PATIENT REGISTRATION FORM

Informed Consent for Treatment
I have sought medical care from Michael Schoenwalder, DO, LLC DBA as Schoenwalder Health & Wellness I have chosen to do this of my own free will, because I believe the alternative/integrative, holistic approach to medicine that is practiced by Dr. Michael Schoenwalder or Kristina Plesons, AGNP is more in keeping with my philosophy. I also understand that Dr. Michael Schoenwalder is a Board-Certified Internist, who will employ standard drug therapy for medical management if indicated.

It is my understanding there is an alternative approach to medical care practiced by a group of physicians, who emphasize the importance of nutrition, exercise, drainage, detoxification, MTHFR, hormonal imbalances, thyroid optimization, adrenal restoration, and chronic inflammatory response syndrome to various biotoxins and environmental toxins. Based on these conditions’ various herbal/homeopathic, natural/biologic, nutritional (vitamins, minerals, amino acids, ozone, and glutathione injections), thyroid medications, cortisol support, and hormone therapies will be used as the mainstays for restoring a patient to his/her optimal state of health. I realize that such therapy is frequently not as rapid as drug therapy; that it requires a great deal more effort from me, the patient, that the simple administration of a medicine for each complaint, and some medical authorities consider it to be unproven, ineffective, and even unsafe, but the underlying philosophy seems more realistic to me that the simple relief of symptoms. I understand since every individual case has its own inherent uniqueness, Dr. Michael Schoenwalder/Kristina Plesons AGNP cannot warrant or “guarantee” his treatment programs will always result in an improvement of the disease being treated.

I also understand that many insurance plans have clauses that limit coverage to “usual and customary fees for reasonable and necessary services.” I realize that some of the integrative/functional medical services provided by Schoenwalder Health & Wellness will not fall under this description, and I do not hold Schoenwalder Health & Wellness responsible for the possible decision by an insurance company that services provided to me are not covered under a specific insurance contract.

I am consulting with Dr. Michael Schoenwalder/Kristina Plesons, AGNP solely for reasons concerning my own health. I am not consulting Dr. Michael Schoenwalder/Kristina Plesons, AGNP to provide any information to any enforcement, regulatory, or investigative agency of any kind.

By checking the box below, I certify that I have read and understand this policy.

Telehealth/Telemedicine Service Consent:
Telehealth/Telemedicine is when you receive a telephone call for a medical consultation in replace an in-office visit with your healthcare provider.

The laws that protect the privacy and confidentiality of health and care information also apply to telehealth-telemedicine. Information obtained during telehealth/telemedicine that identifies you will not be given to anyone without consent except for the purposes of treatment, billing, and healthcare operations. I understand, agree, and expressly consent to Schoenwalder Health & Wellness LLC obtaining, using, storing, and disseminating to necessary third parties, information about me, as necessary to provide the telehealth/ telemedicine services.

As with any telecommunication, I understand that there is a risk of security breach. Electronic systems used will incorporate network security protocols to protect the confidentiality of patient identification and texting data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.
Telehealth/ telemedicine sessions may not always be possible. Disruptions of signals or problems with Internet infrastructure may cause broadcast and reception problems (e.g., poor sound quality, dropped connections, audio interference) that prevent effective interaction between consulting clinician(s), participant, patient, or care team.

I hereby release and hold harmless Schoenwalder Health & Wellness, LLC, and all members of my care team from any loss of information due to technical failures with the telehealth/ telemedicine service.

I understand and agree that the health information I provide at the time of my telehealth/ telemedicine service may be the only source of health information used by the medical professionals during my evaluation and treatment at the time of the telehealth/ telemedicine visit, and that such professionals may not have access to my full medical record or information held at Schoenwalder Health & Wellness.

I understand that I will be given information about test(s), treatment(s), and procedure(s), as applicable including the benefits, risks, possible problems or complications, and alternate choices for my medical care through the telehealth/ telemedicine visit.

I have the right to withhold or withdraw consent to the use of telehealth/ telemedicine services at any time and revert to traditional in-person clinic services. I understand that if I withdraw my consent for telehealth/telemedicine services, it will not affect any future services or care benefits to which I am entitled.

All my questions have been answered to my satisfaction.

I hereby consent to the use of telehealth/ telemedicine in the provision of care and the above terms and conditions.

