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For emergencies call 911

Doctor will be unavailable this April 17-28, 2025, med refills & follow up before/after

those dates; other concerns will be triaged with a covering provider.

Non-urgent: leave a portal message (allow 1-2 business days for response)

Urgent: call/text office (503) 662-1971 & leave a message.

Office address: 736 SE 60th Ave, PDX 97215 Tele/Text: 503 662-1971 Fax: 844 299-0399

MED REFILL REQUESTS: Allow 1-2 business days for a response. Please have enough to last until your next appointment.

___________________ ORDERING SUPPLEMENTS _________________

As a convenience for our patients, our office has partnered with Fullscript, a virtual supplement dispensary, to manage supplement inventory and delivery on our behalf. We are able to provide our community a significant discount to you from what you would pay for the same products as a retail customer. We value and trust Fullscript to provide only medical-grade supplements through their dispensary. Our practice retains a small profit from the sale of these products in order to provide you with a single, convenient site. However, you are under no obligation to purchase these products from us or our partner; you may purchase the same products elsewhere; and your quality of care in our office will not be affected by your decision to purchase or not purchase products from our partner

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Register with Aleksandra Giedwoyn, MD

Welcome to the Heart of Tabor Functional Medicine registration page. Please register as a new patient, and enter your information in the fields below (this also applies to existing patients that are new to the portal). If earlier you received an email inviting you to the portal & you did not respond, please Create Patient Portal Account (for already registered patients)- as I partially started the registration for you.

Basic Contact Information

First Name * Middle Name (or initial) Last Name *

Date of Birth *

Nickname/Preferred Name Gender * Pronouns Race Ethnicity

Your Address

Address 1 * Address 2 City * State * Zip Code * Timezone

Contact Information

Mobile Phone Number Home Phone Number Work Phone Number Preferred Contact Number Email Address (Primary) * Secondary Email Address Home Fax Number

Contact Preferences

Non-medical automated notifications (such as informational or educational emails, news about the practice, promotions, or marketing emails) Email: SMS/Text:

Emergency Contact

First Name * Middle Name Last Name * Relationship to Patient Email Address Phone Number *

Insurance Information

Insurance information is only neccessary if you prefer we "bill insurance" for lab orders. If your insurance coverage for labs is not ideal be sure to ask us about our negotiated cash pricing which may offer significant savings to you.

Plan Name Group Number Member ID Insurance Type

Medical Information

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

Height (in INCHES) Weight (in POUNDS) Personal Medical History (please also include surgeries and hospitalizations) Relevant Family Medical History (indicate which family member if applicable) How Did You Hear About Us?

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

Username *

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

Password * Confirm Password *

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.

"I consent to having medical information sent to my email address (we cannot guarantee the security of messages delivered by email)." "I have read 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 Aleksandra Giedwoyn, MD'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 04/03/2025.

Please check each box to confirm that corresponding forms have been read:

Patient Consent to Treatment

By being a patient you give your permission and authority for care by Aleksandra Giedwoyn, MD in accordance with appropriate test, diagnosis, and analysis. The patient assumes all responsibility/liability if the patient does not report on health forms any past medical history, illnesses, medicines, or allergies.

I hereby consent to the provision of diagnosis, care, and/or treatment by Aleksandra Giedwoyn, MD. I hereby acknowledge and confirm that I am mentally capable of giving informed consent to the provision of the diagnosis, care and/or treatment and am not subject to duress or undue influence.

Right to Refuse Treatment: In giving my general consent to treatment, I understand that I retain the right to refuse any particular examination, test, procedure, treatment, therapy or medication recommended or deemed medically necessary by my individual treating health care providers.

PLEASE READ THIS DOCUMENT CAREFULLY. BY EXECUTING THIS CONTRACT, YOU AGREE TO ALL RIGHTS, DUTIES, AND RESPONSIBILITIES STATED HEREIN.

1. Assignment of Insurance Benefits. You may assign your insurance benefits directly to this office.

2. If You Do Not Have Insurance. All payments are to be paid at the time of services.

3. If You Have Insurance. All deductibles and co-payments are to be paid at the time of service.

4. Cash Patient. All payments are to be paid at the time of services. You are a cash patient until you submit insurance cards, and it is qualified and accepted as your insurance coverage. Please let me know about your secondary insurance carriers.

5. Reasonable Fees. My fees are usual, customary, and reasonable according to professional industry standard, and, therefore, are covered up to the maximum allowance determined by each carrier.

6. Patient Financial Responsibilities:
A.Patient Assistance in Financial Recovery. If your carrier has not paid within sixty (60) days of submission, you agree to take an active part in the recovery of your claim.

B.Patient Responsibility for Uncovered Claims. If your carrier has not paid within ninety (90) days of submission, you accept responsibility for payment in full of any outstanding balance and authorize the office to charge your credit card to collect full payment.

C.Patient Responsible for Cost of Recovery. If your account with Aleksandra Giedwoyn, MD is delinquent more than five months and no payments have to established, the office will take legal action to recovery the full amount owed.

D.Patient Responsible for $75 No Show fee or when canceling with less than 24hrs prior to appointment.

Consent for Telehealth Services

For convenience of accessing care, offers remote telehealth consultations between patients and clinicians via a secure video platform. Additionally, your healthcare provider may consult with other providers or specialists remotely about your care via video or phone. Please carefully review this form and indicate your acceptance below.

Potential benefits of telehealth include:

*Convenience in accessing your providers from your home or another location.

*Protection against the transmission of communicable illnesses between yourself and other patients and clinic staff.

*Improvements to the quality of care when your clinician can consult with other providers as needed.

Inherent in the use of telehealth are technological risks of disruption to the call or video connection and other technical difficulties. You or the provider may discontinue the telehealth consultation if either of you determine that technical difficulties are too disruptive to continue.

We take strong precautions to safeguard the privacy of your protected health information (PHI), including using only HIPAA-compliant platforms for telehealth. Nevertheless, there is an unavoidable risk of unauthorized access when sending/ receiving PHI electronically (for example, via a video feed). You are solely responsible for ensuring privacy and confidentiality on your side - by conducting the visit in a private space where others cannot overhear and cannot see private information on the screen. We do not record (voice or video) telehealth consultations, but the health care provider will retain a medical record of care in their secure electronic health records system.

Some visits - specifically, those that require the clinician to be physically present with you - are not suitable for telehealth. Your provider may ask that you schedule an in-person visit for any issues that require in-person evaluation or treatment. Telehealth is not a substitute for emergency care. If you need urgent care, call 911 or go to the nearest urgent care facility.

You are responsible for the cost of your telehealth consultation. If you are seeking insurance payment or reimbursement for the visit, note that insurance companies may require that you participate in the telehealth consultation from a hospital, a mental health facility, a physician's office, an adult care facility, or your home.

Patient Consent To The Use of Telehealth

*I have read this form - or had it read and explained to me - in full. I fully understand its contents, including the risks, benefits, and alternatives.

*I have been given opportunity to ask questions and any questions have been answered to my satisfaction.

I hereby give my informed consent to the use of telehealth in the course of my diagnosis and treatment.

Sign with mouse or finger:

Clear Signature

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Register with Aleksandra Giedwoyn, MD

Basic Contact Information

Your Address

Contact Information

Contact Preferences

Emergency Contact

Insurance Information

Medical Information

Set Username and Password for Patient Portal

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

Patient Consent to Treatment

Consent for Telehealth Services