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Welcome to the WHM patient portal! We are excited to hear from you. Effective immediately (7/24/24) - Because we are a small practice and hold appointments specifically for those who schedule, all no-shows and/or late cancellations will be charged FULL PRICE of their missed appointments that will NOT be applied to future appointments. Thank you!

Note: Any messages that are longer than a few sentences will warrant scheduling a visit with your practitioner.

Rx's, lab orders and referrals, etc outside of a visit are $30 per deliverable. It can take up to 72 hours for a response through the portal. Please review and update any personal details, insurance and pharmacy information and please add a form of payment for services. Join our Facebook group --> https://www.facebook.com/groups/1529453317518972/

Many thanks in advance,

WHM Admin

Register with West Holistic Medicine

Welcome to the West Holistic Medicine registration page. To register as a new patient, please enter your information in the fields below.Please do not use this form if you are already a patient. To set up patient portal access or amend your information, please contact us.

If you are already a registered patient with online access, you can log in here

Basic Contact Information

First Name * Middle Name (or initial) Last Name *

Date of Birth *

Social Security Number Nickname/Preferred Name Gender * Pronouns Race Ethnicity

Your Address

Address 1 * Address 2 City * State * Zip Code * Timezone

Contact Information

Mobile Phone Number Home Phone Number Work Phone Number Preferred Contact Number Email Address (Primary) * Secondary Email Address Home Fax Number

Contact Preferences

Non-medical automated notifications (such as informational or educational emails, news about the practice, promotions, or marketing emails) Email: SMS/Text:

Emergency Contact

First Name * Middle Name Last Name * Relationship to Patient Email Address Phone Number *

Insurance Information

Note: Our practice does not bill insurance, but this information makes it easier for us to refer you for other services (like labs or specialists). We will, upon request, provide you with forms to submit to insurance on your own behalf.

Plan Name Group Number Member ID Insurance Type

Medical Information

Please enter your basic medical information below. You may also add or edit this information after you've signed up.

Height (in INCHES) Weight (in POUNDS) What services you are seeking? Ex's - Integrative Medicine, Primary Care, Acupuncture, Craniosacral therapy or other.

Set Username and Password for Patient Portal

Please create a username and password that you will use to log into the Patient portal in the future.

Your username must be at least 4 characters long

Username *

Your password must be at least 8 characters long and include at least one number or special character.

Password * Confirm Password *

The patient portal gives you access to your medical records and lets you securely communicate with your doctors. When you sign up, you will receive an email with instructions for logging in.

"I consent to having medical information sent to my email address (we cannot guarantee the security of messages delivered by email)." "I have read and accept the terms of the privacy policy below:" *

The Notice explains how we fulfill our commitment to respect the privacy and confidentiality of your protected health information. This Notice tells you about the ways we may use and share your protected health information, as well as the legal obligations we have regarding your protected health information. The Notice also tells you about your rights under federal and state laws. The Notice applies to all records held by West Holistic Medicine's facilities and programs, regardless of whether the record is written, computerized or in any other form. We are required by law to make sure that information that identifies you is kept private and to make this Notice available to you.

Your Rights

When it comes to your health information, you have certain rights.

This section explains your rights and some of our responsibilities to help you.

Get a copy of your paper or electronic medical record
- You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.
- We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
Correct your paper or electronic medical record
- You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
- We may say "no" to your request, but we'll tell you why in writing within 60 days.
Request confidential communication
- You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
- We will say "yes" to all reasonable requests.
Ask us to limit the information we share
- You can ask us not to use or share certain health information for treatment, payment, or our operations.
  - We are not required to agree to your request, and we may say "no" if it would affect your care.
- If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer.
  - We will say "yes" unless a law requires us to share that information.
Get a list of those with whom we've shared your information
- You can ask for a list (accounting) of the times we've shared your health information for six years prior to the date you ask, who we shared it with, and why.
- We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We'll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
Get a copy of this privacy notice

You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
Choose someone to act for you
- If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
- We will make sure the person has this authority and can act for you before we take any action.
File a complaint if you believe your privacy rights have been violated
- You can complain if you feel we have violated your rights by contacting us using the information in this notice.
- You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to
  
  200 Independence Avenue, S.W.
  Washington, D.C. 20201
  by calling 1-877-696-6775, or visiting HHS.GOV Complaints .
- We will not retaliate against you for filing a complaint.