The check mark on this form is my statement:

I certify that I am the legal representative of the participant or that I am the patient and am 18 years of age or older, or otherwise legally authorized to consent. I have carefully read and understand the above statements. I have had all my questions answered. I understand that this informed consent will become part of my medical record.

General Office Policies & Procedures
We are honored you have entrusted Schoenwalder Health & Wellness with your care. We look forward to helping you on your journey to reclaim your health. Our focus will be on prevention of age-related conditions as well as helping you with chronic conditions that are difficult to manage. The following information is to help keep you informed of our practice policies.
Office Hours: Monday – Thursday 8am – 5:00 pm Friday 8am – Noon.

Telephone Answering Hours: Mon- Thursday 8:30am – 4pm/ Friday 8:30am – NOON.

For Emergency Care after Hours: Call/Text: 314-285-4747 (Answering Service) or go directly to an Urgent/Emergency Care facility.
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Inclement Weather: In the event of severe weather, someone from our office will contact you the day before or the morning of your appointment to let you know if we need to switch you to a telehealth appointment.
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Late Arrivals: If you are more than 15 minutes late, you may be asked to reschedule your appointment as this delay not only affects the physician/nurse practitioner, but also other patients that are scheduled after you.
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Medication Refills: If you are on medications, you will be required to be seen for follow up appointments based on what you are being prescribed. For all non-narcotic prescriptions please call your pharmacy and request the refills- if additional refills are not available, the pharmacy will contact our office and the request will be responded to within 24 hours.
For all narcotic/controlled substances (i.e., Adderall, Percocet, or Hydrocodone), please see controlled medication agreement for details. A drug testing urinalysis will be required at every visit. Our office is not responsible for lost, misplaced, or stolen prescriptions and due to the nature of the medication the prescription will not be replaced.
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Prior Authorization Requests – Sometimes your prescription will require a prior authorization process. If you wish for us to contact your insurance for prior authorization the cost is $50, but if your medication requires a second request or Appeal and you wish us to pursue the appeal process there will be a $75 charge.
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Medication History Consent: The electronic medical recording software we utilize offers access to your medical prescription database filled by other physicians. This is a convenient feature to be used only with your consent. Your agreement to this form also gives us consent to access your medical prescription history only to be used to update your chart with current medication or for continuation of care.
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Referrals: Although we are not a participating/in-network provider with any insurance, some insurance companies will still accept a referral from our office. If your insurance accepts referrals from an out of network provider note the following:

• You are required to notify us at least 72 hours in advance of an appointment requiring a referral. Referrals to other physicians or diagnostic facilities can take up to 72 hours for our office process, failure to obtain a referral in a timely manner can result in making you responsible for all charges incurred at the specialist office.
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Test Results:
Please have your labs drawn at least 2 weeks prior to your appointment so you may review labs with the provider. Should you have laboratory or other diagnostic testing ordered through our practice, you will be notified of the results as soon as they are available (please allow 10 business days from test date).

If you do not have lab testing done prior to the appointment, you may be asked to have a tele-med visit to review the labs. Note: all results must first be reviewed by the ordering provider. You will receive a call or email from the doctor’s assistant. You are ultimately responsible for your results – if you do not receive a call within the time frame listed above, please call the office.
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Telemedicine Consultations: As a convenience, our physician/ nurse practitioner offers telephone consultations. The cost of a telemedicine visit is within the range of $120-$220, and the charges applied are based on complexity of visit and at the discretion of the provider. Payment for the consultation is due the date it is scheduled.

Please note: Telemedicine consultations charges will be incurred in the following instances:

1) a provider calls to discuss your lab/imaging results.
2) responds to a patient’s request for a return call.
3) responds to exchange phone call or text request after hours.
4) scheduled as a telemedicine visit on their schedule.


Card on file will automatically be charged for the visit at the conclusion of the appointment.

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Disability/FMLA (Family Medical Leave Act) Forms: We have a high volume of patients requesting physician statements/FMLA forms to be completed. We require all forms to be submitted with patients’ signature as early as possible to ensure we have enough time to complete them. There is a $75-$150 fee for each set of forms needing to be filled out. Please allow 2 weeks (14 days) for the forms to be completed.
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Use of Artificial Intelligence (AI) Tools
At Schoenwalder Health & Wellness, we may use artificial intelligence tools (such as ChatGPT) to help us create, format, or improve written materials, including patient education handouts, office forms, and general communications. These tools are never used for medical diagnosis or treatment decisions. All documents or summaries prepared with the assistance of AI are reviewed and approved by our staff and providers before being shared with patients. This allows us to save time on administrative tasks while ensuring that all medical guidance comes directly from our clinical team.

