I hereby consent to treatment by Dr. Haylee Nye, ND, MScN.
Procedures and treatments MAY (or may not) include the following:
> Common diagnostic procedures: blood draws, laboratory, physical exams
> Prescription of over-the-counter and pharmaceutical medications
> Hormone replacement: prescription of exogenous hormones such as estrogen, progesterone, testosterone, DHEA, cortisol, thyroid
> Medical nutrition and dietary supplementation
> Botanical medicine: teas, alcoholic tinctures, capsules, tablets, crèmes, plasters, suppositories, include low-dose toxic botanicals
> Psychological, lifestyle and hygiene counseling: diet therapy, exercise, sleep, stress management, etc
> Needles: the injection of medicines, vaccines, anesthestics, nutrients, and other substances
>Injections: including vitamins, minerals, nutritional compounds, herbs, hormones. Route of delivery include intravenous (IV), intra-muscular (IM), subcutaneous (subQ), and others.
> Homeopathic medicine: the use of highly diluted quantities of naturally-occurring plants, animals, nosodes, and minerals to gently stimulate the body’s healing responses
> Physical medicine: neck and spine/extremity adjustments, joint mobilization, soft-tissue therapies and massage, traction, electrical stimulation
> Physiotherapy: including exercises, ultrasound, electrical stimulation, kinesiotaping, and other methods.
> Other procedures recommended for my condition(s)
Potential Risks of Treatment:
All female patients must alert the doctor if they know or suspect that they are pregnant, or if they are nursing a child. Some of the therapies used could present a risk to the mother or baby. In includes calling or messaging the doctor once you learn you are pregnant, to confirm the therapies you’re using the things previously prescribed are safe to continue taking during pregnancy.
There are some rare but potential risks to treatment and procedures. Some of these risks include, but are not limited to the following:
> Reactions to prescribed substances (herbs, supplements, homeopathics, medications): allergic reaction, unpleasant side effects, or exacerbation of symptoms
> Inconvenience of lifestyle changes
> Emotional release, emotional distress, healing crisis
> Needles and injection therapies: bleeding, bruising or staining, hematoma, longstanding or permanent staining of skin (in particular with iron), muscle soreness, local pain, infection at injection site, injury to a nerve, pneumothorax (punctured lung), allergic reaction which could be life threatening.
> Physical Medicine: Bruising, sprains, fractures (most commonly ribs), disc injuries, dislocations, nerve injuries, strokes (mostly from neck adjustments).
You are welcome to ask about risks and benefits of proposed treatments at any time. You are also free to withdraw your consent and discontinue participation in treatments at any time.
Please notify your provider of any past present or future medical conditions, cancer, or as any new symptom or condition arises (this includes pregnancy for women).
Note that doing an individualized vaccine schedule may place yourself, your child, or other families at risk of contracting certain infectious diseases, some of which may cause permanent symptoms and/or death.
Please note that Dr. Haylee Nye is not acting as your primary care physician and it recommended that you have a primary care physician. If you have a serious health problem that requires immediate attention, you should call your other doctors(s), call 911, or have someone take you to the nearest hospital emergency room. Please note that we do NOT have an after-hours answering service or 24-hour call shifts.
If you notice an adverse effect from one of the components of your health plan, you should discontinue it and contact our office.
We reserve the right to terminate the doctor/patient relationship at any time for any reason, and are under no obligation to state the reason for discontinuing care. You will receive a letter in the mail as notification of this termination.
Privacy and Acknowledgments
Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain privacy rights concerning your healthcare information. Under this law, your healthcare provider generally cannot give your information to your employer, use or share your information for marketing or advertising purposes, or share private notes about your mental health counseling sessions without your written consent. As one of your providers, it is our responsibility to keep your information safe and secure. A record will be kept of the health services provided to you. This record will be kept confidential and will NOT be released to others unless required by law or specifically directed by you or your legal representative.
Your record MAY be shared in the following ways:
> For coordination of care; multiple healthcare providers may be involved in your treatment, directly and indirectly.
> With family, friends, relatives, or others that you specifically identified as having access to your health information or treatment.