Your Choices

For certain health information, you can tell us your choices about what we share.

If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us what to share
- Share information with your family, close friends, or others involved in your care
- Share information in a disaster relief situation
- Include your information in a hospital directory
If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
In these cases we never share your information unless you give us written permission
- Marketing purposes
- Sale of your information
- Most sharing of psychotherapy notes
In the case of fundraising
- We may contact you for fundraising efforts, but you can tell us not to contact you again.

Our Uses and Disclosures

How do we typically use or share your health information?

We typically use or share your health information in the following ways.

Treat you
- We can use your health information and share it with other professionals who are treating you.
Example: A doctor treating you for an injury asks another doctor about your overall health condition.
Run our organization
- We can use and share your health information to run our practice, improve your care, and contact you when necessary.
Example: We use health information about you to manage your treatment and services.
Bill for your services
- We can use and share your health information to bill and get payment from health plans or other entities.
Example: We give information about you to your health insurance plan so it will pay for your services.

How else can we use or share your health information?

We are allowed or required to share your information in other ways - usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: HHS.GOV consumer home .

Help with public health and safety issues
- We can share health information about you for certain situations such as:
  - Preventing disease
  - Helping with product recalls
  - Reporting adverse reactions to medications
  - Reporting suspected abuse, neglect, or domestic violence
  - Preventing or reducing a serious threat to anyone's health or safety
Do research
- We can use or share your information for health research
Comply with the law
- We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we're complying with federal privacy law
Respond to organ and tissue donation requests
- We can share health information about you with organ procurement organizations.
Work with a medical examiner or funeral director
- We can share health information with a coroner, medical examiner, or funeral director when an individual dies.
Address workers' compensation, law enforcement, and other government requests
- We can use or share health information about you:
  - For workers' compensation claims
  - For law enforcement purposes or with a law enforcement official
  - With health oversight agencies for activities authorized by law
  - For special government functions such as military, national security, and presidential protective services
Respond to lawsuits and legal actions
- We can share health information about you in response to a court or administrative order, or in response to a subpoena

Electronic Access

We provide electronic access to your health information via the Cerbo Patient Portal.

Our Responsibilities

We are required by law to maintain the privacy and security of your protected health information.
We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
We must follow the duties and privacy practices described in this notice and give you a copy of it.
We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

For more information see: HHS.GOV consumer notice .

Changes to the Terms of this Notice
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.

This notice is effective as of 11/21/2024.

I have read and agree to the Practice Policies below:

Practice Policies

About Our Practice: We are a collaborative of licensed and/or certified professional practitioners who practice within their scope and use evidenced-based approaches as well as health coaching, advocacy and support using various integrative, healing traditions. While we may offer many services that are similar to those provided by a primary care physician, we do not fulfill an insurance company’s requirement that you select a primary care physician in your network, as we do not participate with any insurance carriers.

Payment for Services Rendered: Payment is due at the time of service and may be paid in cash, by check or with a medical savings account card, flexible spending account card, health savings accounts card & all major credit cards. Payments may also be made securely on-line through our patient portal before the visit. West Holistic Medicine, PLLC is not a Medicare/Medicaid provider. West Holistic Medicine will not submit a medical claim to insurance on your behalf. We cannot assist you with claim resolution for our services. We will provide you with a detailed billing summary that you may submit to your insurance for reimbursement. You are ultimately responsible for payment for all services received in this office regardless of insurance coverage. We do ask that you provide front desk team members with your insurance card & valid ID at the time of your appointment as medical expenses such as lab tests and prescription medications may be covered by your health insurance plan per the plan’s rules. Reimbursement of those costs would be dependent on your plan.

