Functional Family Nurse Practitioner is the Assumed Name of the Corporation, Sara Robl, Nurse Practitioner in Family Health, PLLC. Functional Family Nurse Practitioner may be referred to as FFNP, and in all cases, references back to Sara Robl, Nurse Practitioner in Family Health, PLLC.
Services Policy
**Functional Family Nurse Practitioner (FFNP) Services Policies**
Our Mission at Functional Family Nurse Practitioner is to assist you in achieving your health and wellness goals using a holistic approach that incorporates mind, body, and spirit. Our philosophy is to educate, inspire and empower you, with the goal that you may develop sustainable lifestyle practices which promote optimal health and wellness.
This approach complements any existing health care program. You may or may not be utilizing all services.
**Functional Family Nurse Practitioner (FFNP) Intent: ** The intent of any and all services offered and/or nutritional protocols or lifestyle recommendations suggested by Sara Robl, FNP-C and the FFNP 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, FFNP does not act as your Primary Care Provider. You must continue to have a Medical Primary Care Provider and keep them informed of all your healthcare activities.
**Cancellations: ** We request a minimum of 72 hours advance notice for any cancellation or rescheduling of your appointment. This is a consideration to our practitioners. Short notice or no notice will result in an office visit charge at the regular rate or use of one of your Membership visits.
**Consent to Participate in Telemedicine/Telehealth Consultation** By scheduling with Functional Family Nurse Practitioner and by signing this agreement I acknowledge that I am agreeing to participate in telemedicine/telehealth consultation (tele-consults) with the practitioners and/or staff at Functional Family Nurse Practitioner (FFNP). I am seeking this tele-consult for my own purposes and not on behalf of any third party. I understand the risks, benefits, limitations and alternatives to tele-consults (including the option to seek a different practitioner for in-person services) and have chosen of my own free will to participate in tele-consults with Functional Family Nurse Practitioner. 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 FFNP practitioners at any time. I accept that the FFNP practitioner may at any time refer me to a different office if the nature of my consultation is inappropriate for tele-consults. 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.
**Memberships** See your separate Membership Agreement for all terms and conditions.
**Patients outside of New York State. ** Our practitioners are currently only offering services to patients residing in New York State. You must always have a Primary Care Provider that you work with even if consulting with one of our NP practitioners. You agree to keep your Primary Care Provider informed of all your health and lifestyle changes. Be especially mindful if you take prescriptions for high conditions such as high blood pressure and/or diabetes as changes in weight and lifestyle may affect the dosage required for these conditions.
**Payment of Services: ** Payment in full is expected at the time of scheduling or through our Membership options. Functional Family Nurse Practitioner receives payment in cash, credit, and debit card form. There are no service or membership refunds. You agree that your credit card on file will be automatically charged for any Functional Family Nurse Practitioner invoices generated, such as your visit fee or if a supplement order or lab order is requested. You also authorize Functional Family Nurse Practitioner to automatically charge your credit card for any missed appointments or late cancellations of less than 72 hours in advance at the full-service fee. There is no additional charge for rescheduling or canceling appointments more than 72 hours in advance. Keep in mind, membership visits must be used each month, they do not roll over. See your Membership Agreement for full details. 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.
**Primary Care Provider (PCP): ** Sara Robl, FNP-C, is a Family Nurse Practitioner and specializes in Functional Medicine and nutrition counseling operating within the scope of her license. Sara Robl, FNP-C is not a medical doctor, does not act as a Primary Care Provider and is not on call, nor are any Functional Family Nurse Practitioner providers, regardless of license type including MD/DO/DC/ND/PhD/NP. Please maintain a positive, working relationship with your PCP, keep him/her informed of your healing activities and continue your regular medical care and check-ups. This applies to all providers/practitioners with Functional Family Nurse Practitioner.
**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 FFNP cannot issue any refunds, please only purchase items you intend to use. There are no service or membership refunds.