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Medical Records Request: We require 2 weeks to respond to all medical records requests. There is a $26.06 retrieval fee plus $0.55 per page for all requests.
Requests from specialists or the consulting physician office will be supplied at no charge. HIPAA: Since the HIPAA (Health Portability & Accountability Act of 1996) has been passed by the government, it is designed to protect the patient and their privacy as it relates to their medical information, our office now mandates that NO information will be released to any individual, school, business, family member or friend unless the patient, or legal guardian of the patient has signed a HIPAA release form listing them as recipients for this information. NO EXCEPTIONS
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No Refund/Return Policy:
Schoenwalder Health & Wellness, LLC has a NO refund/return policy. All office-visit service fees are non -refundable. All service discount packages/purchases (IV, HOCATT Sauna, HUGO PEMF, Injections) are non- refundable.

If for some reason you are unable to continue the service/therapy - you may apply any credit balance to other services offered.

All opened products purchased in office – are not refundable.

By checking the box below, I am stating my agreement to adhere to the polices mentioned in this statement.

AUTHORIZATION TO UTILIZE UNENCRYPTED EMAIL/ TEXT MESSAGING TO COMMUNICATE PROTECTED HEALTH INFORMATION

1. RISKS OF USING E-MAIL AND TEXT MESSAGING

Schoenwalder Health & Wellness, LLC offers patients the opportunity to communicate by electronic mail (e-mail) and text (SMS) messaging. E-mail and text (SMS) messaging has a number of possible risks that you should consider before using it or authorizing Schoenwalder Health & Wellness, LLC to communicate with you in these manners. We want to make sure you know that unencrypted email and text communications are not secure communications. By checking the box below this document you are authorizing Schoenwalder Health & Wellness, LLC to communicate with you via email and text (SMS) messaging with the understanding that there is no way to secure that information, including information regarding your medical care. Some of the possible risks of using email or text messaging include, but are not limited to, the following:
a. E-mail information or text messages can be sent on to other people, stored on a computer, or printed out on paper for storage.
b. E-mail or text messages can be sent out and received by many recipients, some or all of whom may be sent the e-mail accidently.
c. E-mail or text message senders can easily misaddress their message.
d. E-mail or text message information is easier to change than handwritten or signed documents.
e. E-mail or text message information may be kept on computers/electronic devices even after the sender or the recipient believes they deleted his or her copy.
f. Employers and on-line services have a right to archive (store) and look at e-mails/text messages transmitted through their systems. Some, but not all, employers store e-mail/text messages indefinitely.
g. E-mail/text messages can occasionally be intercepted, changed, forwarded, or used without authorization or detection.
h. E-mail or text messages can be used to introduce viruses into computer systems.
i. E-mail or text messages can be used as evidence in court.

