The Ellenburg Center For Natural Medicine, Inc.
Anchorage, Alaska 99508

I understand the following:
This clinic is not a Medicare/Medicaid Provider
Dr. Michael Ellenburg does not accept insurance. Full payment is due at time of service.

SYMPTOM

Dr. Ellenburg Center For Natural Medicine, Inc.
3500 Latouche St. Suite 360
Anchorage, Alaska 99508

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FAMILY HISTORY

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The Ellenburg Center For Natural Medicine, Inc.
Anchorage, Alaska 99508

RECEIPT OF NOTICE OF PRIVACY POLICIES & CONSENT FORM

Dr. EUenburg Center for Natural Medicine, Inc. 3500 Latouche St Suite 360. Anchorage, Alaska 99508

1n the course ofproviding service to you, we create. receive and store health information that identifies you. It is often necessazyto use and disclose this health information in orderto treat you, to obtain payment for our services and to conduct health care operations involving our office.

The Notice of Privacy Practices you have been given describes these uses and disclosures in detail. You are free to refer to this notice at anytime before you sign this form.· As described in our No.ice of Privacy Practices, the use and disclosure of your health. information for treatment purposes not only includes care and service provided here, but also disclosures of your health information as may be necessary or appropriate for you to receive follow-up care from another health professional. Similarly, the use and disclosure of your health information for purposes of payment includes (1) our submission of your health information to a billing agent or vendor for processing claims or obtaining payment; {2) our submission ofclaims to third-paify payers or insurers for claims review, determination ofbenefits and payment; (3) our submission of your health information to auditors hlredby third-pa.tfy payers and insurers; and (4) other aspects of payment described in our Notice of Privacy Practices.

Our Notice of Privacy Practice will be updated whenever our privacy practices change.

When you sign this consent document, you signify that you agree that we can and will use and disclose your health information to treat you, to obtain payment for our services and tQ perform healthcare operations. You also signify that yon have received a copy of our Notice of Privacy Practices. You have the right to ask us to restrict the uses or disclosures made for purposes of treatment �payment or healthcare operations� but as described on our Notice of Privacy Practices, we are not obligated to agree io these suggested restrictions. If we do agree, however, the restrictions are binding on us. Our Notice of Privacy Practices describes how to ask for a restriction. I have read this document and understand it I consent to the use and disclosure of my health 9 information for purposes of treatment, payment and healthcare operations.. . I acknowledge that I have received the Notice of Privacy Practices from The Dr. EIJenburg Center For Natural Medicine, Inc

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

OUR PLEDGE REGARDING MEDICAL INFORMATION

The privacy of your medical information is important to us. We understand that your medical information is personal and we are committed to protecting it. We create a record of the care and services you receive at our organization. We need this record to provide you with quality care and to comply with certain legal requirements. This notice will tell you about the ways we may use and share medical information about you. We also describe your rights and certain duties we have regarding the use and disclosure of medic

OUR LEGAL DUTY

Law Requires us to:

• Keep your medical information private.
• Give you this notice describing our legal duties, privacy practices, and your rights regarding your medical information
• Follow the terms of the current notice.

We have the right to:

• Change our privacy practice and the terms of this notice at any time, provide that the changes are permitted by law.
• . Make the changes in our privacy practices and the new terms of our notice effective for all medical information that we keep, including information previously created or received before the changes.

Notice of change to privacy practice:

1. Before we make an important change in our privacy practice, we will change this notice and make the new notice available upon request.

USE AND DISCLOSURE OF YOUR MEDICAL INFORMATION

The following section describes different ways that we use and disclose medical information. Not every use or disclosure will be listed. However, we have listed all the different ways we are permitted to use and disclose medical information. We will not use or disclose your medical information for any purpose not listed below, without your specific written authorization. Any specific written authorization you provide may be revoked at any time by writing to us at the address provided at the end of this notice.

FOR TREATMENT:

We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to your doctors, nurses, technicians, medial students, or other people who are taking care of you. We may also share medical information about you to your other health care providers to assist them in treating you.

FOR PAYMENT:

We may use and disclose your medical information for payment purposes. A bill may be sent to you or a third-party payer. The information on or accompanying the bill may include your medical information.

FOR HEAL TH CARE OPERATIONS:

We may use and disclose your medical information for our health care operations. This might include measuring and improving quality, evaluating the performance of employees. Conducting training programs, getting the accreditation, certificates, licenses and credentials we need to serve you.

ADDITIONAL USES AND DISCLOSURES:

In addition to using and disclosing your medical information for treatment, payment, and health care operations, we may use and disclose medical information for the following purposes.

Facility Directory:

Unless you notify us that you object, the following medical information about will be placed in our facility directories: your name; your location in our facility; your condition described in general terms; your religious affiliation, if any. We may disclose this information to members of the clergy or, except for religious affiliation, to others who contact us for information about your name.

Notification

: We may use and disclose medical information to notify or help notify: a family member, your personal representative or another person responsible for your care. We will share information about your location, general condition, or death. If you are present, we will get your permission is possible before we share, or give you the opportunity to refuse permission, In case of emergency, and if you are not able to give or refuse permission, we will share only the health information that is directly necessary for your health care, according to our professional judgment. We will also use our professional judgment to make decisions in your best interest about allowing someone to pick up medicine, medical supplies, x-rays or medical information for you

Disaster Relief:

We may share medical information with a public or private organization or persona who can legally assist in disaster relief efforts.