> With other clinic members or administrative assistant who are involved in your treatment. Information will only be shared on a need-to-know basis.
> To protect the public’s health, such as reporting when the flu is in the area.
> To make required reports to the police, such as gunshot wounds.
> To obtain payment from third party payers, such as insurance companies.
> In other instances as required by law.
> Your provider is also required to report suspected abuse of an elder or child.
Accessing Your Own Medical Records
You have the right to make requests on how and with whom your information is shared. You may look at your health record or request a copy at any time in writing. You may be charged an administrative fee for printed or faxed copies of your record, and it can take up to 30 days for us to deliver your records. Your health records will be kept for a minimum of 7 years after the date of your last visit.
Phone Calls and Electronic Messages:
Preferred method of communication regarding treatment is through portal messages. The doctor reserve the right to request scheduling a visit either via phone or in office for issues that include either a new complaint, request for a new prescription, changes to a treatment plan, management of a new symptom, or medication refills outside of office visits.
E-Mail and Messages:
E-mail is not confidential. You are required to sign a HIPAA consent form to agree to communicating via text or non-secure email. Patients can send secure messages through our secure patient portal. Any messages sent will be added to your patient record. Although creating a portal account is free, please note that there may be a fee for care management done through the portal or by phone outside of an office visit.
Please note that we do NOT have an after-hours answering service or 24-hour call shifts. There is no “on call” service.
I have an OPTIONAL list serv for those who would like to hear about special events, promotions, and blog/vlog updates. You will NOT be automatically subscribed to this listserv, but may opt-in upon filling out the paperwork of your first appointment. This is at your discretion.
Please do not make video or audio recordings of your visits in part or whole without explicitly obtaining the written or verbal consent of your doctor at each visit. Your provider has the right to refuse recordings. If you do record sessions (with permission) in part or whole, you agree to use said recordings for personal use only. They may not be shared with others, posted to the internet, quoted in publication, or used in litigation against your doctor.
Payment for all office visits (whether or not you have insurance) and medicinary items is due in full at the time of service. The clinic accepts all major credit cards except AMEX. You can use Health Savings Account (HSA) or Flexible Spending Account (FSA) cards to pay for your visits, labs and supplements.
Dr. Haylee Nye is not currently recognized as an in-network provider under any insurance plans. If you have out-of-network benefits and would like to get reimbursed, my office will provide you with a coded receipt (called a “superbill”) that can be submitted to your insurance carrier. Your insurance carrier will mail you a check to pay you back in part or whole for your visits here. Check with your insurance provider for specifics about your plan and coverage of out-of-network providers. We do not guarantee any reimbursement or coverage from your insurance provider. Most insurance plans do not reimburse for telephone appointments.
Missed Appointments and Late Cancellations:
You will be charged a $50 fee for any missed appointments or cancellations made with less than 24 hours’ notice. This fee will be automatically charged to the credit card on file.
We understand that sometimes patients arrive late for appointments due to unforeseen circumstances. As a courtesy to other patients and to the Doctor, we must still end your appointment at the scheduled time if you arrive late. You will still be charged for a full visit, and may be required to make another appointment to finish whatever wasn’t covered in your shortened session.
If you are more than 15 minutes late for your appointment, we reserve the right to cancel your appointment and charge a $50 no-show fee to the credit card on file.
We reserve the right to dismiss from the practice patients who no show or late cancel more than three times, even if the appropriate fees are paid.
Your provider may prescribe medications, supplements, botanicals, homeopathics, and other products that may be purchased on site, through our online shop, or elsewhere. Most insurance companies do not cover the natural pharmacy items we prescribe and dispense, though some FSA and HSA accounts will. We do not guarantee coverage.
Blood Tests and Laboratory Tests:
The doctor may order laboratory testing (blood tests, etc) as indicated. We do not guarantee that your insurance will cover these tests in part or whole. Checking coverage is the patient’s responsibility. Call your insurance company for more information. If you wish to have your blood drawn elsewhere, let your provider know and you will be given a requisition to take to a lab of your choosing.