2. CONDITIONS FOR THE USE OF E-MAIL AND TEXT MESSAGING

Because of the risks outlined above, Schoenwalder Health & Wellness, LLC cannot guarantee the security and confidentiality (privacy) of e-mail/text messaging communication, and will not be liable for improper use and/or disclosure of confidential information (including Protected Health Information that is the subject of the federal Health Insurance Portability and Accountability Act of 1996). Thus, you must consent to the use of e-mail/text messaging for patient information. Consent to the use of e-mail/text messaging includes agreement with the following conditions:
a. E-mails/text messages to or from you may be printed out and/or made part of your medical record. Because they may be a part of the medical record, other individuals who are authorized to view the medical record, such as staff and billing personnel, will also have access to those messages.
b. Schoenwalder Health & Wellness, LLC may forward e-mails/text messages internally to other staff or agents of Schoenwalder Health & Wellness, LLC as necessary for diagnosis, treatment, reimbursement, and other operations. Schoenwalder Health & Wellness, LLC may possibly forward e-mail/text messages to other health care providers participating in your care.
c. Although Schoenwalder Health & Wellness, LLC will try to read and respond to an e-mail in an appropriate time frame, Schoenwalder Health & Wellness, LLC cannot guarantee that any particular e-mail will be read and responded to within any particular period of time and it may take up to a week or longer to respond. Thus, you should never use e-mail for medical emergencies or other matters that have to be handled quickly.
d. Text messages may be used by Schoenwalder Health & Wellness, LLC for appointment reminders or to share more generic information. When text messages are sent by you there should not be an expectation of a response from the Schoenwalder Health & Wellness, LLC.
e. If your e-mail requires or invites a response from Schoenwalder Health & Wellness, LLC and you have not received a response within a reasonable time period, it is your responsibility to call the practice in order to determine whether the intended recipient received the e-mail and when the recipient will respond. As an alternative, you can discuss the issue by telephone.
f. You should not use e-mail or text messages to discuss any subjects that you feel should be kept confidential, such as sensitive medical information regarding sexually transmitted diseases, AIDS/HIV, mental health, developmental disability, or substance abuse.
g. Where applicable, there may be a provider charge for the time necessary to respond to the e-mail.
h. You are responsible for protecting your password or other means of access to e-mail or text messaging. Schoenwalder Health & Wellness, LLC is not liable for information that is read by other people through errors caused by you or any third party.
i. If through e-mail or text message communication, it is determined that an office or hospital visit is necessary to address the problem, or if you want to have such a visit, it is your responsibility to schedule the appointment.

3. PATIENT ACKNOWLEDGMENT AND AGREEMENT

I acknowledge that I have read and fully understand the information Schoenwalder Health & Wellness, LLC has provided me regarding the risks and conditions of using e-mail or text messaging. I understand the risks associated with the communication of e-mail or text messages between Schoenwalder Health & Wellness, LLC and me, and consent to the conditions outlined. In addition, I agree to the above instructions, as well as any other instructions that Schoenwalder Health & Wellness, LLC may impose regarding e-mail or text message communications.

Accordingly, I hereby consent and state my preference to have my provider and other staff at Schoenwalder Health & Wellness, LLC communicate with me by email or standard text (SMS) messaging regarding various aspects of my medical care, which may include, but shall not be limited to, test results, prescriptions, appointments, and billing.

I understand that email and standard text (SMS) messaging are not confidential methods of communication and may be insecure. I further understand that, because of this, there is a risk that email and standard text (SMS) messaging regarding my medical care might be intercepted and read by a third-party.
This authorization may be revoked at any time and must be done in writing. It is understood that the revocation will not apply to information that has already been released based on this authorization.

If you agree to the foregoing terms, please indicate your acceptance by checking the box below that you accept the terms and conditions outlined herein.

Missed Appointment/Late Cancellation Notice Fees

Due to the increased number of patient “no shows” and/or last-minute cancellations, we now require 24 hours’ notice if you are unable to keep your appointment. The notice must be done via text or call our office or exchange phone: (314) 285-4747. Failure to do so will result in being charged the full amount of the office visit scheduled for each appointment missed. Three missed appointments without the courtesy of notification will result in termination of patient care at this practice. Please note the appointment reminder calls/texts from our office are a courtesy to you. It is still your responsibility to keep track of your appointment date and time. Not receiving a reminder call/email will not excuse you from the no show fee.

We understand that sometimes emergencies will interfere with schedules, but please make every effort to contact us promptly. Please consider a missed appointment is valuable time that could have been utilized for other patient care needs.

FEE SCHEDULE/STATEMENT OF FINANCIAL RESPONSIBILITY:

It is understood that payment for services rendered by Michael Schoenwalder, DO LLC; DBA as Schoenwalder Health & Wellness is my responsibility.

A copy of this form shall have the same force and effect as the original.

The undersigned is the patient, the patient's legal representative or is authorized by the patient to execute this form and accepts its terms.

Additional Financial Policy information:
We are committed to the success of your medical treatment and care. Please understand that a mutual financial understanding is part of our relationship, please review the following closely.

Each appointment is set for an allotted amount of time. If you use additional time over the allotted time scheduled, you may be charged an additional $85 in 15min increments as they are utilized.

Payment is Due at the Time of Service.
We accept cash, checks, debit, HSA (with Visa or Mastercard Logo), all major credit cards and CareCredit.
All past due balances and fees of service are due at the time of service unless you have made payment arrangements in advance of your appointment.
Any outstanding balances due will be charged to the card on file.

