Service/Informed Consent/Coaching Consultation/HIPAA Policy

---

**Ellements of Health Services Policies**

Our Mission is to assist you in achieving physical, spiritual, and emotional well-being using a holistic approach to health.

This approach complements any existing health care program.

**Ellements of Health (EoH) Intent:** The intent of any and all services offered and/or nutritional protocols or lifestyle recommendations suggested by Dr. Dunham and the EoH team is designed to support the natural physiological & biochemical processes of the human body. The purpose is not to diagnose, treat, prevent or cure any disease. All suggested protocols are from a holistic health perspective. As such, EoH does not act as your primary care physician (PCP) and you must continue to have a medical PCP and keep them informed of all your healthcare activities. EoH is not in any insurance network, and we do not carry any hospital privileges. Upon request, patients can be given a receipt that clearly identifies the appropriate service codes (CPT) and diagnostic codes (ICD-10) that they can send into their insurance company for possible reimbursement based on their individual insurance coverage and deductible. It is important to maintain a relationship with a primary care provider, gynecologist and/or internist for those needs as well as any specialists you are currently seeing.

** Benefits of Functional Medicine and Scope of Practice:**The team at Ellements of Health use diagnostic and treatment methods that - in addition to conventional health care - are known as preventative, complementary, alternative, functional, naturopathic, or integrative medicine (collectively, "Functional Medicine"). Functional Medicine focuses on nutritional and metabolic imbalances, diet, exercise, environmental influences, and psycho-social stressors based on the premise that they directly relate to the development and maintenance of illness. Functional Medicine evaluates these influences and then specifically tries to remedy them. It encourages patients to give up negative lifestyle patterns and establish more positive ones, regardless of the type of medical conditions for which they are seeking treatment.

I understand that, as with any health treatment, Functional Medicine is not without risk. Potential risks of treatment include, but are not limited to, allergic reactions, sensitivities, adverse effects from, or in response to, natural supplements or dietary measures, failure to improve or worsening of my condition, and difficulty adjusting to lifestyle modifications.

I agree to inform Practice's clinical staff of all known factors that might affect treatment, including, but not limited to, all medications, drugs, drug sensitivities and allergies, history of seizures, fits or fainting, presence of a pacemaker, bleeding disorder, use of anti-coagulants, damaged heart valves or occluded vessels, immune deficiencies, or other special risks of infection, as well as any other significant factors within my knowledge. I further agree to inform Practice's clinical staff of any disorder or state of mind that might affect my capacity to make informed health decisions, and should any such impairment exist, I will provide information regarding a surrogate decision maker.

**Consent to Participate in Telemedicine/Telehealth and In person Consultation** By scheduling with Ellements of Health and by signing this agreement I acknowledge that I am agreeing to participate in telemedicine/telehealth and in-person consultation with the practitioners and/or staff at Ellements of Health (EoH). I am seeking this consultation for my own purposes and not on behalf of any third party. I understand the risks, benefits, limitations and alternatives to tele-consults and have chosen of my own free will to participate in tele-consults with Ellements of Health. I understand I am a participant in the decision-making process and I am free to decline any service/treatment/recommendation/suggestion offered by the EoH practitioners at any time.  I understand that tele-consults typically involve the use of audio and/or video or other technology between me and the practitioner. Due to the nature of tele-consults, visits are largely educational and rely heavily on the patient history and laboratory findings. Exam and vital findings via video or phone are limited in nature vs an in-person examination. I agree to bring to the attention of Practice's clinical staff, if, at any time, I have any lack of understanding of such risks, benefits and alternatives, and inquire of clinical staff for further explanation until I have a full understanding before giving consent to any procedure or treatment.

**Scheduling:** It is mandatory that all new patients complete their initial functional medicine intake forms and consents at least 48 hours before their scheduled appointment time. Your provider requires this information in order to complete your medical history review prior to your scheduled appointment.

