Informed Consent & Disclosure
New Patient Forms
Please return your completed new patient forms at least two business days (M-F) prior to your appointment, or your appointment will be cancelled, and you will need to reschedule. Thank you in advance!
Welcome!
I am honored to be a part of your journey to optimal health. To ensure you are fully informed about my services and policies, please read, make sure you understand, and sign the documents included in this new patient packet prior to beginning our work together.
New Naturopathic Medicine Patient Forms
Important Patient Information and Practice Policies
Financial and Cancellation Policies
Credit Card Authorization
Informed Consent for Naturopathic Medicine
Informed Consent for Telemedicine
Notice of Privacy Practices & Acknowledgment of Receipt of Notice of Privacy Practices
Confidential Channel Communication Request Form.
Additionally, if you would like your other health care provider(s) to send me your past labs or other medical records, please complete and sign the Authorization to Release Confidential Health Information and Medical Records form and provide it to them. Thank you for taking the time to read and complete these forms. This ensures I can provide quality care. If you have questions about these forms, please email pribrannigan@gmail.com.
I look forward to working with you as part of your healthcare team!
Warmly, Dr. Priscila Brannnigan, NMD.
IMPORTANT PATIENT INFORMATION AND PRACTICE POLICIES
Notice that Services Are Not Primary Care: Please note that Dr. Priscila Brannigan, NMD, does not act as your primary care provider and does not provide after-hours or urgent care services. The services provided by Dr. Brannigan are in addition to, and not a replacement for, the care of your primary care physician and other medical specialists. Responsibility for your overall medical care should remain with your primary care physician. If you do not have a primary care physician, we recommend you locate one for in-person annual physical examinations and any routine services and screenings that Dr. Brannigan does not provide, as well as for after-hours or urgent health needs, on-call physician access, and emergencies. Dr. Brannigan is happy to work with your primary care physician and other specialists if desired and encourages collaborative care.
Patient Communications: In order to ensure the safety and confidentiality of your health information, Dr. Brannigan uses a HIPAA-compliant Electronic Medical Records System and secure Patient Portal.
Please send all health-related messages to Dr. Brannigan through the Patient Portal. This ensures all messages are secure and retained in your medical record. In addition, through your account on the Patient Portal, you can view your lab results and schedule follow-up appointments. Please do not e-mail or text health-related information and questions outside of the secure Patient Portal, as e-mail can never be guaranteed to be confidential or secure.
Patient Portal Messages: Patient portal messages are for quick clarifications regarding your most recent treatment plan, but they are not a substitute for an appointment with Dr. Brannigan. For anything other than quick clarifications of your most recent treatment plan (e.g., new concerns or symptoms, review of lab results, questions about new supplements etc.), please book a follow-up appointment. You will be asked to make an appointment if there is a new problem, or your questions or concerns are extensive.
Dr. Brannigan will do her best to respond to Patient Portal messages within 2-3 business days, but response time is not guaranteed. Patient Portal messages are not for urgent needs.
Dr. Brannigan does not provide urgent or emergency care. If you need urgent assistance, please go to urgent care. If you need emergency assistance, please call 911.
FINANCIAL AND CANCELLATION POLICIES
A $50 deposit, as well as credit card information, is required upon booking your initial appointment to hold your scheduled appointments.
Services and Fees: The current fee schedule is outlined below, but is subject to change; you will be notified of any changes prior to their effective date. Fees for appointments do not include the cost of any laboratory testing or supplements. Lab interpretation and review require a scheduled visit with Dr. Brannigan at the normal appointment rates.
Naturopathic Consultations:
Comprehensive New Patient Appointment (60+ min): $245
Follow up Appointments to review labs and/or reassess treatment plans 30-40 minutes: $125
Payment
We require a $50 deposit for every appointment booked. Payment is due in full at the time of service. And your credit card on file will be charged for the remainder of your appointment fee as well as any other charges such as supplements purchased after your appointment is over unless another valid credit card is provided at that time. We accept all major credit cards (Visa, Mastercard, AmEx, Discover), checks and cash for in-person services, and HSA/FSA cards (patient is responsible for confirming eligibility). A valid credit card on file is required regardless of payment method and will be charged only as set forth herein.
