Policy and Informed Consent
for Dr. Anita Larrow, ND’s Office
(2025-)
General Policies
Welcome to our practice. We look forward to working with you on your healthcare needs. Please read over and initial the entire document. If you have any questions please feel free to contact Dr. Larrow.
Appointments
It is Dr. Larrow’s responsibility to be onsite providing services, or to inform you appropriately otherwise; you are responsible for keeping the appointment or giving us a 1 business day notice of cancellation. Failure to do so prevents Dr. Larrow from seeing another patient during that period. Should you decide not to keep the appointment without giving the appropriate notice, you agree to pay a $40.00 cancellation fee. In order to enforce this we may ask you for a credit card to hold your appointment otherwise services may be withheld, denied, or limited, depending on the doctor’s discretion and the patient’s immediate needs. Your credit card will not be charged unless you, without notification, miss your appointment. Please note that insurance companies typically do not reimburse for missed appointment fees.
Payment
Anita M. Larrow, ND requires payment in full at the time services are rendered. For your convenience we accept personal check or credit card (VISA, MasterCard, AMEX, Discover) for payment. There will be a $35.00 fee for all returned checks. Please notify Dr. Larow in advance if cash is your prefered method of payment.
Insurance
Dr. Anita M. Larrow, ND is not a contracted provider for any insurance companies nor does Dr. Larrow submit claims to insurance companies on your behalf. She will, however, provide you with the information necessary for you to submit your claim to your insurance company. You agree that this does not insure any coverage from your insurance company.
Emergencies
You agree that if you have a true medical emergency, or serious medical concern, you must call 911 immediately. If you have an urgent medical concern, please contact Dr. Larrow. If it is after regular business hours (8am to 5pm) please leave a message for Dr. Larrow at (415) 912-9934 and she will return your call as soon as possible, or by the next business day. If Dr. Larrow is not available (i.e. scheduled leave, personal emergency, etc.) then another doctor will be scheduled for on call duty to assist you. You agree that if you cannot wait until the next business day, and Dr. Larrow, or a scheduled on call doctor cannot assist you, that it is your responsibility to seek the appropriate medical care as soon as possible.
Privacy Policy
THIS NOTICE DESCRIBES HOW PROTECTED HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
This Notice tells you about the ways Dr. Anita M. Larrow, ND may collect, store, use and disclose your protected health information and your rights concerning your protected health information. “Protected Health Information” is information about you that can reasonably be used to identify you and that relates to your past, present or future physical or mental health or condition, the provision of health care to you or the payment for that care. Federal and state laws require us to provide you with this Notice about your rights and our legal duties and privacy practices with respect to your protected health information. We must follow the terms of this Notice while it is still in effect. Some of the uses and disclosures described in this Notice may be limited in certain cases by applicable state laws that are more stringent than the federal standards.
Uses and Disclosures of Your Protected Health Information
We may use and disclose your protected health information for different purposes. The examples below are illustrationsof the different types of uses and disclosures that we may make without obtaining your authorization.
Treatment: We may use and disclose your protected health information to assist your other health care providers in your diagnosis and treatment.
Health Care Operations: We may use and disclose your protected health information in order to perform various operational activities.
Enrolled Dependents and Family Members: We may mail correspondence containing protected health information to the address we have on record for you.
Other Permitted or Required Disclosures
As Required by Law: We must disclose protected health information about you when required to do so by law.
Public Health Activities: We may disclose your protected health information to public health agencies for reasons such as preventing or controlling disease, injury or disability.
Victims of Abuse, Neglect or Domestic Violence: We may disclose your protected health information to government agencies about abuse, neglect or domestic violence.
Health Oversight Activities: We may disclose protected health information to government oversight agencies (e.g. state insurance departments) for activities authorized by law.
Judicial and Administrative Proceedings: We may disclose protected health information in response to a court or administrative order. We may also disclose protected health information about you in certain cases in response to a subpoena, discovery request or other lawful process.
Law Enforcement: We may disclose protected health information under limited circumstances to a law enforcement official in response to a warrant or similar process; to identify or locate a suspect; or to provide information about the victim of a crime.
Coroners or Funeral Directors: We may release protected health information to coroners or funeral directors as necessary to allow them to carry out their duties.
Research: Under certain circumstances, we may disclose protected health information about you for research purposes, provided certain measures have been taken to protect your privacy.
To Avert a Serious Threat to Health or Safety: We may disclose protected health information about you, with some limitations, when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.
Special Government Functions: We may disclose information as required by military authorities or to authorized federal officials for national security and intelligence activities.
