No medications)

Please list any prescription medications, over-the-counter medications you are currently taking (include dose):

Current Supplements/Vitamins/Herbs ( No supplements)

Please list any supplements, vitamins, and herbs prescription medications, over-the-counter medications you are currently

taking (please include brand, supplement name, and dose—I will often adjust dosages or change supplements dependent on

quality of brand or type):

How would you rate your overall stress level on a scale of 1 to 10 (with 1 being lowest):

Identify major causes of stress in your life:

Are any of your activities associated with potentially harmful substances (chemicals, heavy metals, radioactivity, etc.)? If so,

please list:

Have you had an unintentional weight loss/gain of 10 pounds or more in the last 3 months? Y N

Height: Weight (lbs): Do you consider yourself : overweight underweight ideal weight

Any significant illnesses or injuries in your lifetime? ( None) If yes, please list:

Hospitalization, Surgery, Imaging (MRI, X-Rays, CT, EEG, EKG) ( None)

Year:

Year:

Year:

Allergies ( None)

Do you have allergies or hypersensitivity to:

Drugs:

Foods:

Chemicals/Environmental:


Symptom Location & Severity

Describe briefly the problem(s) you are currently experiencing:

When did this start?

Is it getting: Worse Better

What makes it worse?:

What makes it better?:

Anything else?:

None Most Severe

Please mark the severity of the symptom(s) on the scale (0 to 10)

Please mark the area(s) where you experience symptoms on the figure below

Head

FaceJaw

ShoulderChest

Abdomen

WristHips

Knees

AnklesFeet

Legs

Thighs

Hand

Elbow

Neck

Upr Back

Midback

Lw back

SacrumPelvis

Upr Arms

Arm

Throat


Please check any specific food restrictions/avoidance you have:

Diet/Nutrition

Please mark the choice below that best describes your diet: List any foods avoided:

Omnivore (Mixed diet)

Vegetarian

Vegan

Fast Food & Junk Food

Portion/calorie restriction

Blood Type Diet

Paleo/Low Carb

SCD/GAPS/FODMAPs

Gluten-Free

Autoimmune-Based

D.A.S.H. Diet

Kosher/Halal Diet

Weight Loss Program Diet

Dairy

Soy

Wheat

Corn

Eggs

All Gluten

Salt Restriction

Other:

Health Habits

Tobacco: Packs/day: Cigars Pipe Tobacco Chew Tobacco Marijuana

Alcohol: Wine: Glasses/day: Liquor: shots/day: Beer: Cans or bottles/day:

Men: How many times in the past year have you had 5 or more drinks in a day? None 1 or more

Women: How many times in the past year have you had 4 or more drinks in a day? None 1 or more

Recreational Drugs: How many times in the past year have you used a recreational drug or used a prescription medication

for nonmedical reasons? None 1 or more

Caffeine: Coffee: Cups (oz)/day: Tea: Cups (oz)/day: Soda w/ caffeine: Cans (oz)/day:

Artificial Sweeteners: Splenda Aspartame (NutraSweet/Equal) Saccharine (Sweet n’ Low) Other:

Water: Glasses (oz)/day: Get enough sleep? Yes No # Hours/night:

Frequency: How Many Times/Week: Duration: How long is your typical workout? Minutes.

Type of Exercise:

Response to Exercise: How do you feel after exercise? Better Worse Endurance: Reduced ability to exercise? Y N

Exercise

Family Medical History

Please list any major health conditions your parents, siblings, or extended family members experienced during their lifetime. If

they are deceased, please indicate age at death and check the box (). It is important to look for hereditary-based health condi-

tions, especially cancer, heart disease, diabetes, autoimmune conditions, celiac disease, and thyroid diseases.

Family Member Age Health Conditions

Mother

Father

Sibling

Other:

Do you have any of the above conditions? Yes No If yes, explain:


Check for any symptoms or conditions you have experienced in the past 6 weeks.