No Insurance or Medicare:
Dr. Brannigan’s Naturopathic Services PC is a fee-for-service business and is not contracted with any insurance carriers, and Dr. Brannigan is not a Medicare provider. Therefore, Dr. Brannigan cannot and does not accept or bill insurance or Medicare or submit claims for any services provided. All payment is due at the time of service.
Lab Tests: Dr. Brannigan orders a variety of lab tests including standard panels and functional medicine tests. For many tests payment is between the patient and the lab testing company. For certain specialty labs, payment must be made to VitalForce at the time the test kit is provided. Insurance may cover some labs, depending on your individual plan, but Dr. Brannigan cannot guarantee what and how much your individual insurance plan may cover or what your out-of-pocket costs may be. It is the patient’s responsibility to understand his or her insurance coverage. To prevent the stress of unexpected bills, if you wish to use your insurance for lab testing, we recommend you contact your insurance company to have a good understanding of your lab benefits prior to completing any lab tests.
Cancellation and No-Show Policy
When you schedule an appointment, that time is reserved especially for you and takes a spot from another patient. Therefore, we require that cancellations and scheduling changes be made at least 48 hours prior to your scheduled appointment. Monday appointments must be cancelled before 5pm the Friday prior. For cancellations made less than 48 hours before your scheduled appointment or after 5pm the prior Friday for Monday appointments and No-Shows, you will forfeit your appointment deposit and your credit card on file will be charged for the remainer of your appointment fee. If you reschedule/cancel your appointment with more than 48 hours advance notice, your deposit can either be refunded or used towards another appointment.
Late Arrival Policy:
Dr. Brannigan is committed to being on time with patients’ appointments. If you arrive late to your appointment, your appointment will end at the scheduled time, and you will be charged for the full length of the originally scheduled appointment. If you arrive more than 10 minutes late to your appointment, your appointment may be cancelled, and you will be charged in full for the appointment. By signing below, you agree that you have read, understand, and agree to the terms of the VitalForce Financial and Cancellation
Policies, accept full financial responsibility for services rendered at time of service, and you give Dr. Brannigan’s Naturopathic Services PC dba VitalForce permission to charge your credit card as stated herein.
CREDIT CARD AUTHORIZATION
VitalForce requires a credit card on file to hold your scheduled appointments. This credit card will be charged immediately after your appointment is over for the remainder of your appointment fee unless another valid credit card is provided at the time. It will also be used for Late Cancellation/No-Show Fees and any other charges to your account including supplement purchases.
INFORMED CONSENT FOR NATUROPATHIC MEDICINE
This Informed Consent for Naturopathic Medicine provides important information regarding the services being provided by Dr. Brannigan’s Naturopathic Services PC dba VitalForce. The purpose of this form is for Dr. Brannigan to provide you with written information regarding naturopathic medicine and the potential risks, benefits, and alternatives so that you may make an informed decision about whether to proceed with naturopathic medicine evaluation and treatment. Please ask any questions you have regarding this document and Dr. Brannigan’s services before signing this form. By signing below, you acknowledge and agree to the following: I understand that Dr.
Brannigan is a Naturopathic Doctor licensed in the State of California. Naturopathic Doctors in California are licensed and regulated by the California Board of Naturopathic Medicine. I understand that all recommendations and treatments will be discussed with me before implementation and treatment begins, and that I am encouraged to ask questions including: my suspected diagnosis(es) or condition(s); the nature, purpose, goals and potential benefits of the proposed course of care and treatment; the inherent or potential risks, complications or side effects of the proposed treatment; reasonable available alternatives to the proposed treatment; potential consequences if treatment or advice is not followed and/or nothing is done. I hereby request and authorize Dr. Brannigan to perform, order or recommend, as applicable, naturopathic medical care, evaluation, treatment, procedures and/or other naturopathic medicine services (the “Naturopathic Medicine Services”), as permitted under Dr. Brannigan’s naturopathic license in California, which may include, but are not limited to:
Physical Exams and Common Diagnostic Procedures: Including performing physical exams and assessments (including in-person and via telemedicine), ordering, and interpreting laboratory testing of blood, urine, stool, breath, and saliva, and ordering and performing certain diagnostic imaging as necessary (for review by a licensed radiologist).