**Cancellations:** We request a minimum of 48 hours advance notice for any cancellation or rescheduling of your appointment. This is a consideration for our practitioners.  Failure to notify us of your need to cancel or reschedule your appointment within 48 business hours of your scheduled appointment will result in a no-show fee. The charge for a canceled or rescheduled appointment will be 50% of the cost of the scheduled appointment.

**Payment of Services:** Payment in full is expected at the time of scheduling or at the time of service. Ellements of Health receives payment in credit, HSA/FSA card and cash only. There are no service refunds. You agree that your credit card on file will be automatically charged for any Ellements of Heallth invoice generated such as your visit fee or if a supplement order or lab order is requested. You also authorize Ellements of Health to automatically charge your credit card for any missed appointments or late cancellations of less than 48 hours in advance at the full service fee. There is no charge for rescheduling or canceling appointments more than 48 hours in advance. I am also responsible for any chargeback fees if for some reason my credit card is declined. This authorization is part of my records and will be treated with privacy, confidentiality and respect.

**Additional time charge:** If a visit goes over the scheduled time (ex. 1 hour) then there will be an additional visit charge in 15 minute increments at the prorated rate. Your credit card on file will be charged after the visit is completed.

**Refunds:** Supplements and Lab work is purchased through outside vendors and EoH can not issue any refunds, please only purchase items you intend to use.  At EoH you may receive a refund for individual services that were prepaid but not used and canceled with the 48-hour notice before the appointment. You may receive a refund for a prepaid visit if EoH cancels the appointment and you do not wish to reschedule.

This excludes program packages agreed and purchased in advance and excludes programs purchased under a payment plan. There is no refund for program services purchased with a payment plan in which the patient decides to discontinue appointments prior to appointment(s) fulfillment or before completion of program duration. There is no refund for a purchase bought as a set of visits/services/package/program plan unless there are extenuating circumstances discussed and agreed upon with Dr. Dunham.

There are no refunds for services that have already been fulfilled (ex. after a visit).  Keep in mind, membership visits must be used each month, they do not roll over. See your Membership Agreement for full details.

**Memberships** See your separate Membership Agreement for all terms and conditions.

**Primary Care Physician (PCP):** Dr. Eleanor Dunham is a Doctor of Medicine and specializes at Ellements of Health in functional medicine and nutrition operating within the scope of her license. Dr. Dunham does not act as a primary care physician and is not on call, nor are any Ellements of Health practitioners regardless of license type including MD/DO/DC/ND/PhD/NP. Please maintain a positive, working relationship with your medical doctor, keep him/her informed of your healing activities and continue your regular medical care and check-ups. This applies to all providers/practitioners with Ellements of Health.

**Care During Pandemic** For visits held in person, we follow strict guidelines per the State of PA and face masks must be worn at all times by both practitioner and patient/client for in person visits. Surfaces are wiped down between visits and gloves are worn when indicated. We ask that patients/clients do NOT come to an in-person visit if they have traveled within the last 14 days, have been exposed to someone positive with Covid-19 or have symptoms including cough, fever and loss of taste or smell. If you choose to have an in-person appointment you understand that there is still risk of exposure, by attending the in-person visit you assume all risks related to exposure to Covid-19 and agree to not hold Ellements of Health, Dr. Eleanor Dunham or any of the practitioners/staff/employees/contractors liable for any illness or injury.

**Photo release, Social Media release, Website and Marketing release** You agree to authorize Ellements of Health use of any public reviews (ex. Google, Yelp, Facebook, etc) that you submit or a review emailed to us. These reviews may be used for marketing activities and other online promotions via social media, websites and all printed or digital publications and media in perpetuity. You acknowledge that participation is voluntary, there is no financial compensation and this includes photos, graphics and testimonials. You release Ellements of Health, LLC and Dr. Eleanor Dunham, MD of any liability or claims by me or any third party related to the use of photographs, graphics or testimonials in printed or digital media.