General

Unintentional weight change

Fatigue Brain fog Trouble sleeping

Fevers

Abnormal Sweating

Chills

Skin

Acne

Bruises easily

Dryness

Rashes

Varicose veins

Slow wound healing

Jaundice (Yellow skin/eyes)

Itching

Swelling/Allergic Reactions

Swelling in ankles

Head, Ears, Eyes, Nose, Throat

Headaches

Hair loss/texture change

Fainting/Passing out

Jaw pain or popping

Glaucoma

Eye problems

Impaired hearing

Ear pain/discharge

Ringing in ears

Nasal congestion/Runny nose

Sinus problems

Nose bleeds

Problems with sense of smell

Teeth grinding

Gum problems

Mouth problems

Swollen Glands

Difficulty swallowing

Respiratory

Chronic Cough

Easily winded

Hay Fever

Shortness of breath

Coughing blood

Wheezing/Asthma

Chronic Phlegm

Bronchitis (Chronic/Reoccurring)

Sore Throat

History of Lung Illness

Current Smoker/History of smoking

Total # years: Packs/day:

Cardiovascular

Chest pain

Palpitations/Flutters

Fluid retention in body (not just ankles)

Abnormal Blood Pressure

High Blood Pressure

Low Blood Pressure

Blood Clots

Leg pain/cramps

Heart murmur

Irregular heartbeat

Mental / Emotional

Treated for emotional problems

Anxiety

Panic Attacks

Mental Illness

Mood Swings

History of abuse

Depression

Seasonal depression

Considered/Attempted suicide

Easily Stressed

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Gastrointestinal

Abdominal pain /cramps

Bloody or black stools

Colitis / Crohn’s

Colon problems

Constipation (Less than 3-5 BMs/wk)

Incomplete stool sensation

Diarrhea

Bloated abdomen

Nausea / Vomiting

Low blood sugar

Appendicitis

Ulcers or H. pylori infection

Liver Disease

Hemorrhoids

Heartburn/Acid Reflux

Excessive Burping / Gas

Painful bowel movements

Poor or decreased appetite

Hernia

Gallbladder Problems

Excessive or increased appetite

Bowel Movements:

How Often?

Is this a change? Yes No

Over the past 2 weeks, how often have you been bothered by any of the follow problems?

Not at all Several Days More than 1/2 the days

Nearly every

day

Little interest or pleasure in doing things

Feeling down, depressed, or hopeless


Check for any symptoms or conditions you have experienced in the past 6 weeks.

Muscle / Joint

Joint pain/arthritis

Joint deformities/nodules

Bursitis/tendonitis

Foot Problems

Muscle Weakness

Muscle spasms/cramps

Restless leg syndrome

Low back pain

Neck pain

Mid back pain

Broken bones

Immune

Reaction to immunizations

Chronic fatigue syndrome

Chronic infections

Frequent colds / flus

Urinary

Increased frequency during the day

Frequency at night

Inability to hold urine/”accidents”

Urgency to urinate

Painful urination

Frequent infections

Cloudy urine

Blood in urine

Difficulty starting urine stream

Decreased flow / force

Men’s Heath

Hernias

Testicular pain

Erectile dysfunction

Premature ejaculation

Testicular masses

Penile discharge / sores

Prostate disorders/disease

Reduced sex drive

Sexually Transmitted Diseases

Herpes (Type 1 Or 2)

Sexual Orientation:

Women’s Health

Breast

Breast infection

Rashes around breasts

Breast tenderness / pain

Breast lumps

Nipple discharge

Reproductive/Menses

Ovarian cysts

Fertility problems

Cervical dysplasia

Endometriosis

Painful menses

Reduced sex drive

Sexually Transmitted Diseases

Herpes (Type 1 Or 2)

Heavy / Excessive flow

Decreased / Absent menstrual flow

PMS:

Mood changes/irritability

Breast tenderness/swelling

Cramping

Pain during menses

Spotting/bleeding between menses

Age of 1st Menses

Length of cycle days

Duration of menses days

Last Menstrual Period:

Date of last PAP: Abnormal

Birth Control (type)

# Pregnancies ____ # Miscarriages _____

# Live births ____ # Abortions _____

Menopausal?

(If yes) age of final Menses

Menopause symptoms:

Sexual Orientation:

Neurological

Seizures

Vertigo or dizziness

Change in pulse rate laying down

Paralysis

Numbness or Tingling

Loss of Balance

Tremors

Loss of speech

Memory problems Short term memory Long term memory

Endocrine

Hypothyroidism

Hyperthyroidism/Grave’s disease

Hashimoto’s Thyroid Disease

Change in skin color or texture

Excessive hunger

Excessive Thirst

Excessive urination

Sensitivity to cold

Cold hands / feet

Sensitivity to heat

Weight loss/gain

Adrenal Fatigue/Failure

Goiter

Diabetes (Type 1 or 2)




