Terms of Service
By signing to TOS on the intake form, telehealth, or group telehealth, you have agreed to the following terms of service as arranged in 8 sections:
NOTICE OF HIPAA 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.
Uses and Disclosures
The following categories describe the different ways in which we may use and disclose your individually identifiable health information, unless you object:
Treatment. Your health information may be used by staff members or disclosed to other health care professionals for the purpose of evaluating your health, diagnosing medical conditions, and providing treatment. For example, results of laboratory tests and procedures will be available in your medical record to all health professionals who may provide treatment or who may be consulted by staff members. Additionally, we may disclose your health information to others who may assist in your care, such as other healthcare providers, your spouse, your children or parent.
Payment. Your health information may be used in order to bill and collect payment for the services and items you may receive from us. For example, we may use and disclose your health information to obtain payment from third parties that may be responsible for such costs, such as family members. Also we may use your health information to bill you directly for services and items.
Health Care Operations. Your health information may be used as necessary to support the day to day activities and management of Coze Health, LLC. For example, information on the services you received may be used to support budgeting and financial reporting, activities to evaluate and promote quality, to develop protocols and clinical guidelines, to develop training programs, and to aid in credentialing medical review, legal services, and insurance.
Appointment Reminders. Your health information will be used by our staff to contact you and send you appointment reminders.
Information About Treatments. Your health information may be used to send you information that you may find interesting on the treatment and management of your medical condition. We may also send you information describing other health related products and services that we believe may interest you.
Law Enforcement. Your health information may be disclosed to law enforcement agencies to support government audits and inspections, to facilitate law enforcement investigations, and to comply with government mandated reporting.
Release of Information to Family/Friends. Our practice may release your health information to a friend or family member that is involved in your care, or who assists in taking care of you. For example, a parent or guardian may ask that a babysitter take their child for an appointment. In this example, the babysitter or friend may have access to this child’s medical information.
Patient Mass Communication. We may use your name and email address(es) and/or text numbers to contact you with bulk messaging. For instance, to share new promotions for the clinic, to send clinic newsletters, or to notify you of a physician’s upcoming absence, such as for vacations.
Other uses and disclosures in certain special circumstances.
• Public Health Risks - (i.e. vital statistics, child abuse/neglect, exposure to communicable diseases, reporting reactions to drugs or problems with products or devices.)
• Health Oversight Activities
• Lawsuits and Similar Proceedings – May use or disclose in response to a court or administrative order, if you are involved in a lawsuit or similar proceeding or in response to a discovery request, subpoena, or other lawful process.
• Deceased Patients – may be required to release to a medical examiner or coroner. If necessary, we may also release information in order for funeral director to perform their jobs.
• Organ and Tissue Donation
• Serious Threats to Health or Safety
• Military - If you are a member of the U.S. or foreign military forces (including veterans) and if required by the appropriate authorities.
• National Security
• Inmates – Our practice may disclose your health information to correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official.
Disclosure would be necessary for the institution to provide health care services to you, for the safety and security of the institution, and/or to protect your health and safety or the health and safety of others.
• Worker’s Compensation
Disclosures of your health information or its use for any purpose other than those listed above requires your specific written authorization. If you change your mind after authorizing a use or disclosure of your information, you may submit a written revocation of the authorization. However, your decision to revoke the authorization will not affect or undo any use or disclosure of information that occurred before your notified us of your decision to revoke your authorization.
You have certain rights under the federal privacy standards. These include:
● The right to request restrictions on the use and disclosure of your protected health information for treatment, payment, or health care operations. You have the right to restrict our disclosure to only certain individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to your request; however, if we do not agree, we are bound by our agreement except when otherwise required by law, in emergencies or when the information is necessary to treat you. You must make your request in writing to the attention of the Privacy Officer. Your request must be described in a clear and concise fashion: a) the information you wish restricted; b) whether you are requesting to limit our practice’s use, disclosure or both; c) to whom you want the limits to apply.