Reminders: As a courtesy, we call, text or e-mail according to patient preference to confirm your appointment prior to the scheduled time; ultimately it is your responsibility to keep the scheduled appointment or reschedule. While generally we need to see patients via appointments, we can sometimes accommodate walk-in visits.

Cancellation: If you find that you need to cancel an appointment, it is important that we receive at least 24-hour notice. This enables us to fill the time slot. We reserve the right to 50% of the charge for an appointment canceled with less than a 24-hour notice or for missed appointments. Should we need to close our doors due to inclement weather or other severe circumstances, we will post the closing or schedule change on www.westholisticmemedicine.com and our voice message.

About Dietary Supplements or Nutraceuticals: Dietary supplements were defined in a law passed by Congress in 1994 called the Dietary Supplement Health and Education Act (DSHEA).
According to DSHEA, a dietary supplement is a product that is intended to supplement the diet; contains one or more dietary ingredients (including vitamins, minerals, herbs or other botanicals, amino acids, and certain other substances) or their constituents; is intended to be taken by mouth, in forms such as tablet, capsule, powder, softgel, gelcap, or liquid; is labeled as being a dietary supplement.

Research has confirmed health benefits of some dietary supplements but not others. Herbal supplements are one type of dietary supplement. An herb is a plant or plant part (such as leaves, flowers, or seeds) that is used for its flavor, scent, and/or potential health-related properties. “Botanical” is often used as a synonym for “herb.” An herbal supplement may contain a single herb or mixtures of herbs. The law requires that all of the herbs be listed on the product label.

Some dietary supplements may interact with medications or pose risks if you have medical problems or are going to have surgery. Most dietary supplements have not been tested in pregnant women, nursing mothers, or children. The U.S. Food and Drug Administration (FDA) regulates dietary supplements, but the regulations for dietary supplements are different and less strict than those for prescription drugs. Inform your provider about all healing modalities you use including all medications, supplements and botanicals.

West Holistic Medicine, PLLC may recommend supplements to you as a part of your wellness plan. In order to facilitate access to hand-picked quality manufacturers and personalized products, we use an on-line dispensary service called Healthwave.

Patients have the option to buy supplements or other recommended products through our on-line dispensary. Through our on-line dispensary, patients receive a 30% discount off of retail price. There no obligation on the part of patients of West Holistic Medicine, PLLC to purchase supplements through our on-line dispensary. The the quality of care you receive at West Holistic Medicine, PLLC will not be affected by the decision to purchase supplements, or not, through our on-line dispensary. We do not receive any percentage of sales or financial or marketing gain through this arrangement. While this is a service we provide to facilitate access to quality, vetted products that can serve to support your health at your convenience, we are not responsible for any contamination, substitution or problem with a supplement due to manufacturing or shipping. We would be happy to direct you to other vendors/sources that is your preference.

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Register with West Holistic Medicine

Basic Contact Information

Your Address

Contact Information

Contact Preferences

Emergency Contact

Insurance Information

Medical Information

Set Username and Password for Patient Portal

Get a copy of your paper or electronic medical record

Correct your paper or electronic medical record

Request confidential communication

Ask us to limit the information we share

Get a list of those with whom we've shared your information

Get a copy of this privacy notice

Choose someone to act for you

File a complaint if you believe your privacy rights have been violated

In these cases, you have both the right and choice to tell us what to share

In these cases we never share your information unless you give us written permission

In the case of fundraising

Treat you

Run our organization

Bill for your services

Help with public health and safety issues

Do research

Comply with the law

Respond to organ and tissue donation requests

Work with a medical examiner or funeral director

Address workers' compensation, law enforcement, and other government requests

Respond to lawsuits and legal actions

Electronic Access

Practice Policies