Returned Checks: There is a $30 fee for each returned check. You are required to pay our returned check processing fee plus the amount of the check that was written by cash or money order within 15 days of notification from us.

Failure to do so may result in our office contacting a collection agency for further review. If we receive two (2) returned checks from a patient, we will no longer accept another check from that patient. Cash or money orders will need to be the method of payment.
Proof of Insurance:

Please provide proof of insurance cards and a valid photo ID with you at each visit. It is your responsibility to notify the office of changes in your health insurance. Insurance cards will be checked at EVERY visit so please have your most current insurance card available for verification. We do not bill your insurance, but in the event, we order laboratory testing or tests from another facility we are required to supply this information.

You will be financially responsible for charges and the filing to any insurance carrier.

Please be aware that some or all the services you receive may be non-covered or not considered medically necessary by your insurer. You must pay for these services in full. Since each insurance plan/group policy can vary greatly, you are responsible for knowing your insurance benefits.

Note: If you have Medicare or a Medicare Advantage Plan, you will not be able to submit any claims from our office to them for reimbursement.
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RELEASE OF INFORMATION, ASSIGNMENT OF BENEFITS, AND FINANCIAL RESPONSIBILITY

I hereby authorize Michael Schoenwalder, DO LLC DBA Schoenwalder Health & Wellness (facility) to release by electronic means or otherwise any medical and/or billing information concerning my care, including copies of my medical records to the following:

a. Any person or entity responsible for payment for the medical services rendered to me at the facility, including third party payers, self-insurers, worker's compensation carriers and government agencies or any person or entity acting as the agent or contractor of such party responsible for payment, in connection with obtaining payment for the medical services rendered to me at by employees of the facility or any person providing services at the facility.

b. Federal, State, or other governmental or quasi-governmental agencies or such other parties required by law for reporting purposes or for purposes of determining eligibility in government sponsored benefit programs.

c. Any health professionals involved in my care for the purpose of facilitating the continuity of my medical care.
This includes information related to alcohol abuse, drug abuse, psychological or psychiatric conditions and Acquired Immune Deficiency Syndrome (AIDS). I acknowledge that the above authorization has no expiration date and is valid to authorize the release of medical records and billing information at any time a valid request is received.

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Fee Schedule

Medical Consultations (IN OFFICE/ TELEMED)
Acute Consultation $140
Initial Consultation $445.00
Follow Up Consultation $190
Comprehensive Exam-required 1/year $255
Well Woman Exam $255

*Specialty labs may be recommended prior to your office visit - costs for lab testing are not included
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Administration Fees

New Patient Appointment Deposit $225
Contolled Prescription Admin $25
Missed Appointment Fee cost of appt
Medical Marijuana Form $75
Physician Statement/ Letter $75.00
Prior Authorization Initial $35/Appeal $75
Physician Short Form/Letter $35
Returned Check $30
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It is our policy that every patient has at least one annual comprehensive review and a six-month follow-up appointment with a provider to receive any medication refills or treatment protocols such as IV, Hugo, Ozone Sauna, and laser therapy)

Credit Card On File Policy:
I authorize Michael Schoenwalder DO LLC DBA Schoenwalder Health & Wellness to charge my credit card account. This card will automatically be charged when you miss your appointment without prior cancellation via email. Please note that once your credit card information is entered, it is encrypted and cannot be viewed or accessed by our organization. Our system is registered with PayPal and is a certified PCI compliant provider. Refusal to provide credit card information will not exempt you from receiving a charge for missed appointment fees. If you supply a credit card to us verbally, it will be assumed you have authorized the use of this card for any outstanding balances.

Notice of Privacy Practices:

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

If you have any questions about this Notice, please contact:

Office Manager at 314-721-2140

Who Will Follow This Notice?
1. Schoenwalder Health & Wellness;
2. Schoenwalder Health & Wellness’ personnel and staff; and
3. Schoenwalder Health & Wellness’ subcontractors.

We understand that medical information about you and your health is personal and are committed to protecting this information. When you receive care from Schoenwalder Health & Wellness, a record of the care and services you receive is made. Typically, this record contains your treatment plan, history and physical, test results, and billing record. This record serves as a:
1. Basis for planning your treatment and services;
2. Means of communication among the physicians and other health care providers involved in your care;
3. Means by which you can verify that services billed were actually provided;
4. Source of information for public health officials; and
5. Tool for assessing and continually working to improve the care rendered.

