Privacy Pledge Form

Privacy Pledge Form

Privacy Pledge
Nourishing Medicine is committed to your privacy. There are several circumstances in which Nourishing Medicine may have to disclose
your health care information such as :referral to another health care provider or hospital for additional diagnosis, assessment or
treatment; to a third party if they are responsible for payment of your received services; for the purposes of quality control or other
operational procedures with Nourishing Medicine.

Along with this consent form you have a right to a copy of our privacy policy upon request. You have the right to review this policy prior
to signing this form. We reserve the right to change our privacy policy. If we make changes to our privacy policy you will be notified in
writing when you come in for treatment or by mail.

You have the right to request that we do not disclose your health information to specific individuals, companies, or organizations. If you would like to place a restriction on the use of disclosure of your health information, please inform Nourishing Medicine of this in writing. Please note that we are not required to agree to your restrictions; however, if we are in agreement, then they will be binding with us.

You may revoke your authorization at any time. However, your revocation must be in writing. We will not be able to honor your revocation request if we have already released your health information before we received your request for revocation. If you were required to give your authorization as a condition of obtaining insurance, the insurance company may have a right to your health information if they decide to contest any of your claims.

I have read your consent policy and agree to the terms. I am also acknowledging that I have received a copy of this consent and a copy of your privacy notice (Notice of Privacy Practices for Protected Health Information).

Insurance Authorization and Cancelation Policy
Please check the following boxes to acknowledge having read:

  • I authorize the release of my medical or other information necessary to process my insurance claims. I also request payment of government benefits to myself or to the party who accept assignment. (If desire, please ask for a copy of the 1500 HIC form for further information.)

  • I authorize payment of medical benefits to the undersigning physician or supplier for services described below.

  • I understand that I am responsible for payment of all benefits not covered by my insurance whether in part or full, and for the payment of copays, coinsurance and deductibles as required by my insurance carrier. I agree this may be charged to my credit card on file.

  • I understand there is a 24 hour cancelation policy. I agree to a $75 cancelation fee as a new patient and a $50 cancelation fee for follow up appointments. I agree this may be charged to my card on file and will not be billed to my insurance.

Legal Name

Authorized Provider Representative

Date Signed


none 8:00 AM - 4:00 PM 8:30 AM - 1:00 PM 10:00 AM - 6:00 PM 10:00 AM - 5:00 PM Closed By Appointment Only Closed nurse practitioners # # # 200 West lincoln Highway,
Waterman, IL 60556