● The right to receive confidential communications concerning your medical condition and treatment
● The right to inspect and copy your protected health information. We will provide a copy or summary of your health information, usually within 30 days of your request. We may charge a reasonable, costbased fee. Our practice may deny your request to inspect and/or copy in certain limited circumstances; however, you may request a review of the denial.
● The right to amend or submit corrections to your protected health information. This request must be made in writing and submitted to Privacy Officer with reasons to support your request. We may deny your request if you ask us to amend information that is in our opinion: a) accurate and complete; b) not part of the health information kept by or for the practice; c) not part of the health information which you are permitted to inspect and copy; or d) not created by our practice, unless the individual or entity that created is not available to amend the information. We will provide a written explanation for any denial in 60 days.
● The right to receive an accounting of how and to whom your protected health information has been disclosed. We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any that you asked us to make). We will provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
● The right to receive a printed copy of this notice, even if you have agreed to receive the notice electronically.
Requests to Inspect Protected Health Information
You may generally inspect or copy the protected health information that we maintain. As permitted by federal regulation, we require that requests to inspect or copy protected health information be submitted in writing. You may obtain a form to request access to your records by contacting your physician and/or privacy officer. Your request will be reviewed and will generally be approved unless there are legal or medical reasons to deny the request.
Coze Health Medical LLC Family Practice’s Duties
We are required by law to maintain the privacy of your protected health information and to provide you with this notice of privacy practices. We also are required to abide by the privacy policies and practices that are outlined in this notice.
Right to Revise Privacy Practices
As permitted by law, we reserve the right to amend or modify our privacy policies and practices. These changes in our policies and practices may be required by changes in federal and state laws and regulations. Upon request, we will provide you with the most recently revised notice on any office visit. The revised policies and practices will be applied to all protected health information we maintain.
If you would like to submit a comment or complaint about our privacy practices, you can do so by sending a letter outlining your concerns to:
COZE Health Medical LLC
Attn: Privacy Officer
156 Sagamore Pkwy W Ste A
West Lafayette, IN 47906
If you believe that your privacy rights have been violated, you should call the matter to our attention by sending a letter describing the cause of your concern to the same address. You will not be penalized or otherwise retaliated against for filing a complaint.
NOTICE OF INFORMED CONSENT
Practices and Consent to Use and Disclose Health Information
I consent to all necessary steps taken for examination, diagnosis and treatment. If at any time I have questions about my examination, diagnosis or treatment, I will not proceed until my questions have been answered so that I am fully informed. I understand that giving the providers all relevant information i important for my proper diagnosis and treatment. I understand complete compliance with my provider’s instructions is critical to the success of any treatment prescribed.
I acknowledge that I was provided with a copy (digital, URL, or paper version) of the COZE Health Medical LLC Notice of HIPAA Privacy Practice
Practices regarding uses and disclosure of information regarding me and my health (“Health Information”).
I hereby consent to the use and disclosure of my health information, for the purposes and activities permitted under the federal privacy and state privacy laws, which are described in the COZE Health Notice of Privacy Practices.
I specifically authorize the release, to the fullest extent permitted by law, for treatment, payment or operations purposes as described in the Notice of Privacy Practices, of information regarding the results of any HIV/AIDS testing or treatment, mental health treatment and substance abuse treatment.
I authorize COZE Health Medical LLC to release information to my health plan or to a health and wellness provider approved by my health plan for purposes of advising me concerning appropriate measures to maintain or improve my health or any condition reflected in my records.
I authorize COZE Health Medical LLC to release information to my designated insurance plan for the purpose of health plan administration, including receiving or making payment for services rendered on my behalf. I understand a patient is responsible for all charges incurred, subject to contract and program rules, regardless of my insurance states. If it becomes necessary to send this account to collections, the patient will be responsible for all additional charges.
I authorize COZE Health Medical LLC to communicate via e-mail and text messaging regarding appointment reminders and other reminders or notifications regarding available documents or messages on the patient portal.
