Welcome to Signature Primary Care and Wellness's Patient Portal

Please indicate the service(s) in which you would like to enroll:

Local Primary Care and Wellness Membership

$197 registration fee, $97 monthly fee (six month minimum commitment)

Dr. Robin Newburn

Dr. Paige Gutheil

No preference

Local 90-Day Consult Program $625

Virtual 90-Day Consult Program $625 (Please enter your referral code below if you have prepaid for this program and you will not be charged)

Signature Wellness Services (check those you may be interested in):

Professional Services

$125 per session. Discounted bundle and Membership pricing available.

Counseling Coaching Massage Therapy Acupuncture

Registered Dietician Physical Therapy Personal Training

Esthetic and Wellness Device Services

Pricing personalized based on your needs at time of consultation.

Emscuplt Neo Emsella Emface

Styku 3-0 Body scanner Other

Please contact me to discuss which membership services would be best for me!

Basic Contact Information

First Name * Middle Name (or initial) Last Name * Date of Birth * Sex * Nickname/Preferred Name

Home Address

Address 1 * Address 2 City * State * ZIP Code *

Contact Information

Home Phone Number * Work Phone Number Mobile Phone Number Preferred Contact Number Email Address Confirm Email Address I don't have an email address

Emergency Contact

Emergency Contact First Name * Emergency Contact Middle Name Emergency Contact Last Name * Relationship to Patient Emergency Contact Phone Number *

Health History

Please list significant current and past medical diagnoses:

Please list past surgeries:

Please list all current medications, vitamins, supplements:

Set Username and Password for Patient Portal

To gain online access to your medical records and secure communications, 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.
Each participating member on your account must have a unique username and password.

Username *

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

Password * Confirm Password *

Billing

You are required to have a credit/debit card on file as a payment source for services and fees. FOR MEMBERSHIPS, this will be used to automatically draft your registration fee and monthly membership fee, however no charges will be made before your membership is accepted. FOR WELLNESS SERVICES, this will be used to pay for services received at the time of service.

Card Details

Card Number * Expiration Date (mm/yy) * / CVC Code*

Card Billing Address

First name on card * Last name on card * Billing Address * Zip/Postal Code * State/Province *

When would you like your membership to start?

I am covered by an insurance plan

Note: Signature Primary Care and Wellness does not bill insurance for its services with only the rare exception listed at SignaturePrimaryCareandWellness.com. Our clinicians are considered out of network providers with most insurances. Medicare beneficiaries are not permitted to seek reimbursement for SPC services from Medicare. We are happy to work with your insurance to process referrals, prescriptions, prior authorizations, etc.

Authorizations/Acknowledgements:

On behalf of all of the members on this account, I understand and agree to the following (read and check all items indicating your acceptance):

For Memberships:

I will be charged a one-time registration fee per enrollee in primary care services as described at SignaturePrimaryCareandWellness.com and in the membership agreement below.

I will be charged a recurring fee per member for primary care services as described at SignaturePrimaryCareandWellness.com and in the membership agreement below.

I am responsible for updating my demographic information and payment source should they change in the future.

If I cancel before three months of membership are paid for, a cancellation fee equal to the remaining balance necessary to equal three months of membership will be charged. After three months of membership, I can cancel at any time and that cancellation will take effect the day of the next membership draw (since the membership fee is billed retroactively). All cancellations must be provided in writing. Memberships are not prorated.

I may change my membership (SPC/Basic/Premium) quarterly if I desire by providing written intent prior to the quarter (Jan., Apr., July, Sept.)

If my membership lapses, I may re-apply at any time subject to a re-registration fee of the lesser of $250 or the amount necessary to bring my membership up to date. Acceptance will be dependent upon availability of space in our patient panel.

Prescriptions, certain vaccinations and other items provided, but not covered by my monthly primary care membership fee, will be discussed with me in advance and charged to my account's credit/debit card at the time such items are provided to me.

My participation is voluntary and subject to the terms and conditions of membership detailed at SignaturePrimaryCareandWellness.com and the agreement below.

I understand this agreement does not include comprehensive health insurance coverage nor is it a contract of insurance.

For Wellness Services (Counseling, Coaching, Massage Therapy, Acupuncture, Dietician, Physical Therapy, Personal Training, EmsculptNeo, Emsella, Emface):

The services I request will be discussed with me in advance and charged to my account's credit/debit card at the time I request those services. Unless otherwise agreed upon in writing, rates are charged as follows: $100 per session for non-members, $80 for members. Discounted bundle pricing available.

