Privacy Practices




This notice of the Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment, or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control you protected health information. “Protected health information” is information about you including demographic information that may identify you and that related to your past, present, or future physical or mental health or condition and related health care services.

We are required by law to maintain the privacy of your protected health information and to provide you with this notice of privacy practices. We also are required to abide by the privacy policies and practices that are outlined in this notice.

Uses and Disclosures of PHI

Your protected health information may be used and disclosed by your doctor, our office staff, and others outside of our office that are used in our care and treatment for the purposes of providing health care services to you, to pay your health care bills, to support the operation of the provider’s practice and any other use required by law.


We will use and disclose your PHI to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care for you. For example, your PHI may be provided to a physician to whom you have been referred to ensure that the doctor/physician has the necessary information to diagnose or treat you.


Your PHI will be used as needed, to obtain payment for your health care services. We may use and share PHI for the services we provide to you and to collect payment for the service billed to you, form you, your insurance company, or a third party. We may also share PHI with another provider so that provider can bill and collect for services you received.

Healthcare Options

We may use or disclose, as needed, your PHI in order to support the business activities of your provider’s practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing and conducting or arranging for other business activities. For example, we may disclose your PHI to medical school students that see patients at our office. In addition we may use a sign in sheet at the registration desk where you will be asked to sign your name and indicate your doctor. We may also call you by your name in the waiting room when your provider is ready to see you.

Law Enforcement

Your health information may be disclosed to law enforcement agencies to support government audits and inspections, to facilitate law-enforcement investigations, and to comply with government mandated reporting.

Public Health Reporting

Your health information may be disclosed to public health agencies as required by law. For example, we are required to report certain communicable diseases to the state’s public health department.

Appointment Reminders
Information About Treatments

Other uses and disclosures require your authorization. Disclosure of your health information or its use for any purpose other than those listed above requires your specific written authorization. If you change your mind after authorizing a use or disclosure of your information you may submit a written revocation of the authorization. However, your decision to revoke the authorization will not affect or undo any use or disclosure of information that occurred before you notified us of your decision to revoke your authorization.

Individual Rights

You have certain rights under the federal privacy standards. These include:

  • The right to request restrictions on the use and disclosure of your protected health information
  • The right to receive confidential communications concerning your medical condition and treatment
  • The right to inspect and copy your protected health information
  • The right to amend or submit corrections to your protected health information
  • The right to receive an accounting of how and to whom your protected health information has been disclosed
  • The right to receive a printed copy of this notice
Right to Revise Privacy Practices

As permitted by law, we reserve the right to amend or modify our privacy policies and practices. These changes in our polices and practices may be required by changes in federal and state laws and regulations. Upon request, we will provide you with the most recently revised notice on any office visit. The revised policies and practices will be applied to all protected health information we maintain.

Requests to Inspect Protected Health Information

You may generally inspect or copy the protected health information that we maintain. As permitted by federal regulation, we require that requests to inspect or copy protected health information be submitted in writing. You may obtain a form to request access to your records by contacting Dr. Potter. Your request will be reviewed and will generally be approved unless there are legal or medical reasons to deny the request.

HIPAA Privacy Standards: Complaints

If you would like to submit a comment or complaint about our privacy practices, you can do so by sending a letter outlining your concerns to:

Dr. Jennifer Potter, ND
744 San Antonio Road
Suite 1
Palo Alto, CA 94303

If you believe your privacy rights have been violated, you should call the matter to our attention by sending a letter describing the cause of your concern to the same address. You will not be penalized or otherwise retaliated against for filing a complaint.

Informed Consent for Treatment

I, the patient, hereby authorize Dr Jennifer Potter ND, to perform the following specific procedures as necessary to facilitate my diagnosis and treatment.

Common diagnostic procedures

Venipuncture, Pap smears, radiography, laboratory, x-ray

Minor office procedures

Cleaning and dressing a wound, ear lavage, skin scraping, skin cryotherapy

Medicinal use of nutrition

Therapeutic nutrition, nutritional supplementation, and intravenous and muscular vitamin injections

Botanical medicine

Botanical substances may be prescribed as teas, alcohol or glycerite based tinctures, capsules, tablets, creams, plasters, or suppositories

Homeopathic medicine

The use of highly dilute quantities of naturally occurring plants, animals, and minerals to gently stimulate the body’s healing responses

Lifestyle counseling

Diet therapy, promotion of wellness including recommendations for exercise, sleep, stress reduction, weight management, and balancing of work and social activities

Physical medicine

Hydrotherapy, stretching, manipulation, electrical muscle stimulation, and therapeutic ultrasound

Vaccine counseling

Per the scope of practice in California, Naturopathic Doctors do not offer vaccinations. Dr Potter is happy to discuss vaccinations and immune support recommendations. We refer to MD/DO providers for vaccinations

Patients should recognize the potential risks and benefits of these procedures as described below:

Potential Risks

Allergic reactions to prescribed herbs and supplements, side effects of natural medications, aggravation of pre-existing symptoms, discomfort, pain, infection, nausea, light headedness, inconvenience of lifestyle changes; injury from injections, venipuncture, or procedures. Notify the doctor if you experience any symptoms, which may be secondary to the above procedures and or go to the urgent care or emergency room.

Potential Benefits

Restoration of health and the body’s maximal functional capacity without the use of drugs or surgery, relief of pain, and symptoms of disease, assistance in injury and disease recovery, and prevention of disease or its progression.

Notice to Pregnant Women

All female patients must alert the doctor if they know or suspect that they are pregnant as some of the therapies used could present a risk to the pregnancy.

Laboratory Testing

Dr Potter utilizes standard laboratory tests and specialty testing to assess the condition of the patient’s health and guide treatment plans. As the patient, I understand that refusal to have laboratory tests and/or specialty tests performed can and or will affect results of treatment. Also, lab results need to be interpreted by a professional trained in laboratory diagnostics.  The laboratory records belong to the patient, but Dr. Potter respectfully requests that patients come in for a medical review of the labs after the results are returned. .

Supplements and Vitamins

Dr Potter utilizes supplements and vitamins from companies that design products for physicians and healthcare providers. Dr Potter does profit from the products purchased by the patients. I understand that I do not have to buy products from Dr Potter. Also, I understand that if I buy products elsewhere that I am responsible for the content of those products and the therapeutic value of the products.

Release of Records

Medical records can be faxed to another health care provider per medical release. Full chart copies are subject to $1/page copy fee, should a hard copy be requested.

With this knowledge, I voluntarily consent to the above procedures, realizing that no guarantees have been given to me, by Dr Potter regarding cure or improvement of my condition. I understand that I am free to withdraw my consent and to discontinue participation in these procedures at any time.

I understand that a record will be kept of the health services provided to me. This record will be kept confidential and will not be released to others unless so directed by myself, or my representative, or unless it is required by law. I understand that my medical record will be kept for a minimum of three, but no more than ten years after the date of my last visit. I understand that information from my medical record may be analyzed for research purposes, and that my identity will be protected and kept confidential. I understand that any questions I have will be answered by my practitioner to the best of her ability.


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