Informed Consent Delegating Physician/Provider and Delegatee Performing Medical Services
The delegating physician/provider is delegating the following services and is accountable for the performance of these services by the delegate. Counseling and patient education related to therapeutic lifestyle changes including:
1. Perform initial and serial follow up Vitals and/or anthropometry,
2. Perform initial and serial follow up bioimpedence measurements,
3. Assessment/review of a lifestyle-associated health history,
4. Review and serial follow up of a symptom based health assessment,
5. Provide patient education regarding Physician’s instructions, lab values, etc.,
6. Diet/Menu plan counseling and monitoring,
7. Exercise/activity plan counseling and monitoring,
8. Therapeutic nutritional protocol implementation and monitoring,
9. Stress management counseling and monitoring,
10. Sleep/recuperation/restoration counseling and monitoring, and
11. Keeping detailed medical chart records of all counseling/services performed.
These delegated medical services are specific and detailed per physician/provider approved, evidence based protocols. I understand my COZE Health Medical LLC physician/provider is delegating therapeutic lifestyle changes to a lifestyle educator and agree to receive services from the delegatee.
An Explanation of Our Financial Policy
As doctors and staff, we are passionate about what we do, and we feel that we have a calling to provide as many people as possible with the highest quality natural health care possible. Just as our services are unique to this region, our financial policies set us apart from mainstream medicine. We have prepared this handout to answer questions you or your family members may have about the rationale for our financial policies. If, after reading this, you still have questions, feel free to speak with our staff.
Why We Sell Nutritional Supplements and How We Price Them
We recommend nutritional supplements as an adjunct to dietary and lifestyle modification. This approach is central to the well-researched and science-based practice of functional medicine, which all of our professional staff have studied. We sell therapeutic, quality nutritional supplements as a service to our patients. With a few exceptions, we do not sell nutritional products of similar quality to those that are widely available over the counter. We purchase high-quality nutritional products from the top nutritional research laboratories in North America and Great Britain, and we price them to cover our costs of providing them. However, we keep our markups as low as possible, and we intentionally do not profit from the sale of nutritional products. Many other clinics have commended our pricing policy as ethical and fair.
Selling Nutritional and Herbal Supplements
According to the Federal Food, Drug, and Cosmetic Act, as amended, Section 201(g)(1), the term drug is defined as an “article intended for use in the diagnosis, cure, mitigation, treatment, or prevention of disease.” Technically, vitamins, minerals, trace elements, amino acids, herbs, or homeopathic remedies are not classified as drugs. However, these substances can have significant effects on physiology and must be used rationally. In this office, we provide nutritional counseling and make individualized recommendations regarding use of these substances in order to upgrade the quality of foods in a patient’s diet and to supply nutrition to support the physiological and bio-mechanical processes of the human body. Although these products may also be suggested with a specific therapeutic purpose in mind, their use is chiefly designed to support given aspects of metabolic function. Use of nutritional supplements may be safely recommended for patients already using pharmaceutical medications (drugs), but some potentially harmful interactions may occur. For this reason, it is important to keep all of your healthcare providers fully informed about all medications and nutritional supplements, herbs, or hormones you may be taking.
Sale of Nutritional Supplements through COZE Health Medical LLC
You are under no obligation to purchase nutritional supplements from our online services. As a service to you, we make nutritional supplements available through our website. We purchase these products only from manufacturers who have gained our confidence through considerable research and experience. We determine quality by considering: (1) the quality of science behind the product; (2) the quality of the ingredients themselves; (3) the quality of the manufacturing process; and (4) the synergism among product components. The brands of supplements that we carry in our facility are those that meet our high standards and tend to produce predictable results. While these supplements may come at a higher financial cost than those found on the shelves of pharmacies or health food stores, the value must also include assurance of their purity, quality, bioavailability (ability to be properly absorbed and utilized by the body), and effectiveness. The chief reason we make these products available is to ensure quality. You are not guaranteed the same level of quality when you purchase your supplements from the general marketplace. We are not suggesting that such products have no value; however, given the lack of stringent testing requirements for dietary supplements, product quality varies widely. If you have concerns about this issue, please discuss them with our staff.
