For your convenience please download the following forms and please read them carefully, fill them out, and sign them prior to your office visit.
It is my legal duty to safeguard your Protected Health Information (PHI).
By law I am required to insure that your PHI is kept private. The PHI constitutes information created or noted by me that can be used to identify you. It contains data about your past, present, or future health or condition, the provision of health care services to you, or the payment for such health care. I am required to provide you with this Notice about my privacy procedures.
This Notice must explain when, why, and how I would use and/or disclose your PHI. Use of PHI means when I share, apply, utilize, examine, or analyze information within my practice. PHI is disclosed when I release, transfer, give, or otherwise reveal it to a third party outside my practice. With some exceptions, I may not use or disclose more of your PHI than is necessary to accomplish the purpose for which the use or disclosure is made.
I am legally required to follow the privacy practices described in this Notice. I reserve the right to change the terms of this Notice and my privacy policies at any time. Any changes will apply to PHI already on file with me. Before I make any important changes to my policies, I will immediately change this Notice and post a new copy of it in my office. You may also request a copy of the complete Notice from me, download it, or you can view a copy of it in my office.
* We reserve the right to cancel the workshop if the minimum attendance requirement is unmet OR because of unforeseen restrictions. In these cases, you will receive a full refund.
* An administration fee of $50 is non-refundable.
* Cancel by 30 days or more for a refund minus the $50.
* 100% of the deposit will be non-refundable for cancelations less than 30 days before the training begins.
* We are not responsible for travel or lodging costs.