Informed Consent and Request for Naturopathic Medical Care, Classical Chinese Medicine Treatment and Acupuncture

As a patient I have the right to be informed about my health condition(s) and recommended treatment. This disclosure is to help me become better informed so that I may make the decision to give, or withhold, my consent as to whether or not to undergo care with Dr. Shawn Soszka (Evergreen Integrative Medicine, LLC), having had the opportunity to discuss the potential benefits, risks and hazards involved. I, , hereby request and consent to examination and treatment with Naturopathic Medicine, Classical Chinese Medicine (CCM) and Acupuncture with Dr. Shawn Soszka, and/or other licensed doctors of naturopathic medicine or licensed acupuncturists serving as backup for him, hereafter called allied health care provider. I understand that I have the right to ask questions and discuss to my satisfaction with Dr. Shawn Soszka, and/ or with the allied health care provider providing backup:

(1) my suspected diagnosis(es) or condition(s) (2) the nature, purpose, goals and potential benefits of the proposed care (3) the inherent risks, complications, potential hazards or side effects of treatment or

procedure (4) the probability or likelihood of success (5) reasonable available alternatives to the proposed treatment procedure (6) potential consequences if treatment or advice is not followed and/ or nothing is done

I understand that a Naturopathic evaluation and treatment may include, but are not limited to: Physical exam (including general, musculoskeletal, EENT, heart and lung, orthopedic and

neurological assessments). Common diagnostic procedures (including venipuncture, pap smears, diagnostic imaging,

laboratory evaluation of blood, urine, stool and saliva). Dietary advice and therapeutic nutrition (including use of foods, diet plans, nutritional

supplements and intra-muscular vitamin injections). Trigger point injection therapy with vitamin substances. Botanical/ herbal medicines, prescribing of various therapeutic substances including plant,

mineral, and animal materials. Substances may be given in the forms of teas, pills, creams, powders, tinctures which may contain alcohol, suppositories, tropical creams, pastes, plasters, washes or other forms.

Homeopathic remedies (highly diluted quantities of naturally occurring substances) Hydrotherapy (use of hot and cold water, may include transcutaneous electrode

stimulation). Counseling (including but not limited to visualizations for improved lifestyle strategies). Over the counter and prescription medications (including only those medications on the

Formulary of Oregon Naturopathic Physicians).




The scope of practice of acupuncture is outlined below. I understand that Classical Chinese medicine and Acupuncture evaluation and treatment may include, but are not limited to: Acupuncture (insertion of specialized disposable stainless steel sterilized needles through

the skin into underlying tissues at specific points on the body’s surface). Use of electrical, mechanical and magnetic devices. Moxabustion: indirect burning of herbal material (mugwort) in the form of a loosely

compacted herb or stick near or on the skin. Cupping (used to relieve symptoms of pain and chest congestion in which glass cups are

placed on the skin with a vacuum created by heat). Tui-na (ancient Chinese massage). Dietary advice (based on traditional Chinese medicine theory). Herbs (use of herbal formulas in the form of teas, powders, tinctures, pastes, and plasters,

which may be taken internally or used externally as a wash. Formulas may include shells,minerals and animal materials).

Potential benefits: Restoration of the body’s maximal and optimal functioning capacity, relief of pain and other symptoms of disease, assistance with injury and disease recovery, and prevention of disease or its progression.

Potential risks: Pain, discomfort, blistering, minor bruising, discoloration, infections, burns, itching; loss of consciousness and deep tissue injury from needle insertions, pneumothorax, allergic reaction to prescribed herbs, supplements; soft tissue or bony injury from physical manipulations; aggravation of pre-existing symptoms.

Notice to pregnant women: All female patients must alert the provider if they have confirmed or suspect pregnancy as some of the therapies prescribed could present a risk to the pregnancy. Labor- stimulating techniques or any labor-inducing substances will not be used unless the treatment is specifically for the induction of labor and any treatment intended to induce labor requires a signed letter from a primary care provider authorizing or recommending such treatment.

Notice to individuals with bleeding disorders, pace makers, and/ or cancer. For your safety it is vital to alert your provider, Dr. Shawn Soszka, of these conditions.

Please INITIAL the following:

_______ I understand that Dr. Shawn Soszka does not prescribe controlled narcotic pain medications. Appropriate referrals will be provided to manage my prescriptive pain medication needs.