Laboratory Testing Informed Consent
The purpose of optional diagnostic laboratory testing ordered by COZE Health Medical LLC is to evaluate nutritional, biochemical, or physiological imbalance and to determine any need for medical referral. These lab tests in our office identify nutritional imbalances and toxicities underlying chronic diseases, advanced hormone testing, functional medicine multi-tissue antibody testing for the early detection and monitoring of today's complex autoimmune conditions, or preventive and/or diagnostic tests to monitor health (ie., lipid panel, metabolic panel, etc.). This office utilizes conventional lab tests as well as genetic, chemical and functional medicine assessment. These tests are designed to assist our doctors and other healthcare providers in finding the underlying causes of your condition. Functional medicine has evolved through the efforts of scientists and clinicians from the fields of clinical nutrition, molecular biology, biochemistry, physiology, conventional medicine, and a wide array of scientific disciplines. We do provide an in-house site for your convenience and is subject to a sitting charge. Your medical physician may or may not agree with the necessity for—or our interpretation of—these tests. If you have any questions or concerns, please discuss them with our doctors.
Coze Health Medical LLC complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex.
To our patients: You have the right to request that Coze Health Medical LLC communicate with you by alternative means or at alternate locations. This form instructs Coze Health Medical LLC on your approved communication method and who is involved in your care. By signing this form, you are indicating that your doctor and other staff (nurses, office assistants, etc.) may share limited information with the people named on the form. Limited information will primarily be verbal information but may also include some written or printed information (e.g. care instructions). This form does not grant people names on it the right to obtain access to, or copies of, your health records. If your family member or friend wishes to obtain all or part of your health records, you must authorize their release through our Health Information Management (Medical Records) department.
I give consent for Coze Health Medical LLC to contact me via phone calls, text messages, automated messages, and voice mails regarding my healthcare per selected options on this form. I give consent to contact next of kin in the case of emergency. I give consent to contact those individuals listed for receiving shared health information in my care as documented in the electronic health record recorded at intake appointment or further provided either verbally or in writing to a Coze Health Medical LLC staff member.
Note: This form and designated list will not expire. We will act upon the information you provide on this form unless you inform us that it has changed.
CHRONIC CARE MANAGEMENT
By signing this Agreement, you consent to Coze Health Medical LLC (referred to as “Provider”), providing chronic care management services (referred to as “CCM Services”) to you as more fully described below. CCM Services are available to you because you have been diagnosed with one (1) or two (2) or more chronic conditions which are expected to last at least twelve (12) months and which place you at significant risk of further decline. CCM Services include 24-hours-a-day, 7-days-a-week access to a health care provider in Provider’s practice to address acute chronic care needs; systematic assessment of your health care needs; processes to assure that you timely receive preventative care services; medication reviews and oversight; a plan of care covering your health issues; and management of care transitions among health care providers and settings. The Provider will discuss with you the specific services that will be available to you and how to access those services. You consent to the Provider providing CCM Services to you. You authorize electronic communication of your medical information with other treating providers as part of coordination of your care. You acknowledge that only one practitioner can furnish CCM Services to you during a calendar month. You understand that cost-sharing will apply to CCM Services, so you may be billed for a portion of CCM Services even though CCM Services will not involve a face-to-face meeting with the Provider. All Medicare and lifestyle medicine patients are expected to maintain a chronic care management agreement with the practice.
You have the following rights with respect to CCM Services:
The Provider will provide you with a written or electronic copy of your care plan. You have the right to stop CCM Services at any time by revoking this Agreement effective at the end of the then current month. You may revoke this agreement verbally (by calling 765-204-1122) or in writing to (156 Sagamore Pkwy W, Ste A, West Lafayette, IN 47906).
GROUP CLASS INFORMED CONSENT [c. 2018 American College of Lifestyle Medicine)
Group Medical Visit Consent and Authorization Form
Group medical visits are medical appointments conducted in a group setting in which the physician and each patient discuss the patient’s personal medical condition and treatment in the presence of the group. Because each patient will be disclosing personal health and other personal information to the group, participation in group medical visits and the release of personal health information within the group is strictly voluntary and is not required in order to receive treatment from Coze Health Medical LLC.