I may be charged a $25 "no-show" fee if I do not provide 24 hours cancellation for an appointment and it is unable to be filled.

I am responsible for updating my demographic information and payment source should they change in the future.

My participation is voluntary and subject to the terms and conditions of membership detailed at SignaturePrimaryCareandWellness.com and the agreement below.

For all Signature Primary Care and Wellness clients:

"I have read, understand and accept the terms of the Privacy Policy below:" *

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 Signature Primary Care and Wellness'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 11/21/2024.

I hereby consent and state my preference to have the physicians and staff at Signature Primary Care and Wellness communicate with me by email or standard SMS messaging regarding various aspects of my medical care, which may include but shall not be limited to, medical history, test results, prescriptions, appointments, and billing information.

I understand that email and standard 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 SMS messaging regarding my medical care might be intercepted and read by a third party. Signature Primary Care and Wellness does offer all patients access to the patient portal, which is an encrypted and secure means of communication as an alternative to email and SMS communication.

I understand that I use the Signature Primary Care and Wellness, LLC space and participate in activities within that space at my own risk and SPC&W, LLC is not liable for personal injury or other damages sustained on its property.

"I have read, understand and accept the terms of Medicare Private Contract below:" *

Attached Medicare Private Contract

This agreement is between the providers of Signature Wellness ("Physician"), whose principal place of business is 5212 West Broad Street Columbus, Ohio 43228, and the above listed patient who is a Medicare Part B beneficiary seeking services covered under Medicare Part B pursuant to Section 4507 of the Balanced Budget Act of 1997. The Physician has informed Patient that Physician has opted out of the Medicare program effective on for a period of at least two years, and is not excluded from participating in Medicare Part B under Sections 1128, 1156, or 1892 or any other section of the Social Security Act.

Physician agrees to provide the following medical services to Patient (the "Services"): all primary care services within the scope of practice of the Physician.

In exchange for the Services, the Patient agrees to make payments to Physician pursuant to the Attached Fee Schedule. Patient also agrees, understands and expressly acknowledges the following:

Patient agrees not to submit a claim (or to request that Physician submit a claim) to the Medicare program with respect to the Services, even if covered by Medicare Part B.
Patient is not currently in an emergency or urgent health care situation.
Patient acknowledges that neither Medicare's fee limitations nor any other Medicare reimbursement regulations apply to charges for the Services.
Patient acknowledges that Medi-Gap plans will not provide payment or reimbursement for the Services because payment is not made under the Medicare program, and other supplemental insurance plans may likewise deny reimbursement.
Patient acknowledges that he has a right, as a Medicare beneficiary, to obtain Medicare-covered items and services from physicians and practitioners who have not opted-out of Medicare, and that the patient is not compelled to enter into private contracts that apply to other Medicare-covered services furnished by other physicians or practitioners who have not opted-out.
Patient agrees to be responsible, whether through insurance or otherwise, to make payment in full for the Services, and acknowledges that Physician will not submit a Medicare claim for the Services and that no Medicare reimbursement will be provided.
Patient understands that Medicare payment will not be made for any items or services furnished by the physician that would have otherwise been covered by Medicare if there were no private contract and a proper Medicare claim were submitted.
Patient acknowledges that a copy of this contract has been made available to him.
Patient agrees to reimburse Physician for any costs and reasonable attorneys' fees that result from violation of this Agreement by Patient or his beneficiaries.

Date:

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Join Us

Please indicate the service(s) in which you would like to enroll:

Signature Wellness Services (check those you may be interested in):

Basic Contact Information

Home Address

Contact Information

Emergency Contact

Health History

Set Username and Password for Patient Portal

Billing

Card Details

Card Billing Address

Authorizations/Acknowledgements:

For Memberships:

For Wellness Services (Counseling, Coaching, Massage Therapy, Acupuncture, Dietician, Physical Therapy, Personal Training, EmsculptNeo, Emsella, Emface):

Get a copy of your paper or electronic medical record

Correct your paper or electronic medical record

Request confidential communication

Ask us to limit the information we share

Get a list of those with whom we've shared your information

Get a copy of this privacy notice

Choose someone to act for you

File a complaint if you believe your privacy rights have been violated

In these cases, you have both the right and choice to tell us what to share

In these cases we never share your information unless you give us written permission

In the case of fundraising

Treat you

Run our organization

Bill for your services

Help with public health and safety issues

Do research

Comply with the law

Respond to organ and tissue donation requests

Work with a medical examiner or funeral director

Address workers' compensation, law enforcement, and other government requests

Respond to lawsuits and legal actions

Electronic Access