Dietary Advice and Therapeutic Nutrition: Including use of nutritional counseling, dietary plans, nutritional supplements, and IV infusions and IM injections (with vitamins, minerals, and amino acids).
Botanical/Herbal Medicines: Botanical substances and plant derivatives may be prescribed as teas, alcohol or glycerin tinctures, capsules, tablets, creams, or suppositories.
Homeopathic Medicine: The use of highly dilute quantities of naturally occurring plants, animals, and minerals to gently stimulate the body's healing responses.
Bioidentical Hormone Replacement Therapy: The use of bioidentical hormone replacement therapy, including thyroid medication, to help restore and balance hormone levels as needed.
Other Pharmaceutical Medications: Other medications may be prescribed as necessary, as permitted within the scope of California naturopathic medicine licensure.
Lifestyle Counseling: Recommendations to promote improved lifestyle strategies relating to exercise and movement, stress management, nutrition, and environment.
I understand naturopathic doctors are not psychologists or psychiatrists and any counseling is for support of improved lifestyle strategies only. I also understand the U.S. Food and Drug Administration has not approved nutritional, herbal, and homeopathic substances to treat specific diseases.
No Guarantees and Patient Responsibility
I understand that results from the Naturopathic Medicine Services are not guaranteed, and Dr. Brannigan does not make any representations, promises, claims, warranties, assurances or guarantees that my medical problems or conditions will be helped or cured by any of Naturopathic Medicine Services. I understand that my failure to comply with any treatment recommendations and instructions may impede results. I understand that as with all existing methods of diagnosis and treatment, the Naturopathic Medicine Services have both benefits and risks.
Potential Benefits: Restoration of health, mental and physical resilience, and the body’s maximal functional capacity; relief of pain and symptoms of disease; assistance in injury and disease recovery; and prevention of disease or its progression.
Potential Risks: Herbs, dietary supplements, and homeopathic remedies are available over the counter and considered safe based upon their long history of use and when used as instructed. However, they may lack therapeutic effect or could cause allergic reactions or unpleasant side effects which could possibly range from mild to severe. Additionally, the interactions between herbs, and between herbs and medications are also not always thoroughly understood. While unlikely, and while Dr. Brannigan is trained in herbal medicine, it is possible to have an adverse reaction or experience a reduction or increase in the effect of other medications when taking herbs. These can have serious consequences for some medications, such as for the control of high blood pressure or blood sugar. Homeopathic medicines can potentially cause aggravation or worsening of current or pre-existing symptoms. I am aware that unforeseeable complications could occur, and that while Dr. Brannigan will make every reasonable effort to screen for contraindications to care, I do not expect Dr. Brannigan to be able to anticipate and explain all possible risks and complications.
Following Doctor Instructions: I understand it is extremely important that I follow Dr. Brannigan’s instructions with respect to dosing and administration of homeopathic medicines, nutritional supplements, and prescription medications. I understand that taking more than prescribed or self-treating with additional supplements or dosages of medications can be dangerous.
Complete Medical History: I understand that some treatments may be unsafe if I have certain health conditions or take certain medications or supplements, whether prescribed or over-the-counter. For this and other reasons, I understand that it is vital that I truthfully and accurately disclose all health information requested by Dr. Brannigan as well as keep Dr. Brannigan updated as to any changes, including any new treatments or procedures I am undergoing. I understand that failure to do so may negatively affect my treatment outcome and the safety of any treatments I receive, and I understand that there shall be no liability on the part of Dr. Brannigan should I fail to do so.
Notice Regarding Pregnancy and Breastfeeding: I understand that some treatments could present a risk during pregnancy and breastfeeding, and I agree that I will notify Dr. Brannigan immediately if I am pregnant, become pregnant, am planning to become pregnant, or if I am breastfeeding.
INFORMED CONSENT FOR TELEMEDICINE
Because Dr. Priscila Brannigan offers naturopathic consultations via telemedicine, this form is to obtain your informed consent for telemedicine consultations with Dr. Brannigan. This Informed Consent for Telemedicine is intended as an addition to the informed consent for naturopathic medicine and does not change the terms of that informed consent.