Fundraising

We may provide medial information to one of our affiliated fundraising foundations to contact you for fundraising purpose. We will limit our use and sharing to information that describes you in general, not personal, terms and the dates of your health care. In any fundraising materials, we will provide you a description of how you may choose not to receive future fundraising communications.

Research in Limited Circumstances:

We may use medical information for research purpose in limited circumstances where the research has been approved by a review board that has reviewed the research proposal and established protocols to ensure the privacy of medical information.

Funeral Director, Coroner, Medical Examiner

To help them carry out their duties, we may share the medical information of a person that has died with a coroner, medical examiner, funeral director, or an organ procurement organization.

Specialized Government functions

Subject to certain requirements, we may digciose or use hesith information for military personnel and veterans, for national socurtty and intligence actvites, fo protective services of the President and others, for medical suitabilty determinations for the Department of stat, for correctional Institution and othr law enforcement custodial iuations, and or government programs.

Court Orders and Judicial and Administrative Proceedings:

We may disclose medical information in response to a court or administrative order, subpoena, discovery rogues? or other lawful process, under certain circumstances. Under imited Gircumstances, such as a cour order, warrant, grand jury subpoena, we may sharg your medical information with the law enforcement officials. We may share limited information with a law forcement concoming the medical information of a suspect fugitive, materia witness, crime victim of issing person. We may share the medical information of an inmate or other person in lawful Custody witha law enforcement offical or corroctional institution under cerain circumstances.

Public Health Activities:

As required by law, we may discos your medical information to public health o legal authorites charged wh proventing or controling disease, injury or disablfy, including child abuse or neglect. We may also disclose your medical information o persons. subject fo jurisdiction of the Food and Drug Adminstration for purpose of reporting adverse events associated with product defects or problems, to ‘enable product recalls, ropairs of replacements, to track products, or to conduct activiles required by the Food and Drug Administration, We may also, When we are authorized by law 10 do 50, nofy a person who may have been exposed to 2 communicable disease of otherwise be at isk of contracting or spreading a disease or condition.

Victims of Abuse, Neglect, or Domestic Violence:

We may use and disclose medical information to appropriats authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence of the possible icin of other crimes. Wo may share your medical information fis necessary to prevent a serious that to your health or safaty of others. Wo may sharo medical information when necessary o help law enforcement officals capture a person who has adritied to being part of a rime or has escaped from legal custody.

Workers Compensation:

We may disclose medical information when authorized or necessary to comply with laws relating 0 workers compensation or other smiar programs.

Health Oversight Activities:

We may disciose medical information to an agency providing health oversight for oversight acivies authorized by Taw, including audits, ci, administrative, or criminal Investigations or proceedings, inspection, ensure or discipinary actions, or oher authorized activites.

Law Enforcement:

Undo ceain circumstances, we iscoso heath information o law enforcement ffals. These cicumsances include reporting roquired by certain laws (such 2s the reporting of certain type of wounds), pursuant to certain subpoenas or court orders, reporting limited information concoming Kenticatons and location atthe request of a law enorooment offical, reports rogarding suspected vicims of cimas at the oquest of a aw enforcomont offical, eportng death, cimes on our premises, and cimes in omargencies.

Appointment Reminders:

We may us and disclose medical information for purpose of sending you appointment postcards or otherwise reminding You of your appointments.

Alternative and Additional Medical Services:

We may use and disclose medical information o furnish you with information about heat related benefits and services that may be of interest 10 you. and to describe or recommend treatment altemnatives.

YOUR INDIVIDUAL RIGHTS

You Have a Right

• Look at o get copies of certain parts of your medical Information. You may request that we provide copies i a format other than photocopies. We will ise the format you request unloss ii io practical fo us to do so. You must make your request in wring. You may get the form to request access. by using the contact information listed a the end of this notice. you requost copies, we wil charge you § .35 cents for each page, and postage fou want the copios mailed to you. Contact us using the information fisted at the end of this noios fo a ul explanation of our fee struciur.
• Receve a ist of all he imes we our business associates shared your medical information for purposes othr than treatment, payment, and health aro operations and other specified exceptions
• Roguest that we replace additonal restrictions on ou uso or disclosure of your medical information. We are no required to agree fo these addional Testictons, but if we do, we illaide by our agreement (ex08p in the case of an emergency).
• Request that we communicate with you about your medica information by different means o to diferent locations. Your request that we ‘communicate your medical information to you by diferent means or at dferent locations must be made in wring to the contact person fisted at the ‘ond of tis notice.
• Request that we change cortain parts of your medica information. We may deny you request ff we did not create th information that you want ‘changed or for certain thar reasons. It we deny your request, provide you a writen explanatn. You may respond with statement or disagreement. that we will be added tothe information you waned changed. If we accept your request to change the information, we will make reasonable eforts to tell others, including peopl you name, of the change and to include the changes in any fture sharing of that information.
• you have received this notice electronically. and wish to receive a paper copy, you have the right to obiain a paper copy by making a request in wring tthe contact person fisted atthe end ofthis notice.

QUESTIONS AND COMPLANTS

you have any questions about this notice or if you think that we may have violated your privacy rights, please contact us. You may also subrit a writen complain to the U.S Department of health and Human Service. You may contact us to submit a complaint or submit requests involving any of Your rights In Section 4 of tis notice by writing to the folowing address. We will provide you with the address to fil your complaint with the U.S Department of Health and Human Services. We will not retaliate in any way if You choose to fie a complaint.