New Patient Intake Form

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

The following is the Notice of Privacy Practices of WeightZen. HIPAA is a federal law that requires us to maintain the privacy of your protected health information and to provide you with notice of our legal duties and privacy policies with respect to your protected health information. We are required by law to abide by the terms of this Notice of Privacy Practices.

Your Protected Health Information

Your “protected health information” (PHI) broadly includes any health information, oral, written or recorded, that is created or received by us, other healthcare providers, and health insurance companies or plans, that contains data, such as your name, address, social security number, and other information, that could be used to identify you as the individual patient who is associated with that health information.

Uses or Disclosures of Your Protected Health Information

Generally, we may not “use” or “disclose” your PHI without your permission, and must use or disclose your PHI in accordance with the terms of your permission. “Use” refers generally to activities within our office. “Disclosure” refers generally to activities involving parties outside of our office. The following are the circumstances under which we are permitted or required to use or disclose your PHI. In all cases, we are required to limit such uses or disclosures to the minimal amount of PHI that is reasonably required.

Without Your Written Authorization

Without your written authorization, we may use within our office, or disclose to those outside our office, your PHI in order to provide you with the treatment you require or request, to collect payment for our services, and to conduct other related health care operations as follows:
Treatment activities include: (a) use within our office by our professional staff for the provision, coordination, or management of your health care at our office; and (b) our contacting you to provide appointment reminders or information about treatment alternatives or other health-related services that may be of interest to you.
Payment activities include: (a) if you initially consent to treatment using the benefits of your contract with your health insurance plan, we will disclose to your health plans or plan administrators, or their appointed agents, PHI for such plans or administrators to determine coverage, for their medical necessity reviews, for their appropriateness of care reviews, for their utilization review activities, and for adjudication of health benefit claims; (b) disclosures for billing for which we may utilize the services of outside billing companies and claims processing companies with which we have Business Associate Agreements that protect the privacy of your PHI; and (c) disclosures to attorneys, courts, collection agencies and consumer reporting agencies, of information as necessary for the collection of our unpaid fees, provided that we notify you in writing prior to our making collection efforts that require disclosure of your PHI.
Health care operations include: (a) use within our office for training of our professional staff and for internal quality control and auditing functions (b) use within our office for general administrative activities such as filing, typing, etc.; and (c) disclosures to our attorney, accountant, bookkeeper and similar consultants to our healthcare operations, provided that we shall have entered into Business Associate Agreements with such consultants for the protection of your PHI.
PLEASE NOTE THAT UNLESS YOU REQUEST OTHERWISE, AND WE AGREE TO YOUR REQUEST, WE WILL USE OR DISCLOSE YOUR PERSONAL HEALTH INFORMATION FOR TREATMENT ACTIVITIES, PAYMENT ACTIVITIES, AND HEALTHCARE OPERATIONS AS SPECIFIED ABOVE, WITHOUT WRITTEN AUTHORIZATION FROM YOU.
As Required By Law we may use or disclose your PHI to the extent that such use or disclosure is required by law.
Examples of instances in which we are required to disclose your PHI include: (a) disclosures regarding reports of child abuse or neglect, including reporting to social service or child protective services agencies; (b) health oversight activities including audits, civil, administrative, or criminal investigations, inspections, licensure or disciplinary actions, or civil, administrative, or criminal proceedings or actions, or other activities necessary for appropriate oversight of government benefit programs; (c) judicial and administrative proceedings in response to an order of a court or administrative tribunal, or other lawful process; (d) to the extent necessary to protect you or others from a serious imminent risk of danger presented by you; (e) for worker’s compensation claims, and (f) as required by the Secretary of Health and Human Services to investigate or determine our compliance with federal regulations, including those regarding government programs providing public benefits.
All Other Situations, with you specific authorization except as otherwise permitted or required as described above, we may not use or disclose your PHI without your written authorization. Further, we are required to use or disclose your PHI consistent with the terms of your authorization. You may revoke your authorization to use or disclose any PHI at any time, except to the extent that we have taken action in reliance on such authorization, or, if you provided the authorization as a condition of obtaining insurance coverage, other law provides the insurer with the right to contest a claim under the policy.

Right To Inspect and Copy Your Protected Health Information, Including In Electronic Format

You have the right of access in order to inspect, and to obtain a copy of your PHI, including any PHI maintained in electronic format, except for
(a) personal notes and observations of the treating provider,
(b) information compiled in reasonable anticipation of, or for use in, a civil, criminal, or administrative action or proceeding,
(c) health information maintained by us to the extent to which the provision of access to you is at our discretion, and we exercise our professional judgment to deny you access, and
(d) health information maintained by us to the extent to which the provision of access to you would be prohibited by law.
We require written requests for copies of your PHI; they should be sent to our Privacy-Security Officer at the mailing address below. If you request a copy of your PHI, we will charge a fee for copying, or for electronic records, for labor. We reserve the right to deny you access to and copies of all or certain PHI as permitted or required by law. Upon denial of a request for access or request for information, we will provide you with a written denial specifying the basis for denial, a statement of your rights, and a description of how you may file an appeal or complaint.

Amendments to this Notice of Privacy Practices

We reserve the right to revise or amend this Notice of Privacy Practices at any time. These revisions or amendments may be made effective for all PHI we maintain even if created or received prior to the effective date of the revision or amendment. Upon your written request, we will provide you with notice of any revisions or amendments to this Notice of Privacy Practices, or changes in the law affecting this Notice of Privacy Practices, by mail or electronically within 60 days of receipt or your request.

To Contact Us
This is our contact information referred to above.
Privacy-Security Officer is Ed Sussman
Mailing address is: 200 E. 78th St., Suite 1A, New York, NY 10075.
Phone: 212.203.2146
Fax: 212.527.0345
Email: Ed@weightzen.com

Dear Patient,

Thank you for choosing our provider. We look forward to working with you. As you know, there are charges for the services we provide. For patients using their in network benefits we are pleased to bill your insurance company on your behalf as long as you are covered for the services we provide. Please make sure you provide us with the most recent insurance information and please update us with any changes as they occur. For patients using out of network benefits we will provide you with the necessary documents for you to submit to your insurance company for reimbursements soon after the service is rendered.

Patients are responsible for the payment of copay, co-insurance, deductibles and all services not covered by insurance. Since you are responsible for payments for provided services, it is our policy to obtain and securely store your credit card information. In providing credit card information and signing below, you authorize us to collect payment for any amounts due in the event you have not paid at the time of service. We are compliant with privacy regulations.

Cancellation policy: We believe that in order for patients to receive good care they need to keep their appointments. In addition, by not providing adequate notice it prevents other patients from using the services we provide. Please note that we require 24 hour (one business day) to reschedule your appointment. A cancel or no show fee of $50 for Nutritionists and $100 for Doctors will be charged to your card for any no show or cancelled appointment without 24 hour notice (one business day). We charge for cancelled, missed or late appointments due to transportation, weather, work issues except in the event of a major storm with governmental initiated city-wide restrictions.

All cancellations must be emailed to Jo@weightzen.com to avoid incurring a late fee.