Dr. Priscila Brannigan is a licensed naturopathic doctor in the State of California, which gives her the ability to practice naturopathic medicine and diagnose and treat patients who are located in California. Therefore, you must be present in California during your telemedicine consultations with Dr. Brannigan.
Telemedicine involves the use of electronic communications to enable the doctor at a different location from the patient to share medical information with that patient. The information may be used for diagnosis, treatment, follow-up and/or education. During a telemedicine consultation, Dr. Brannigan will be providing care to you via live two-way audiovisual electronic communications or telephone instead of in-person.
The interactive video connection and electronic communication system used by Dr. Brannigan for the telemedicine consultations is HIPAA-compliant and designed to protect the confidentiality of patient data.
Expected benefits of a telemedicine consultation include: Dr. Brannigan can provide care to patients who are located throughout California. More efficient medical evaluation and management.
Potential risks associated with the use of telemedicine include, but not limited to: There is the potential that conditions that could be diagnosed with an in-person visit may go undetected in a remote encounter, especially because a full physical exam cannot be performed.
The video connection may not work, or it may stop working during the consultation, or there may be other technical difficulties or failures during the consultation.
The video picture or information transmitted may not be clear enough to be useful for the consultation or to allow for appropriate care. This may cause a delay in medical evaluation and treatment. Security protocols may fail, causing a breach of privacy of personal medical information and/or unauthorized access to the video connection during the consultation.
If the video connection is interrupted, please call (858) 888-0347 or email: pribrannigan@gmail.com.
Notice of Privacy Practices
THIS NOTICE IS REQUIRED BY LAW AND DESCRIBES HOW PROTECTED HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Dr. Brannigan’s Naturopathic Services PC dba VitalForce (“VitalForce,” “we,” “our” or “us”) provides service with respect for your personal information. Protecting your privacy and healthcare information is fundamental in the course of our relationship.
This Notice tells you about the ways we may collect, store, use and disclose your protected health information and your rights concerning your protected health information. “Protected health information” is information about you that can reasonably be used to identify you and that relates to your past, present or future physical or mental health or condition, the provision of health care to you or the payment for that care. Federal and state laws require us to provide you with this Notice about your rights and our legal duties and privacy practices with respect to your protected health information. We must follow the terms of this Notice while it is still in effect. Some of the uses and disclosures described in this Notice may be limited in certain cases by applicable state laws that are more stringent than the federal standards.
Uses and Disclosures of Your Protected Health Information
We may use and disclose your protected health information for different purposes. The examples below are illustrations of the different types of uses and disclosures that we may make without obtaining your authorization.
Treatment. We may use and disclose your protected health information for your treatment and to provide you with treatment-related health care services. For example, we may disclose protected health information to other doctors, healthcare providers, naturopathic assistants, technicians, or other personnel, including people outside our office, who are involved in your medical care and need the information to provide you with medical care.
Payment. We may use and disclose protected health information so that we may bill and receive payment from you for the treatment and services you received.
Health Care Operations. We may use and disclose your protected health information in order to perform various operational activities of our business.
Appointment Reminders, Treatment Alternatives and Health Related Benefits and Services. We may use and disclose protected health information to contact you and to remind you that you have an appointment with us. We also may use and disclose protected health information to tell you about treatment alternatives or health-related services that may be of interest to you. We will not, however, send you communications about health-related or non-health-related products or services that are subsidized by a third party without your authorization.
Other Permitted or Required Disclosures
Other Permitted or Required Disclosures
As Required by Law. We must disclose protected health information about you when required to do so by law.
Public Health Activities. We may disclose your protected health information to public health agencies for reasons such as preventing or controlling disease, injury, or disability.
Victims of Abuse, Neglect, or Domestic Violence. We may disclose your protected health information to government agencies about abuse, neglect or domestic violence.
Health Oversight Activities. We may disclose protected health information to government oversight agencies (e.g., state insurance departments) for activities authorized by law.
Business Associates. We may disclose protected health information to our business associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services. For example, we may use another company to perform billing services on our behalf. All of our business associates are obligated to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.