Consent, Authorization to Disclose and Confidentiality Agreement
By signing this Agreement, I consent to participate in group medical visits, in the clinic or virtually, at Coze Health Medical LLC. I authorize Coze Health Medical LLC physicians/allied health professionals conducting the group medical visit in which I participate to disclose my personal health information and other private information (“Private Information”) in the presence of all participants attending the group medical visit. I also agree to respect the privacy of all participants, including their family members, who attend the group medical visit by keeping their Private Information confidential and not disclosing such information I acknowledge the possibility that my Private Information may be disclosed by other participants in group medical visits contrary to their Confidentiality Agreement, and I voluntarily assume all of the risks associated with such disclosure. I understand that I may revoke this authorization at any time by delivery of a dated and signed letter to Coze Health Medical LLC. I understand that such revocation will not prohibit Coze Health Medical LLC from making any disclosures already made or taking any actions already taken in reliance on this authorization prior to the receipt of such revocation.
Further, I understand that such revocation will preclude my participation in additional Coze Health Medical LLC group medical visits, but will not prevent me from receiving other types of treatment from Coze Health Medical LLC. If not earlier revoked, this authorization will expire at the conclusion of my treatment through Coze Health Medical LLC group medical visits.
THE INFORMATION AUTHORIZED FOR RELEASE MAY INCLUDE INFORMATION INDICATING THE PRESENCE OF CONDITIONS INCLUDING, BUT NOT LIMITED TO, DIABETES, HIGH BLOOD PRESSURE, HIGH CHOLESTEROL, HEART DISEASE, DEPRESSION, ANXIETY, CONSTIPATION, GASTROESOPHAGEAL REFLUX DISEASE, OTHER GI CONDITIONS, KIDNEY DISEASE, OBSTRUCTIVE SLEEP APNEA, GOUT, CANCER AND ARTHRITIS.
TELEHEALTH INFORMED CONSENT NOTICE
A telehealth appointment consists of a synchronous audio and video medical appointment. Telehealth appointments are subject to co-pays, co-insurance, and deductibles as allowed by federal and local law and subject to insurance regulations. Patients who receive services in a telehealth appointment must be located in a state in which the physician is licensed, and must confirm at the time of appointment the state in which they are located during the appointment.
1. I hereby authorize Coze Health Medical LLC to use the telehealth practice platform for telecommunication for evaluating, testing and diagnosing my medical condition.
2. I understand that technical difficulties may occur before or during the telehealth sessions and my appointment cannot be started or ended as intended.
3. I accept that the professionals can contact interactive sessions with video call; however, I am informed that the sessions can be conducted via regular voice communication if the technical requirements such as internet speed cannot be met.
4. I understand that my current insurance may not cover the additional fees of the telehealth practices and I may be responsible for any fee that my insurance company does not cover.
5. I agree that my medical records on telehealth can be kept for further evaluation, analysis and documentation, and in all of these, my information will be kept private.
REMOTE PATIENT MONITORING PROGRAM
Remote patient Monitoring consists of a second portal the patient and provider have access to track medical concerns like: nutrition, weight, and blood pressure. Only patients who require remote patient monitoring will receive a remote patient monitoring prescription by their physician. Patients will managed by a third-party Remote Patient Monitoring partner who will contact the patient to review the prescription, insurance requests, and onboard the patient into the program. Alerts will be sent directly to the physician. Remote Patient Monitoring is subject to co-pays, co-insurance, and deductibles as allowed by federal and local law and subject to insurance regulations. Patients who receive services through remote patient monitoring must be located in a state in which the physician is licensed, and must confirm at the time of appointment the state in which they are located during the appointment.
INTEGRATED BEHAVIORAL HEALTH
Integrated Behavioral Health consists of a primary care provider by monitoring behavioral health through general behavioral health screenings and coordination of medical care with behavioral counselors/psychotherapists or other behavioral health caregivers. A patient will benefit from this program if the physician prescribes this program. The program requires consent for participation and this form is acknowledgement for consent to participate in this program. Integrated Behavioral Health is subject to co-pays, co-insurance, and deductibles as allowed by federal and local law and subject to insurance regulations.
effective 3/1/2020. updated 11/27/2020