This Notice tells you the ways we may use and disclose your Protected Health Information (referred to herein as “medical information”). It also describes your rights and our obligations regarding the use and disclosure of medical information.
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Our Responsibilities

Schoenwalder Health & Wellness is required by law to:
1. Maintain the privacy and security of your medical information;
2. Provide you with notice of our legal duties and privacy practices with respect to information we collect and maintain about you;
3. Abide by the terms of this notice;
4. Notify you if we are unable to agree to a requested restriction;
5. Accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations; and
6. Notify you, and the Department of Health & Human Services, of any unauthorized acquisition, access, use or disclosure of your unsecured medical information. We are required by law to notify you following a breach of unsecured protected health information. Unsecured medical information means medical information not secured by technology that renders the information unusable, unreadable, or indecipherable as required by law.
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The Methods in Which We May Use and Disclose Medical Information about You

The following categories describe different ways we may use and disclose your medical information. The examples provided serve only as guidance and do not include every possible use or disclosure.

For Treatment.
We will use and disclose your medical information to provide, coordinate, or manage your health care and any related service. For example, we may share your information with your primary care physician or other specialists to whom you are referred for follow-up care.

For Payment.
We will use and disclose medical information about you so that the treatment and services you receive may be billed and payment may be collected from you, an insurance company, or a third party. For example, we may need to disclose your medical information to a health plan in order for the health plan to pay for the services rendered to you.

For Health Care Operations.
We may use and disclose medical information about you for office operations. These uses and disclosures are necessary to run Schoenwalder Health & Wellness in an efficient manner and provide that all patients receive quality care. For example, your medical records and health information may be used in the evaluation of services, and the appropriateness and quality of health care treatment.

Appointment Reminders.
We may use and disclose medical information in order to remind you of an appointment. For example, Schoenwalder Health & Wellness may provide a written or telephone reminder that your next appointment with Schoenwalder Health & Wellness is coming up.

Research.
Under certain circumstances, we may use and disclose medical information about you for research purposes. For example, a research project may involve comparing the surgical outcome of all patients for whom one type of procedure is used to those for whom another procedure is used for the same condition. All research projects, however, are subject to a special approval process. Prior to using or disclosing any medical information, the project must be approved through this research approval process. We will ask for your specific authorization if the researcher will have access to your name, address, or other information that reveals who you are, or will be involved in your care.

As Required by Law.
We will disclose medical information about you when required to do so by federal or Texas laws or regulations.

To Avert a Serious Threat to Health or Safety.

We may use and disclose medical information about you to medical or law enforcement personnel when necessary to prevent a serious threat to your health and safety or the health and safety of another person.

Sale of Practice.
We may use and disclose medical information about you to another health care facility or group of physicians in the sale, transfer, merger, or consolidation of our practice.
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Special Situations

Organ and Tissue Donation.
If you have formally indicated your desire to be an organ donor, we may release medical information to organizations that handle procurement of organ, eye, or tissue transplantations.

Military and Veterans.
If you are a member of the armed forces, we may release medical information about you as required by military command authorities.

Workers’ Compensation.
We may release medical information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.

Qualified Personnel.
We may disclose medical information for management audit, financial audit, or program evaluation, but the personnel may not directly or indirectly identify you in any report of the audit or evaluation, or otherwise disclose your identity in any manner.

Public Health Risks.
We may disclose medical information about you for public health activities. These activities generally include the following activities:

To prevent or control disease, injury, or disability;

To report reactions to medications or problems with products;

To notify people of recalls of products they may be using;

To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; and

To notify the appropriate government authority if we believe you have been the victim of abuse, neglect, or domestic violence.

All such disclosures will be made in accordance with the requirements of Texas and federal laws and regulations.

Health Oversight Activities.
We may disclose medical information to a health oversight agency for activities authorized by law. Health oversight agencies include public and private agencies authorized by law to oversee the health care system. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, eligibility or compliance, and to enforce health-related civil rights and criminal laws.

Lawsuits and Disputes.
If you are involved in certain lawsuits or administrative disputes, we may disclose medical information about you in response to a court or administrative order.
Law Enforcement. We may release medical information if asked to do so by a law enforcement official:
In response to a court order or subpoena; or
If Schoenwalder Health & Wellness determines there is a probability of imminent physical injury to you or another person, or immediate mental or emotional injury to you.