**Updates to EoH Policies** All current updates to our Policies will be immediately applicable to you & all previous signers and posted on the Ellements of Health website and in our Charm software. You may view them there or request an updated copy emailed to you at any time.

*Stopping Medication:**  Ellements of Health practitioners will **NOT** take you off any medication, which can only be done with your prescribing physician. If your goal is to decrease your need for medication, we can suggest a protocol to encourage health and then you may work with your primary physician to monitor your progress and see if you are able to lower or eliminate your medication dosage over time. Keep your primary physician informed.

**Emergencies:** In case of an emergency, call your PCP, visit your local urgent care or call 911.

You may or may not be utilizing all of the services mentioned below:

**INFORMED CONSENT FOR FUNCTIONAL MEDICINE & NUTRITION CARE (Which includes all items mentioned above).**

To the patient (or their legal guardian, court-appointed conservator, or agent):  Please read this entire form prior to signing it.  Please ask any questions prior to signing this form if you are unclear about anything in this form.

**Other Procedures** - There are a number of other procedures used by Dr. Eleanor Dunham, MD and the EoH Team that may be utilized.  Treatment may include IV therapy, neurotoxine and filler and other modalities (such as stretching, traction, nutrition, health coaching & exercise recommendations, etc.). This informed consent extends to our staff (employed or contracted), our nutrition advisors ( Doctor of Medicine, Nurse Practitioners, health coaches, nutritionists) to include all EoH practitioners. Additionally, there may be referrals to other associated practitioners in the EoH office or outside doctors/practitioners as necessary, and their treatment should involve the same informed consent with disclosure of risks and benefits as is being done here.

**Updates to Informed Consent** All current updates to our Informed Consent will be immediately applicable to you & all previous signers and posted on the Ellements of Health website and in our Charm software. You may view them there or request an updated copy emailed to you at any time.

No Guarantee - Results Dependent on Consultant

We can not guarantee results but will share good practices that have been effective in our clinical experience and in practice by those we have coached and worked with over the years. It will always be incumbent on you to “do the work”, to do your research and take action steps.

Not Legal Advice - Not Tax Advice

Our team may share experience and practical stories based on their practice or those of clients they have coached or what is considered standard in the industry. However, we are not an attorney and none of the advice shared constitutes legal or tax advice. Please consult legal advice or tax advice when/as needed and note that the laws may different by your county, state or country and often differ by medical license.

​

Care During Pandemic Our visits are currently being held remotely and have no risk of exposure to Covid-19 and/or any virus. For visits held in person, we follow strict guidelines per the State of PA. Surfaces are wiped down between visits and gloves are worn when indicated. We ask that clients do NOT come to an in-person visit if they have traveled within the last 14 days, have been exposed to someone positive with Covid-19 or have symptoms including cough, fever and loss of taste or smell. If you choose to have an in-person appointment you understand that there is still risk of exposure, by attending the in-person visit you assume all risks related to exposure to Covid-19  and agree to not hold Ellements of Health, Dr. Eleanor Dunham  or any of the staff/employees/contractors liable for any illness or injury.   

​

Updates to Policies

All current updates to our Policies will be immediately applicable to you & all previous signers and posted on the Ellements of Health website and in our Charm software. You may view them there or request an updated copy emailed to you at any time.

**HIPAA Notice of Privacy Practices**

Ellements of Health, LLC

Eleanor Dunham, MD

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

In the course of your care as a patient or client with any practitioner at Ellements of Health (EoH), we may use or disclose personal and health-related information about you in the following ways:

-Your personal health information, including your clinical records, may be disclosed to another health care provider or hospital if it is necessary to refer you for further diagnosis, assessment or treatment.

-Your health care records, as well as your billing records, may be disclosed to another party, such as an insurance carrier, an HMO, a PPO, or your employer if they are or may be responsible for the payment of your services.

-Your name, address, phone number, and your health care records may be used to contact you regarding appointment reminders, to provide information about alternatives to your present care, or to provide other health-related information that may be of interest to you.

