We look forward to providing you with high quality, natural healthcare. We encourage your questions and participation in all aspects of your health, and look forward to working with you to increase your health and vitality, both now and in the future.

We value your time, and realize that office visits may be an interruption in an otherwise very busy schedule for you. For this reason, we’ve taken steps to assure that your time in the clinic is as focused and efficient as it can be. Please note the following:
• Physicians of Blossom Natural Health and Wellness are available for office visits by appointment only. Consultation after hours is available by special arrangement. All calls received will be returned within 24 hours or at the start of the next business day.
• Payment for services rendered is expected at the time of service unless other arrangements have been agreed upon in advance. If immediate, full payment will present major difficulties for you, please arrange a payment plan prior to your visit.
• Patients are welcome to call with questions at any time. There are no charges for brief conversations. Longer consultations will be billed accordingly.
• Blossom Natural Health and Wellness accepts checks, cash or credit cards for office visits and pharmacy purchases. Checks should be made payable to “Blossom Natural Health and Wellness”. For all returned checks, there will be a charge of $25.00.
• If you have health insurance, Blossom Natural Health and Wellness will provide courtesy insurance billing. You must provide your insurance information at the beginning of your scheduled visit. Please bring your insurance card and your completed Insurance Verification sheet (provided within this packet), to the office with you at the time of your visit.

We look forward to seeing you in our clinic. Our goal is to provide you with the utmost health care and service that exceeds your expectations.

Sincerely,
Blossom Natural Health and Wellness

For NATUROPATHIC MEDICAL SERVICES and the general services of DR. MEREDITH DISTANTE / DR. BROOKE BECK, we will bill your insurance company for payment only after your insurance coverage has been verified. Blossom Natural Health and Wellness provides an “Insurance Verification” form, which guides patients through calling their insurance company to determine their coverage. This form must be filled out completely prior to your first appointment. If you do not check your benefits, we will not bill your insurance. For all insurance patients, you remain responsible for full payment of all service fees, should your insurance company deny any claims, or parts of any claim. You will be billed and expected to pay any outstanding balance.

If you are not billing insurance then you are responsible for your balance at the time of your visit. You will receive the non-billing discount (NBD) for these visits.

If you would like us to bill your insurance, then you are responsible for your co-pay or co-insurance at the time of service. If your insurance has a deductible, we will bill towards this deductible if you wish, or you may choose to receive the non-billing discount and submit the claims yourself. Your insurance may pay only a portion of the charge for your treatment; you are responsible for any balance on your account. We will bill you for the balance once we have received payment and explanation of benefits from your insurance.

For accounts over 30 days past due, a monthly interest charge of 10% will be charged, unless a payment plan has been arranged in advance. On any accounts over 60 days past due, or over $250.00, continued services will be on a cash basis only.

If you are unable to keep an appointment, 2 business days notice is required to reschedule or cancel your appointment, so that we may make that time available to other patients who may need it. For missed appointments, or cancellation with less than 2 business days notice, you may be charged $55.00. If you cancel or miss your first appointment without providing this advanced notice, there is a $100 deposit required to reschedule your appointment. This deposit will be used towards your visit[s] / supplement purchase - however, this deposit will be forfeited if this appointment is missed or cancelled with less than 2 business days notice.

All supplements, herbs, homeopathic remedies, and other natural medicines purchased through Blossom Natural Health and Wellness are non-returnable and non-refundable. We cannot re-sell supplements that have left the office; we cannot guarantee that these items were protected from conditions that may affect their quality or integrity. Please note that most insurance companies do not reimburse for the natural medicines dispensed from our pharmacy.

If my insurance company requires a release of my medical records, I hereby give my permission by signing this form. I also authorize payment of medical benefits to the provider for services described on the claim if Blossom Natural Health and Wellness submits claims.

1. When did my coverage begin and when is it valid thru?

2. Do I need a referral from my primary care physician (PCP) for alternative services?

3. Is Dr. Meredith Distante/Dr. Brooke Beck In-Network or a Preferred Provider with my plan

4. What are my benefits for Naturopathic services?

5. What is my deductible for the year and has any or all of it been met?

Are Naturopathic services subject to this Deductible?

6. What was the name of the representative I spoke with:

7. Address for Claims submission?

Please fill this out prior to your appointment. If you have trouble getting the information you need, please feel free to call the clinic for assistance. Thanks so much!
*Please be aware that this is not a guarantee of payment, if an insurance company provides you with inaccurate information, they may not honor the benefits that were quoted.