Workers’ Compensation: We may disclose protected health information to the extent necessary to comply with state law for workers’ compensation programs.
Other Uses or Disclosures With an Authorization
Other uses or disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law. You may revoke an authorization at any time in writing, except to the extent that we have already taken action on the information disclosed or if we are permitted by law to use the information to contest a claim or coverage under the Plan.
Your Rights Regarding your Protected Health Information
You may have certain rights regarding protected health information that Dr. Anita M. Larrow, ND maintains about you.
Right To Access Your Protected Health Information: You have the right to review or obtain copies of yourprotected health information records, with some limited exceptions. Usually the records include billing, claims payment and case or medical management records. Your request to review and/or obtain a copy of your protected health information must be made in writing. We may charge a fee for the costs of producing, copying and mailing your requested information, but we will tell you the cost in advance.
Right to Amend Your Protected Health Information: If you feel that your protected health information maintained by Dr. Anita M. Larrow, ND is incorrect or incomplete, you may request that we amend the information. Your request must be made in writing and must include the reason you are seeking a change. We may deny your request, if for example, you ask us to amend information that was not created by Dr. Anita M. Larrow, ND or you ask us to amend a record that is already accurate and complete. If we deny your request to amend, we will notify you in writing. You then have the right to submit to us a written statement of disagreement with our decision and we have the right to rebut that statement.
Right to an Accounting of Disclosures: You have the right to request an accounting of disclosures we have made of your protected health information. The list will not include our disclosures related to your treatment, our payment or health care operations, or disclosures made to you or with your authorization. The list may also exclude certain other disclosures, such as for national security purposes. Your request for an accounting of disclosures must be made in writing and must state a time period for which you want an accounting. his time period may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (paper or electronically). For additional lists within the same time period, we may charge for providing the accounting, but we will tell you the cost in advance.
Right to Request Restrictions on the Use and Disclosure of Your Protected Health Information: You have the right to request that we restrict or limit how we use or disclose your protected health information for treatment, payment or health care operations. We may not agree to your request. If we do agree, we will comply with your request unless the information is needed for an emergency. Your request for a restriction must be made in writing. In your request, you must tell us (1) what information you want to limit, (2) whether you want to limit how we use or disclose your information, or both, and (3) to whom you want the restrictions to apply.
Right to Receive Confidential Communications: You have the right to request that we use a certain method to communicate with you or that we send information to a certain location if the communication could endanger you. Your request to receive confidential communications must be made in writing. Your request must clearly state that all or part of the communication from us could endanger you. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
Right to a Paper Copy of This Notice: You have a right at any time to request a paper copy of this Notice, even if you had previously agreed to receive an electronic copy.
Contact Information for Exercising Your Rights: You may exercise any of the rights described above by contacting our office. See the end of this Notice for the contact information. Health Information Security Dr. Anita M. Larrow, ND requires its employees to follow its security policies and procedures that limit access to health information about patients to those employees who need it to perform their job responsibilities. In addition, Dr. Anita M. Larrow, ND maintains physical, administrative and technical security measures to safeguard your protected health information. Dr. Larrow’s practice uses Electronic Health Records (EHR) to maintain patient information. These EHR records are stored appropriately, and responsibly, with services that respect PHI, and have agreed to the HIPAA compliant Business Associate Agreement (BAA) with Dr. Larrow as required by federal law. The services used for EHR may change over time depending on the needs of Dr. Larrow’s practice and the requirements of local and federal law. Patients will be notified appropriately of these changes.
Changes to This Notice
We reserve the right to change the terms of this Notice at any time, effective for protected health information that we already have about you as well as any other information that we receive in the future. We will provide you with a copy of the new Notice whenever we make a material change to the privacy practices described in this Notice. Any time we make a material change to this Notice, we will promptly revise and issue the new Notice with the new effective date.
Complaints
If you are concerned that we have violated your privacy rights, or you disagree with a decision we made about access to your records, you may file a complaint with us by contacting the person listed below. You may also send a written complaint to the U.S. Department of Health and Human Services. The person listed below can provide you with the appropriate address upon request.
We support your right to protect the privacy of your protected health information. We will not jeopardize your care or retaliate against you or penalize you for filing a complaint.
Our Legal Duty
We are required by law to protect the privacy of your information, provide this notice about our information practices, and follow the information practices that are described in this notice.
Informed Consent and Request for Naturopathic Medicine
You are hereby requesting and consenting to receive naturopathic medical care by the above named California licensed naturopathic doctor and/or other licensed naturopathic doctors who now or in the future may treat me while working at or associated with or serving as on-call for the above named doctor, whether signatories to this form or not. I have also read and understand the attached NOTICE OF PRIVACY PRACTICES, which discusses my rights under the Health Insurance Portability and Accountability Act of 1996.