Judicial and Administrative Proceedings. We may disclose protected health information in response to a court or administrative order. We may also disclose protected health information about you in certain cases in response to a subpoena, discovery request, or other lawful process.
Law Enforcement. We may disclose protected health information under limited circumstances to a law enforcement official in response to a warrant or similar process; to identify or locate a suspect; or to provide information about the victim of a crime.
To Avert a Serious Threat to Health or Safety. We may disclose protected health information about you, with some limitations, when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.
Other Uses or Disclosures with an Authorization: Other uses or disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law. You may revoke an authorization at any time in writing, except to the extent that we have already taken action on the information disclosed or if we are permitted by law to use the information.
Your Rights Regarding your Protected Health Information
You may have certain rights regarding protected health information that we maintain about you.
Right To Access Your Protected Health Information. You have the right to review or obtain copies of your protected health information records, with some limited exceptions. Your request to review and/or obtain a copy of your protected health information must be made in writing. We may charge a fee for the costs of producing, copying and mailing your requested information, but we will tell you the cost in advance.
Right to Amend Your Protected Health Information. If you feel that your protected health information maintained by VitalForce is incorrect or incomplete, you may request that we amend the information. Your request must be made in writing and must include the reason you are seeking a change. We may deny your request if, for example, you ask us to amend information that was not created by VitalForce, or you ask us to amend a record that is already accurate and complete. If we deny your request to amend, we will notify you in writing. You then have the right to submit to us a written statement of disagreement with our decision and we have the right to rebut that statement.
Right to an Accounting of Disclosures. You have the right to request an accounting of disclosures we have made of your protected health information. The list will not include our disclosures related to your treatment, our payment or health care operations, or disclosures made to you or with your authorization. The list may also exclude certain other disclosures, such as for national security purposes. Your request for an accounting of disclosures must be made in writing and must state a time period for which you want an accounting.
Right to Request Restrictions on the Use and Disclosure of Your Protected Health Information. You have the right to request that we restrict or limit how we use or disclose your protected health information for treatment, payment, or health care operations. We may not agree to your request. If we do agree, we will comply with your request unless the information is needed for an emergency. Your request for a restriction must be made in writing. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit how we use or disclose your information, or both; and (3) to whom you want the restrictions to apply.
Right to Receive Confidential Communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you by mail or at work. To request confidential communication, you must make your request in writing, to us. Your request must specify how or where you wish to be contacted. We will accommodate reasonable requests.
Right to a Paper Copy of This Notice. You have the right at any time to request a paper copy of this Notice, even if you had previously agreed to receive an electronic copy. As required by law, patient records will be kept for a period of at least seven (7) years after the date of the patient’s last visit.
Health Information Security: VitalForce maintains physical, administrative, and technical security measures to safeguard your protected health information and requires any staff to follow such security policies and procedures as well as limits access to health information about patients to those individuals who need it to perform their job responsibilities.
Health Information Security: VitalForce maintains physical, administrative, and technical security measures to safeguard your protected health information and requires any staff to follow such security policies and procedures as well as limits access to health information about patients to those individuals who need it to perform their job responsibilities.
Concerns: If you are concerned that we have violated your privacy rights, or you disagree with a decision we made about access to your records, you may file a complaint with us by contacting the person listed below. You may also send a written complaint to the U.S. Department of Health and Human Services. The person listed below can provide you with the appropriate address upon request. We support your right to protect the privacy of your protected health information. We will not retaliate against you or penalize you for filing a complaint.
Changes to This Notice: We reserve the right to change the terms of this Notice at any time, effective for protected health information that we already have about you as well as any other information that we receive in the future. We will provide you with a copy of the new Notice whenever we make a material change to the privacy practices described in this Notice. Any time we make a material change to this Notice, the new Notice will contain the new effective date.
You may always obtain a copy of our current Notice by any of the following means:
Contacting VitalForce by email or by phone.
Asking for a copy at the time of your next consultation.
If you have any questions or complaints, please contact:
Privacy Officer: Dr.Priscila Brannigan, NMD
858-888-0347
Pribannigan@gmail.com