Insured is:

Insured Relationship to Patient

This is to acknowledge that I have been informed and understand that:
1. Any treatment or advice provided to me as a patient of Blossom Natural Health and Wellness is not mutually exclusive from any other treatment or advice that I may be receiving now or in the future, from another healthcare provider.
2. I am at liberty to seek or continue medical care from a physician, surgeon, or other healthcare provider.
3. No physician, healthcare provider, or staff member of Blossom Natural Health and Wellness is recommending that I refrain from seeking or following the advice of another licensed healthcare provider.
4. Naturopathic and homeopathic therapies provided by this clinic may be different from those usually offered by another licensed healthcare provider.
5. Naturopathic and homeopathic treatments can lead to a temporary aggravation of symptoms that are considered part of a healing reaction. On rare occasions, aggravations do not disappear quickly and may indicate a problem with the medicine. Should I experience any symptoms that I associate with natural medicines prescribed, I understand I should call my healthcare practitioner.
6. I hereby authorize and consent to treatment.

In this document, “I” and “my” refer to the patient, and “N.D.” refers to the physicians of Blossom Natural Health and Wellness

I consent to the use or disclosure of my protected health information by N.D. for the purpose of analyzing, diagnosing or providing treatment to me, obtaining payment for my health care bills or to conduct health care operations of N.D. I understand that analysis, diagnosis or treatment of me by N.D. may be conditioned upon my consent as evidenced by my signature below.

I understand I have the right to request a restriction as to how my protected health information is used or disclosed to carry out treatment, payment or healthcare operations of the practice. N.D. is not required to agree to the restrictions that I may request. However, if N.D. agrees to a restriction that I request, the restriction is binding on N.D. I have the right to revoke this consent, in writing, at any time, except to the extent that N.D. has taken action in reliance on this Consent.

My "protected health information" means health information, including my demographic information, collected from me and created or received by my physician, another health care provider, a health plan, my employer or a health care clearinghouse. This protected health information relates to my past, present or future physical or mental health or condition and identifies me, or there is a reasonable basis to believe the information may identify me.

I have been provided with a copy of the Notice of Privacy Practices of N.D. and understand that I have a right that Notice's Notice of Privacy Practices prior to signing this document. The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that will occur in my treatment, payment of my bills or in the performance of health care operations of N.D. This Notice of Privacy Practices also describes my rights and duties of the N.D. with respect to my protected health information.

N.D. reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised notice of privacy practices by calling the office of N.D. and requesting a revised copy be sent in the mail or asking for one at the time of my next appointment.

This notice describes how health information about you may be used and disclosed and how you can get access to this information. It is effective April 14, 2003, and applies to all protected health information contained in your health records maintained by us. We have the following duties regarding the maintenance, use and disclosure of your health records:
(1) We are required by law to maintain the privacy of the protected health information in your records and to provide you with this Notice of our legal duties and privacy practices with respect to that information.
(2) We are required to abide by the terms of this Notice currently in effect.
(3) We reserve the right to change the terms of this Notice at any time, making the new provisions effective for all health information and records that we have and continue to maintain. All changes in this Notice will be prominently displayed and available at our office.

There are a number of situations in which we may use or disclose to other persons or entities your confidential health information. Certain uses and disclosures will require you to sign an acknowledgement that you received this Notice of Privacy Practices. These include treatment, payment, and health care operations. Any use or disclosure of your protected health information required for anything other than treatment, payment or health care operations requires you to sign an Authorization. Certain disclosures that are required by law, or under emergency circumstances, may be made without your Acknowledgement or Authorization. Under any circumstance, we will use or disclose only the minimum amount of information necessary from your medical records to accomplish the intended purpose of the disclosure.

We will attempt in good faith to obtain your signed Acknowledgement that you received this Notice to use and disclose your confidential medical information for the following purposes. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by our office once you have provided Consent.

Treatment: We will use your health information to make decisions about the provision, coordination or management of your healthcare, including analyzing or diagnosing your condition and determining the appropriate treatment for that condition. It may also be necessary to share your health information with another health care provider whom we need to consult with respect to your care. These are only examples of uses and disclosures of medical information for treatment purposes that may or may not be necessary in your case.

Payment: We may need to use or disclose information in your health record to obtain reimbursement from you, from your health-insurance carrier, or from another insurer for our services rendered to you. This may include determinations of eligibility or coverage under the appropriate health plan, pre-certification and pre-authorization of services or review of services for the purpose of reimbursement. This information may also be used for billing, claims management and collection purposes, and related healthcare data processing through our system.

Operations: Your health records may be used in our business planning and development operations, including improvements in our methods of operation, and general administrative functions. We may also use the information in our overall compliance planning, healthcare review activities, and arranging for legal and auditing functions.