I understand that the methods of treatment are permitted under the California Naturopathic Doctors Act, which may include but are not limited to nutritional counseling, herbs, homeopathy, nutritional supplements, oral chelation, hormone therapy, hydrotherapy, intramuscular injections, and IV therapy.
I understand and I am informed that the evaluation, diagnosis and treatment may include, but is not limited to:
Interview: history taking, current and past medical history, family history, social and emotional histories, drugs and supplements currently taking, along with the review of systems.
Physical Examination: general exam, cardiac, lung, EENT, neurological, musculoskeletal, abdominal, etc.
Common Diagnostic Procedures: venipuncture and tests such as, diagnostic imaging, laboratory evaluation of blood, urine, stool and saliva, and pap smears.
CLIA Approved Tests: pregnancy tests, urine analysis, etc.
Dietary Advice and Therapeutic Nutrition: which may include lifestyle and nutritional counseling, diet plans, oral nutritional supplements (with vitamins, minerals, and amino acids), intra-muscular and intravenous vitamin, or supplemental injections.
Botanical Medicines: substances may be given in the forms of teas, tinctures (which may contain alcohol), pills, suppositories, and creams.
Homeopathic Remedies: highly diluted substances of naturally occurring plant, animal or other substances for healing.
Prescription Medications: to be filled at a pharmacy.
Physical Medicine: muscle release techniques, trigger point therapy.
Chelation: heavy metal detoxification, oral and intravenous therapy.
Over the counter medications.
I understand and I am informed that in the practice of Naturopathic Medicine there are risks and benefits with evaluation, diagnosis and treatment including, but not limited to the following:
Potential Risks: allergic reactions (hives, rashes, tingling of the tongue, headache or similar condition) to prescribed supplements, medications, and herbs; which may be severe such as anaphylaxis, cardiac arrest and death. Side effects between natural medications and pharmaceuticals, inconvenience of lifestyle changes, aggravation of present conditions, injuries such as pain, discomfort, discoloration, and pneumothorax from injections, venipuncture, and other procedures. Soft tissue or bony injury from physical manipulation. I understand that while this document describes the most common risks of treatment, other side effects and risks may occur. In order to properly treat your medical condition, the doctor must be contacted promptly if an adverse reaction or condition occurs. In any event, if an emergency medical condition arises, please seektreatment immediately from a trauma center or call 9-1-1.
Potential Benefits: restoration of the body’s maximal functioning capacity, relief of pain and symptoms of disease, assistance in injury and disease recovery and prevention of disease or its progression.
Notice to Cancer Patients: Naturopathic doctors do not treat cancer. However, Naturopathic doctors treat the immune system to be able to respond better to cancer. All healing is done by restoration of the immune system to full function.
Notice to Women: all female patients must alert the provider if they know or suspect that they are pregnant, since some of the therapies could present a risk to the pregnancy and/or fetus
I do not expect the doctor to be able to anticipate and explain all risks and complications, and I wish to rely on the doctor to exercise judgment in recommending the treatments that the doctor feels at the time, based on the facts then known, are in my best interest. I have had the opportunity to ask questions and discuss with Dr. Anita M. Larrow, ND, and/or an allied health care provider to my satisfaction:
my suspected diagnosis or condition
the nature, purpose and potential benefit of the proposed care
the inherent risks, complications, potential hazards, or side effects of the treatment or procedure
the probability or likelihood of success
reasonable available alternatives to the proposed treatment / procedure
the possible consequences if treatment or advice is not followed and/or nothing is done.
With this knowledge I voluntarily consent to the above procedures, and practices realizing that no guarantees have been given to me by Anita M. Larrow, ND or any of its personnel regarding cure or improvement of my condition. I understand that I am free to withdraw my consent and discontinue participation at any time.
Communications and Practice Updates
Lastly, and optionally, I agree, and consent to allow Anita M. Larrow, ND to put my email address in the subscription list for her 3rd party newsletter service, and that I may be informed of important general schedule, updates, and information regarding Dr. Larrow’s practice through the 3rd party newsletter service that she is currently using. This agreement does not state that Dr. Larrow’s newsletter is the only means of communicating the practice information mentioned as the information will also be posted on the company’s website, blogs, mentioned in verbal phone contact, or other electronic communications with or for me.
Questions, Complaints? Please contact:
Dr. Anita M. Larrow, ND
2732 Chamise Ct.
Fairfield, CA 94533
(415) 912-9934
anita@drlarrownd.com