**Photo release, Social Media release, Website and Marketing release** You agree to authorize Functional Family Nurse Practitioner, Sara Robl, Nurse Practitioner in Family Health, PLLC and Sara Robl, FNP-C to 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 Functional Family Nurse Practitioner and Sara Robl, FNP-C 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 FFNP Policies** All current updates to our Policies will be immediately applicable to you & all previous signers and posted on the Functional Family Nurse Practitioner website and in our Jane App software. You may view them there or request an updated copy emailed to you at any time.
**Stopping Medication: ** Functional Family Nurse Practitioner will evaluate taking you off any medication on a case-by-case basis, and only in coordination with your Prescribing Provider. 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 Prescribing Provider to monitor your progress and see if you are able to lower or eliminate your medication dosage over time. Keep your Prescribing Provider informed. Never stop taking a medication without consultation with your Prescribing Provider.
**Emergencies: ** In case of an emergency, call your PCP, visit your local emergency room, urgent care or call 911.
INFORMED CONSENT
**OFFICE SERVICES**
You may or may not be utilizing all of the services mentioned below:
Functional Family Nurse Practitioner offers a variety of holistic healthcare and/or coaching services including nutrition, health coaching, functional medicine, nutritional lab education, all through practitioners operating within their scope of practice. All of these holistic services are collectively referred to as Nutrition Care/Support or Ancillary Services.
**INFORMED CONSENT 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.
**Alternatives to Ancillary Services** - Other treatment options for your condition may include rest, acupuncture, physical therapy, medical care, medications (both over the counter and prescribed), hospitalization, surgery, no treatment and others. If you choose to use other treatment options, you should discuss the risks and benefits with your medical doctor or other providers.
*Updates to Informed Consent** All current updates to our Informed Consent will be immediately applicable to you & all previous signers and posted on the Functional Family Nurse Practitioner website and in our Jane App software. You may view them there or request an updated copy emailed to you at any time.
DO NOT SIGN THIS FORM UNTIL YOU HAVE READ AND UNDERSTAND THIS FORM. UPON DOING SO, PLEASE COMPLETE THE INFORMATION AND SIGN THIS FORM.
HIPPA Privacy NOTICE
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.
Effective Date: November 1, 2022
Your health information is private, and no one without a legitimate need to know may have access to it. Functional Family Nurse Practitioner (“Practice”) is required by law to maintain the privacy of your health information and to provide you with a notice of its legal duties and privacy practices. In the unlikely event that your health information becomes unsecured, Practice will provide you with prompt notification.
Practice will not use or disclose your health information except as described in this Notice of Privacy Practices (“Notice”). This Notice applies to all of the medical records generated during your treatment at Practice.
EXAMPLES OF DISCLOSURE FOR TREATMENT, PAYMENT AND HEALTH OPERATIONS
The following categories describe the ways that Practice may use and disclose your health information:
Treatment: Practice will use your health information in the provision and coordination of your healthcare. We may disclose all or any portion of your medical record information to your physician, consulting physician(s), nurses and other healthcare providers who have a legitimate need for such information in the care and continued treatment of the patient. For example, a healthcare provider treating you for an injury can ask another healthcare provider about your overall health condition.
Payment: Practice may release medical information about you for the purposes of determining coverage, billing, claims management, medical data processing and reimbursement. The information may be released to an insurance company, third-party payor or other entity (or their authorized representatives) involved in the payment of your medical bill and may include copies or excerpts of your medical record that are necessary for payment of your account. For example, to the extent Practice bills for services it provides to you, a bill sent to a third-party payor may include information that identifies you, your diagnosis, the procedures and supplies used.
Routine Healthcare Operations: Practice may use and disclose your medical information during routine health care operations to run our practice, improve your care, and contact you when necessary. For example, we can use your health information to manage your treatment and services.
Business Associates: Practice may use and disclose certain health information about you to its business associates. A business associate is an individual or entity under contract with Practice to perform or assist Practice in a function or activity that necessitates the use or disclosure of medical information. Examples of business associates include but are not limited to, a copy service used by the Clinic to copy medical records, consultants, independent contractors, accountants, lawyers, medical transcriptionists and third-party billing companies. Practice requires the business associate to protect the confidentiality of your medical information. In addition, Practice requires any subcontractor of Practice’s business associate to protect the confidentiality of your medical information.