Coroners, Medical Examiners and Funeral Directors.

We may release medical information to a coroner or medical examiner when authorized by law (e.g., to identify a deceased person or determine the cause of death). We may also release medical information about patients to funeral directors.

Inmates.
If you are an inmate of a correctional facility, we may release medical information about you to the correctional facility for the facility to provide you treatment.

Other Uses or Disclosures.
Any other use or disclosure of PHI will be made only upon your individual written authorization. You may revoke an authorization at any time provided that it is in writing and we have not already relied on the authorization.

Electronic Disclosure.
We may use and disclose your medical information electronically. For example, your medical information is maintained on an electronic health record. If another provider requests a copy of your medical record for treatment purposes, we may forward such record electronically.

DISCLOSURES REQUIRING AUTHORIZATION

Psychotherapy Notes.
Psychotherapy notes are notes by a mental health professional that document or analyze the contents of a conversation during a private counseling session – or during a group, joint, or family counseling session. If these notes are maintained separate from the rest of your medical records, they can only be used and disclosed as follows. In general, psychotherapy notes may not be used or disclosed without your written authorization, except in the following circumstances.

Psychotherapy notes about you may be used and disclosed without your written authorization in the following situations:

The mental health professional who created the notes may use them to provide you with further treatment;

The mental health professional who created the notes may disclose them to students, trainees or practitioners in mental health who are learning under supervision to practice or improve their skills in group, joint, family, or individual counseling;

The mental health professional who created the notes may disclose them as necessary to defend himself or herself or Schoenwalder Health & Wellness in a legal proceeding initiated by you or your personal representative;

The mental health professional who created the notes may disclose them as required by law;
The mental health professional who created the notes may disclose the notes to appropriate government authorities when necessary to avert a serious and imminent threat to the health or safety of you or another person;

The mental health professional who created the notes may disclose them to the United States Department of Health and Human Services when that agency requests them in order to investigate the mental health professional’s compliance, or Schoenwalder Health & Wellness’s compliance, with Federal privacy and confidentiality laws and regulations; and
The mental health professional who created the notes may disclose them to medical examiners and coroners, if necessary, to determine your cause of death.

All other uses and disclosures of psychotherapy notes require your written authorization. You have the right to revoke such authorization in writing.

Marketing.
Marketing generally includes a communication made to describe a health-related product or service that may encourage you to purchase or use the product or service. For example, marketing includes communications to you about new state-of-the-art equipment if the equipment manufacturer pays us to send the communication to you. We will obtain your written authorization to use and disclose PHI for marketing purposes unless the communication is made face-to-face, involves a promotional gift of nominal value, or otherwise permitted by law.

All other uses and disclosures of your information for marketing purposes require your written authorization.
You have the right to revoke such authorization in writing.

Sale of your Medical Information.

Schoenwalder Health & Wellness will not sell your medical information for marketing purposes. However, there are instances in which Schoenwalder Health & Wellness will sell your PHI. For example, should Schoenwalder Health & Wellness merge or the practice is sold to another physician group, your medical record may be part of the asset transfer.

Any other Sale of Protected Health Information requires your written authorization. You have the right to revoke such authorization in writing.

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YOUR RIGHTS REGARDING YOUR MEDICAL INFORMATION

You have the following rights regarding medical information collected and maintained about you:

Right to Inspect and Copy.
The right to inspect and copy medical information that may be used to make decisions about your care. Usually, this includes medical and billing records.

To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to the Privacy Officer for Schoenwalder Health & Wellness.
If you request a copy of the information, Schoenwalder Health & Wellness may charge a fee established by the Missouri Medical Board for the costs of copying, mailing, or summarizing your records.

You can also ask to see or get an electronic copy of health information we have about you.

Ask us how to do this.

Schoenwalder Health & Wellness may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. Another licensed health care professional chosen by Schoenwalder Health & Wellness will review your request and denial. The person conducting the review will not be the person who denied your request. Schoenwalder Health & Wellness will comply with the outcome of the review.

Right to Amend.
If you feel that medical information maintained about you is incorrect or incomplete, you may ask Schoenwalder Health & Wellness to amend the information. You have the right to request an amendment for as long as the information is kept by Schoenwalder Health & Wellness.