-**We may also provide treatment in an “open” or “group adjusting”  or "group nutrition" or "group coaching" environment where other patients may be seen and advised at the same time in close proximity to you.**  This situation would necessitate the discussion of your health, subjective symptoms/treatment, etc. in the presence of other patients. **You may always choose to exclusively participate in private appointments.**

You have a right to confidential communications and to request restrictions relative to such contacts.  You also have the right to be contacted by alternative means or at alternative locations.  Such requests must be made to us in writing.  Such requests are not automatic and require the agreement of this office.

If you are not at home to receive an appointment reminder, a message may be left on your answering machine or with a person in your household.  

Further, you have the right to inspect or obtain a copy of the information we will use for these purposes.  You also have the right to refuse to provide authorization for this office to contact you regarding these matters.  If you do not provide us with this authorization it will not affect the care provided to you or the reimbursement avenues associated with your care.

Under federal law, we are also permitted or required to use or disclose your health information without your consent or authorization in the following circumstances:

-If we are providing health care services to you based on the orders of another health care provider.

-If we provide health care services to you in an emergency.

-If we are required by law to provide care to you and we are unable to obtain your consent after attempting to do so.

-If there are substantial barriers to communicating with you, but in our professional judgment we believe that you intend for us to provide care.

-If we are ordered by the courts or another appropriate agency.

You have a right to receive an accounting of any such disclosures made by this office.  Any use or disclosure of your protected health information, other than as described in the examples outlined above, will only be made upon your written authorization.  We normally provide information about your health care to you at the time you receive health coaching, functional medicine, nutritional advice, etc from us.  We may also mail, email or text information to you regarding your health care or about the status of your account. If you would like to receive this information at an address other than your home or, if you would like the information in a different form, please advise us in writing as to your preferences. We use a HIPAA compliant EHR system and email but please keep in mind there are inherent risks in electronic communication. If you would prefer to not utilize email as a form of communication please inform Ellements of Health in writing and please do not email the office. Sending an email to and asking questions pertaining to health or your personal information will be presumed as you granting permission to communicate via email along with this signed HIPAA form.

You have the right to inspect and/or copy your health information for seven years from the date that the record was created for as long as the information remains in our files.  In addition, you have the right to request an amendment to your health information.  As per allowance by HIPAA recommendations & as a non-covered entity, the charge will be 25 cents per page.

Requests to inspect, copy or amend your health-related information should be provided to us in writing.

We make every effort to follow the state and federal recommendations to maintain the privacy of your patient file and the health protected health information therein.

We also make every effort to follow the state and federal recommendations to provide you with this notice of our privacy practices with respect to your health information.  We make every effort to abide by the terms of this notice while it is in effect.

We reserve the right to alter or amend the terms of this privacy notice.  If changes are made to our privacy notice, we will notify you in writing as soon as possible following the changes.  Any change in our privacy notice will apply for all of your health information in our files.

You also have the right to lodge a complaint with the Secretary of the Department of Health and Human Services at 200 Independence Ave, S.W. Washington D.C. 20201.  If you choose to lodge a complaint with this office or with the Secretary your care will continue and you will not be disadvantaged by this office or our staff in any manner whatsoever.

This notice is effective (updated)  as of March 27, 2023.  This notice and any alterations or amendments made hereto will expire seven years after the date upon which the record was created.

All current updates to our Privacy Policy will be immediately applicable to you and all previous signers and posted on the Ellements of Health website and in our Charm software. You may view them there or request an updated copy emailed to you at any time.

Contract Electronically:

You agree that the Terms, combined with your act of using the Site and/or the services offered on or through the Site have the same legal force and effect as a written contract with your written signature and satisfy any laws that require a writing or signature, including any applicable Statute of Frauds. You further agree that you shall not challenge the validity, enforceability or admissibility of the Terms on the grounds that it was electronically transmitted or authorized. In addition, you acknowledge that you have had the opportunity to print the Terms.