_______ I understand that Dr. Shawn Soszka, will only prescribe medications if he believes that they are in the best interest of myself, the patient. Appropriate referrals will be provided to manage my prescriptive medication needs.




_______ I understand the US Food and Drug Administration has not approved nutritional, herbal and homeopathic substances; however these have been used widely in Europe, China and the USA for years.

_______ I understand that Dr. Shawn Soszka is not a psychologist or psychiatrist. Counseling services are provided for the support of improved lifestyle strategies.

_______ I understand that electronic health record technology allows integration between medical providers and pharmacies, as such I permit Dr. Shawn Soszka to reconcile my pharmacy history into the medical chart notes created by Dr. Soszka to better serve my healthcare needs.

_______ I have received a HIPAA Patient Privacy statement from Dr. Shawn Soszka (Evergreen Integrative Medicine, LLC). (HIPAA document attached on next page.)

I do not expect Dr. Shawn Soszka, and/or any allied health care provider to be able to anticipate and explain all of the risks and complications, and I wish to rely on the provider to exercise all judgment during the course of the procedure based on the known facts.

I also understand that it is my responsibility to request Dr. Soszka explains therapies and procedures to my satisfaction. I further acknowledge that no guarantee of services have been made to me concerning the results intended from any treatment provided to me.

By signing below I acknowledge that I have been provided ample opportunity to read this form or that it has been read to me. I understand all of the above and give my oral and written consent to the evaluation and treatment. I intend this as a consent form to cover the entire course of treatments for my present condition and any future conditions for which I seek treatment.

_____________________________________ ___________________________________________ Printed Name of Patient Signature of Patient Date

_____________________________________ ___________________________________________ Printed Name of Guardian Signature of Guardian Date (Required for patients under age 18)




HIPAA Privacy Disclosure & Policies As a patient, you have the right to know how your private, confidential healthcare and personal information is being protected. Protected health information is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services. Below are the methods in which we secure your information confidentially in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPPA).

In-Office Security Notes that are taken during appointments are stored within a secured, electronic health record (EHR) software (Practice Fusion©), all patient information is stored on their secure servers. No patient data is stored on Dr. Soszka’s computer. Any paper records are kept within the clinic and secured in staff only areas of the clinic at all times. If patient paper charts/printed materials are in public areas, they are kept with the names covered. Access to the clinic office areas is limited to staff, practitioners, preceptors, and supervised guests.

Healthcare operations: We may use or disclose, as needed, your protected health information in order to support the business activities of the practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, and conducting or arranging for other business activities. For example, I may disclose your protected health information to medical school students that see patients in my office. I may call you by name in the waiting room when ready to see you. I may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment.

Consultations We consult with other qualified healthcare practitioners and clinical/laboratory specialists while working on patient cases and treatment plans. These conversations and transfers of information by phone, in person, by fax or email are confidential and names are not used unless necessary and consent is provided from you either verbally or in writing.

Records Released Your confidential healthcare information is private and cannot be copied and shared with anyone else without your written, signed consent. Copies of released records are sent by mail or fax and are accompanied by a Confidential Patient Information Cover Sheet if faxed.

Definitions and Penalties to Comply Protected health information is any information, whether oral or recorded, in any form or medium that: 1) is created or received by a healthcare provider, health plan, public health authority, employer life insurer, school or university in the normal course of business, and 2) relates to the past, present or future physical or mental health or condition of an individual; the provision of healthcare to an individual; or the past, present or future payment for the provision of healthcare to an individual.




This information may reside in any medium: tape, paper, disc, fax, email, and/or digital voice message.

Your Rights The following is a statement of your rights with respect to your protected health information.

You have the right to inspect and copy your protected health information. Under federal law, however, you may not inspect or copy the following records; psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information.

You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. Your physician is not required to agree to a restriction that you may request. If physician believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use another Healthcare Professional.

You have the right to request to receive confidential communications from us by alternative means or at an alternative location.

You may have the right to have your physician amend your protected health information. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.

You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. We reserve the right to change the terms of this notice and will inform you via posting in the office of any changes. You then have the right to object or withdraw as provided in this notice.

Complaints: You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our HIPAA Compliance Officer, Dr. Shawn Soszka, ND, LAc, of your complaint. We will not retaliate against you for filing a complaint. His email is [email protected].

shawn s. soszka, nd, msom, lac · 2018-06-28 · 7215 se 13th ave, portland, or 97202 (503)...

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