To request an amendment, your request must be made in writing and submitted to Schoenwalder Health & Wellness. In addition, you must provide a reason that supports your request.
Schoenwalder Health & Wellness may deny your request for an amendment if it is not in writing or does not include a reason to support the request.

In addition, Schoenwalder Health & Wellness may deny your request if you ask us to amend information that:

Was not created by Schoenwalder Health & Wellness, unless the person or entity that created the information is no longer available to make the amendment;

Is not part of the medical information kept by Schoenwalder Health & Wellness;

Is not part of the information which you would be permitted to inspect and copy; or
Is accurate and complete.

Right to an Accounting of Disclosures.
To request an “accounting of disclosures.” This is a list of the disclosures made of your medical information for purposes other than treatment, payment, or health care operations.

To request this list you must submit your request in writing to our office by emailing ContactUs@SchoenwalderHealth.com . Your request must state a time period, which may not be longer than six (6) years. Your request should indicate in what form you want the list (for example, on paper or electronically). The first list you request within a 12-month period will be free. For additional lists within the 12-month period, you may be charged for the cost of providing the list. Schoenwalder Health & Wellness will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

Right to Request Restrictions.
To request a restriction or limitation on the medical information Schoenwalder Health & Wellness uses or discloses about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information Schoenwalder Health & Wellness discloses about you to someone who is involved in your care or the payment for your care.
Schoenwalder Health & Wellness is not required to agree to your request, unless the request pertains solely to a healthcare item or service for which Schoenwalder Health & Wellness has been paid out of pocket in full and: (i) the restriction pertains to payment or a healthcare operation and (ii) the disclosure is not otherwise required by law. Should Schoenwalder Health & Wellness agree to your request, Schoenwalder Health & Wellness will comply with your request unless the information is needed to provide you emergency treatment.
To request restrictions you must make your request in writing to Schoenwalder Health & Wellness. In your request, you may indicate: (1) what information you want to limit; (2) whether you want to limit Schoenwalder Health & Wellness’s use and/or disclosure; and (3) to whom you want the limits to apply.

Right to Request Confidential Communications.
To request that Schoenwalder Health & Wellness communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that Schoenwalder Health & Wellness contact you only at work or by mail.
To request that Schoenwalder Health & Wellness communicate in a certain manner, you must make your request in writing to the Privacy Officer. You do not have to state a reason for your request. Schoenwalder Health & Wellness will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

Right to Revoke an Authorization.

There are certain types of uses or disclosures that require your express authorization. For example, Schoenwalder Health & Wellness may not sell your information to a third party for marketing purposes without first obtaining your authorization. If you provide authorization for a particular use or disclosure of your medical information, you may revoke such authorization in writing by contacting us via email at ContactUs@SchoenwalderHealth.com . We will honor your revocation except to the extent that we have already taken action in reliance of the specific authorization.

Right to Receive a Copy of this Document.

You have a right to obtain a paper copy of this document upon request.
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CHANGES TO THIS NOTICE
We reserve the right to change our practices and to make the new provisions effective for all PHI we maintain. Should our information practices change, we will post the amended Notice of Privacy Practices in our office and on our website. You may request that a copy be provided to you by contacting the Privacy Officer.
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COMPLAINTS
If you believe your privacy rights have been violated, you may file a complaint with Schoenwalder Health & Wellness or with the Office for Civil Rights, U.S. Department of Health and Human Services. To file a complaint with Schoenwalder Health & Wellness, contact the Practice Manager at 314-721-2140. Your complaint must be filed within 180 days of when you knew or should have known that the act occurred. The address for the Office of Civil Rights is:
Secretary of Health & Human Services
Region VII, Office for Civil Rights
U.S. Department of Health and Human Services
601 East 12th Street – Room 248
Kansas City, Missouri 64106
All complaints should be submitted in writing.
You will NOT be penalized for filing a complaint.
We are legally required to give you this Notice and to get a signed statement that you received it. By signing this form, you are saying that you have received Schoenwalder Health & Wellness LLC Notice of Privacy Practices.

Schoenwalder Health & Wellness LLC Notice of Privacy Practices tells you how we can use and disclose your health information. It also describes certain rights you have about your health information kept by us. Please review the Notice of Privacy Practices carefully.

Checking the box below hereby acknowledges receipt of Notice of Privacy Practices for Michael Schoenwalder, DO. DBA SCHOENWALDER HEALTH AND WELLNESS LLC.