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Register with Campbell Integrative Family Medicine

Welcome to Campbell Integrative Family Medicine! We are so glad that you found us here and are ready to become a patient.

  • BEFORE you complete this form, please note that we DO NOT accept nor file any insurance.
  • We operate under a private membership agreement and fees for this are disclosed here: https://www.campbellfamilymedicine.com/cambell-membership
  • If you have specific or additional questions after reviewing this information then please send us an email: info@campbellfamilymedicine.com
  • Please do not use this form if you are already a registered patient of the practice.
  • Submission of this form does not notify us of your intent to begin care - please send a separate email or call the office.

Basic Contact Information

Date of Birth *

Your Address

Contact Information

Emergency Contact

Insurance Information

Note: Our practice does not bill insurance, but this information makes it easier for us to refer you for other services (like labs or specialists)

Medical Information

Please enter your basic medical information below. You may also add or edit this information after you've signed up.

Set Username and Password for Patient Portal

Please create a username and password that you will use to log into the Patient portal in the future.

Your username must be at least 4 characters long

Your password must be at least 8 characters long and include at least one number or special character.

The patient portal gives you access to your medical records and lets you securely communicate with your doctors. When you sign up, you will receive an email with instructions for logging in.

The Notice explains how we fulfill our commitment to respect the privacy and confidentiality of your protected health information. This Notice tells you about the ways we may use and share your protected health information, as well as the legal obligations we have regarding your protected health information. The Notice also tells you about your rights under federal and state laws. The Notice applies to all records held by Campbell Integrative Family Medicine's facilities and programs, regardless of whether the record is written, computerized or in any other form. We are required by law to make sure that information that identifies you is kept private and to make this Notice available to you.
Your Rights

When it comes to your health information, you have certain rights.

This section explains your rights and some of our responsibilities to help you.

  • Get a copy of your paper or electronic medical record
    • You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.
    • We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
  • Correct your paper or electronic medical record
    • You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
    • We may say "no" to your request, but we'll tell you why in writing within 60 days.
  • Request confidential communication
    • You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
    • We will say "yes" to all reasonable requests.
  • Ask us to limit the information we share
    • You can ask us not to use or share certain health information for treatment, payment, or our operations.
      • We are not required to agree to your request, and we may say "no" if it would affect your care.
    • If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer.
      • We will say "yes" unless a law requires us to share that information.
  • Get a list of those with whom we've shared your information
    • You can ask for a list (accounting) of the times we've shared your health information for six years prior to the date you ask, who we shared it with, and why.
    • We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We'll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
  • Get a copy of this privacy notice

    You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

  • 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.
    • We will make sure the person has this authority and can act for you before we take any action.
  • File a complaint if you believe your privacy rights have been violated
    • You can complain if you feel we have violated your rights by contacting us using the information in this notice.
    • You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to

      200 Independence Avenue, S.W.
      Washington, D.C. 20201
      by calling 1-877-696-6775, or visiting HHS.GOV Complaints .
    • We will not retaliate against you for filing a complaint.
Your Choices

For certain health information, you can tell us your choices about what we share.

If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

  • In these cases, you have both the right and choice to tell us what to share
    • Share information with your family, close friends, or others involved in your care
    • Share information in a disaster relief situation
    • Include your information in a hospital directory
    If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
  • In these cases we never share your information unless you give us written permission
    • Marketing purposes
    • Sale of your information
    • Most sharing of psychotherapy notes
  • In the case of fundraising
    • We may contact you for fundraising efforts, but you can tell us not to contact you again.
Our Uses and Disclosures

How do we typically use or share your health information?

We typically use or share your health information in the following ways.

  • Treat you
    • We can use your health information and share it with other professionals who are treating you.

    Example: A doctor treating you for an injury asks another doctor about your overall health condition.

  • Run our organization
    • We can use and share your health information to run our practice, improve your care, and contact you when necessary.

    Example: We use health information about you to manage your treatment and services.

  • Bill for your services
    • We can use and share your health information to bill and get payment from health plans or other entities.

    Example: We give information about you to your health insurance plan so it will pay for your services.

How else can we use or share your health information?

We are allowed or required to share your information in other ways - usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: HHS.GOV consumer home .

  • Help with public health and safety issues
    • We can share health information about you for certain situations such as:
      • Preventing disease
      • Helping with product recalls
      • Reporting adverse reactions to medications
      • Reporting suspected abuse, neglect, or domestic violence
      • Preventing or reducing a serious threat to anyone's health or safety
  • Do research
    • We can use or share your information for health research
  • Comply with the law
    • We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we're complying with federal privacy law
  • Respond to organ and tissue donation requests
    • We can share health information about you with organ procurement organizations.
  • Work with a medical examiner or funeral director
    • We can share health information with a coroner, medical examiner, or funeral director when an individual dies.
  • Address workers' compensation, law enforcement, and other government requests
    • We can use or share health information about you:
      • For workers' compensation claims
      • For law enforcement purposes or with a law enforcement official
      • With health oversight agencies for activities authorized by law
      • For special government functions such as military, national security, and presidential protective services
  • Respond to lawsuits and legal actions
    • We can share health information about you in response to a court or administrative order, or in response to a subpoena

Electronic Access

We provide electronic access to your health information via the Cerbo Patient Portal.

Our Responsibilities
  • We are required by law to maintain the privacy and security of your protected health information.
  • We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
  • We must follow the duties and privacy practices described in this notice and give you a copy of it.
  • We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

For more information see: HHS.GOV consumer notice .

Changes to the Terms of this Notice
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.

This notice is effective as of 04/27/2024.

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