There are certain circumstances under which we may use or disclose your health information without first obtaining your Acknowledgement or Authorization. Those circumstances generally involve public health and oversight activities, law-enforcement activities, judicial and administrative proceedings, and in the event of death. Specifically, we may be required to report to certain agencies information concerning certain communicable diseases, sexually transmitted diseases or HIV/AIDS status. We may also be required to report instances of suspected or documented abuse, neglect or domestic violence. We are required to report to appropriate agencies and law-enforcement officials information that you or another person is in immediate threat of danger to health or safety as a result of violent activity. We must also provide health information when ordered by a court of law to do so. We may contact you from time to time to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

Others Involved in Your Healthcare: Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your protected health information that directly relates to that person’s involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose protected health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition or death. Finally, we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your healthcare.

Communication Barriers and Emergencies: We may use and disclose your protected health information if we attempt to obtain consent from you but are unable to do so because of substantial communication barriers and we determine, using professional judgment, that you intend to consent to use or disclosure under the circumstances. We may use or disclose your protected health information in an emergency treatment situation. If this happens, we will try to obtain your consent as soon as reasonably practicable after the delivery of treatment. If we are required by law or as a matter of necessity to treat you, and we have attempted to obtain your consent but have been unable to obtain your consent, we may still use or disclose your protected health information to treat you.

Except as indicated above, your health information will not be used or disclosed to any other person or entity without your specific Authorization, which may be revoked at any time. In particular, except to the extent disclosure has been made to governmental entities required by law to maintain the confidentiality of the information, information will not be further disclosed to any other person or entity with respect to information concerning mental-health treatment, drug and alcohol abuse, HIV/AIDS or sexually transmitted diseases that may be contained in your health records. We likewise will not disclose your health-record information to an employer for purposes of making employment decisions, to a liability insurer or attorney as a result of injuries sustained in an automobile accident, or to educational authorities, without you written authorization.

You have certain rights regarding your health record information, as follows:
(1) You may request that we restrict the uses and disclosures of your health record information for treatment, payment and operations, or restrictions involving your care or payment related to that care. We are not required to agree to the restriction; however, if we agree, we will comply with it, except with regard to emergencies, disclosure of the information to you, or if we are otherwise required by law to make a full disclosure without restriction.
(2) You have a right to request receipt of confidential communications of your medical information by an alternative means or at an alternative location. If you require such an accommodation, you may be charged a fee for the accommodation and will be required to specify the alternative address or method of contact and how payment will be handled.
(3) You have the right to inspect, copy and request amendments to you health records. Access to your health records will not include psychotherapy notes contained in them, or information compiled in anticipation of or for use in a civil, criminal or administrative action or proceeding to which your access is restricted by law. We will charge a reasonable fee for providing a copy of your health records, or a summary of those records, at your request, which includes the cost of copying, postage, and preparation or an explanation or summary of the information.
(4) All requests for inspection, copying and/or amending information in your health records, and all requests related to your rights under this Notice, must be made in writing and addressed to the Privacy Officer at our address. We will respond to your request in a timely fashion.
(5) You have a limited right to receive an accounting of all disclosures we make to other persons or entities of your health information except for disclosures required for treatment, payment and healthcare operations, disclosures that require an Authorization, disclosure incidental to another permissible use or disclosure, and otherwise as allowed by law. We will not charge you for the first accounting in any twelve-month period; however, we will charge you a reasonable fee for each subsequent request for an accounting within the same twelve-month period.
(6) If this notice was initially provided to you electronically, you have the right to obtain a paper copy of this notice and to take one home with you if you wish.

You may file a written complaint to us or to the Secretary of Health and Human Services if you believe that your privacy rights with respect to confidential information in your health records have been violated. All complaints must be in writing and must be addressed to the Privacy Officer (in the case of complaints to us) or to the person designated by the U.S. Department of Health and Human Services if we cannot resolve your concerns. You will not be retaliated against for filing such a complaint.

All questions concerning this Notice or requests made pursuant to it should be addressed to:
MEREDITH DISTANTE, PRIVACY OFFICER

Gender:

What are your primary health concerns? [List in order of importance]

Are you seeking primary care from Blossom Natural Health and Wellness?:

Blossom Natural Health will call patients at times, and we wish to ensure your privacy regarding treatment at our clinic. In the event that we are unable to reach you by phone, please indicate where it is appropriate to leave messages for you:

Has your child had any of the following tests?

Electroencephalogram:

Psychological evaluation:

Hearing

Speech/Language:

Birth History

Term

Did your child have any of the following problems shortly after birth?

Vaccinations

Any Adverse Reactions?

Family History

Is your child hypersensitive or allergic to:

Please list any prescription medications, over the counter medications, vitamins or other supplements your child is taking.

Diet

Review of Systems