Regulatory Agencies: Practice may disclose your medical information to public health or legal authorities charged with preventing or controlling disease, injury or disability. For example, billing practices may be audited by the State Auditor and records are subject to review by the Secretary of Health and Human Services and his/her authorized representatives.
Workers’ Compensation: Practice may release medical information about you for workers’ compensation or similar programs that provide benefits for work-related injuries or illnesses.
Military Veterans: Practice may disclose your medical information as required by military command authorities if you are a member of the armed forces.
Inmates: If you are an inmate of a correctional institution or under the custody of a law enforcement officer, Practice may release your medical information to the correctional institution or law enforcement official.
Organ and Tissue Donation Requests: Medical information can be shared with organ procurement organizations.
Medical Examiner or Funeral Director: Medical information can be shared with a coroner, medical examiner, or funeral director when an individual dies.
Required by Law: Practice will disclose medical information about you when required to do so by law, for example, responding to lawsuits and legal actions.
Other Uses: Any other uses and disclosures will be made only with your written authorization.
PATIENT INFORMATION RIGHTS
Although all records concerning your treatment obtained at Practice are the property of Practice, you have the following rights concerning your medical information:
Right to Confidential Communications: You have the right to receive confidential communications of your medical information by alternative means or at alternative locations. For example, you may request that Practice contact you only at work or by mail.
Right to Inspect and Copy: You have the right to inspect and copy your medical information.
Right to Amend: You have the right to amend your medical information. Any request for amendment should be submitted to Practice in writing, stating a reason in support of the amendment.
Right to an Accounting: You have the right to obtain an accounting of the disclosures of your medical information made during the preceding six (6) year period.
Right to Request Restrictions: You have the right to request restrictions on certain uses and disclosures of your medical information. Practice is not required to honor your request except where: (i) the disclosure is for the purpose of carrying out payment or healthcare operations and is not otherwise required by law, and (ii) the medical information pertains solely to a healthcare item or service for which you, or person other than the health plan on your behalf, has paid Practice in full.
Right to Receive a Paper Copy: You have the right to receive a paper copy of this Notice.
Right to Receive Electronic Copies: You have the right to receive electronic copies of your medical information.
Right to Choose Someone to Act For You: If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
Right to Revoke Authorization: You have the right to revoke your authorization to use or disclose your medical information, except to the extent that action has already been taken in reliance on your authorization. A request to exercise any of these rights must be submitted, in writing, to Practice at 214 East Main St. Waterville, NY 13480, or by contacting Practice at 315-962-1051.
FOR MORE INFORMATION OR TO REPORT A PROBLEM
If you have questions and would like additional information, you may contact our office at 315-962-1051. If you believe your privacy rights have been violated, you may file a complaint with us by calling 315-962-1051 and with the U.S. Department of Health and Human Services Office for Civil Rights by calling 1-800-368-1019, visiting https://ocrportal.hhs.gov/ocr/smartscreen/main.jsf, emailing OCRComplaint@hhs.gov, or sending a letter to:
Centralized Case Management Operations
U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Room 509F HHH Bldg.
Washington, D.C. 20201
We will not retaliate against you for filing a complaint.
CHANGES TO THIS NOTICE
Practice will abide by the terms of the Notice currently in effect. Practice reserves the right to change the terms of its Notice and to make the new Notice provisions effective for all health information that it maintains. An updated version of the Notice may be obtained at Practice.
**We may also provide treatment in an “open” 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. **
**Please see your Membership Agreement for details about our optional group “Open Office Hours”. **
We may also mail, email or text information to you regarding your health care or about the status of your account. 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 Functional Family Nurse Practitioner in writing and please do not email the office. Sending an email to Team@Functionalfamilynp.com 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.
All current updates to our Privacy Policy will be immediately applicable to you and all previous signers and posted on the Functional Family Nurse Practitioner website and in our Jane App software. You may view them there or request an updated copy emailed to you at any time.
We 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.