New Patients

1623 NE Broadway· Portland, OR 97232

Phone: (503) 286-4400

Fax: 503-287-3667

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

If you have any questions about this Notice please contact our Privacy Officer.

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

We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice, at any time. The new notice will be effective for all protected health information that we maintain at that time. Upon your request, we will provide you with any revised Notice of Privacy Practices.

A. HOW THIS MEDICAL OFFICE MAY USE OR DISCLOSE YOUR HEALTH INFORMATION

Your protected health information may be used and disclosed by your physician and his office staff for the purpose of

providing health care services to you. Your protected health information may also be used and disclosed to pay your health

care bills and to support the operation of this practice. Following are examples of the types of uses and disclosures of your

protected health information this office is permitted to make. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by our office.

Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with another provider. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. We will also disclose protected health information to other physicians who may be treating you. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you. In addition, we may disclose your protected health information from time-to-time to another physician or health care provider (e.g., a pharmacist or laboratory) who, at the request of your physician, becomes involved in your care by providing assistance with your health care diagnosis or treatment to your physician. We may also disclose medical information to members of your family or others who can help you when you are sick or injured or after you die.
Payment: Your protected health information will be used and disclosed, as needed, to obtain payment for your health
care services provided by us or by another provider. This may include certain activities that your health insurance plan
may undertake before it approves or pays for the health care services we recommend for you such as: making a
determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity,
and undertaking utilization review activities. For example, we give your health plan the information it requires before it
will pay us. We may also disclose information to other health care providers to assist them in obtaining payment for
services they have provided to you.
Health Care Operations: We may, as needed, use or disclose your protected health information in order to support the
business activities of your physician's practice. These activities include, but are not limited to, quality assessment
activities, employee review activities, licensing, and conducting or arranging for other business activities. Or we may
use and disclose this information to get your health plan to authorize services or referrals. We may also share your
medical information with our "business associates," such as our billing service, that perform administrative services for us. Whenever an arrangement between our office and a business associate involves the use or disclosure of your
protected health information, we will have a written contract that contains terms that will protect the confidentiality and
security of your protected health information.

Appointment Reminders: We will use and disclose protected health information to contact and remind you about appointments. If you are not home, we may leave this information on your answering machine or in a message left with the person answering the phone.
Notification and Communication With Family: We may disclose your health information to notify or assist in notifying
a family member, your personal representative or another person responsible for your care about your location, your
general condition or, unless you had instructed us otherwise, in the event of your death. In the event of a disaster, we may disclose information to a relief organization so that they may coordinate these notification efforts. We may also disclose information to someone who is involved with your care or helps pay for your care. If you are able and available to agree or object, we will give you the opportunity to object prior to making these disclosures, although we may disclose this information in a disaster even over your objection if we believe it is necessary to respond to the emergency circumstances. If you are unable or unavailable to agree or object, our health professionals will use their best judgment in communication with your family and others.
Marketing: We may contact you to give you information about products or services provided by this practice, to
encourage you to maintain a healthy lifestyle and to provide you with health related information that you may find
useful. You may contact our Privacy Officer to request that these materials not be sent to you.
Required By Law: We may use or disclose your protected health information to the extent that the use or disclosure is
required by law. The use or disclosure will be made in compliance with the law and will be limited to the relevant
requirements of the law. You will be notified, if required by law, of any such uses or disclosures.
Public Health: We may, and at times may be required by law, to disclose your health information to public health
authorities for purposes related to: preventing or controlling disease, injury or disability; reporting child, elder or
dependent adult abuse or neglect; reporting domestic violence; reporting to the Food and Drug Administration
problems with products and reactions to medications; and reporting disease or infection exposure. When we report
suspected elder or dependent adult abuse or domestic violence, we will inform you or your personal representative
promptly unless in our best professional judgment, we believe the notification would place you at risk of serious harm
or would require informing a personal representative we believe is responsible for the abuse or harm.
Health Oversight Activities: We may disclose protected health information to a health oversight agency for activities
authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws.
Judicial and Administrative Proceedings: We may disclose your health information in the course of any administrative
or judicial proceeding to the extent expressly authorized by a court or administrative order. We may also disclose
information about you in response to a subpoena, discovery request or other lawful process if reasonable efforts have
been made to notify you of the request and you have not objected, or if your objections have been resolved by a court
or administrative order.
Law Enforcement: We may, and are sometimes required by law, to disclose your health information to a law
enforcement official for purposes such as identifying or locating a suspect, fugitive, material witness or missing
person, complying with a court order, warrant, grand jury subpoena and other law enforcement purposes.
Coroners, Funeral Directors, and Organ Donation: We may disclose protected health information to a coroner or
medical examiner in connection with their investigations of deaths. We may also disclose protected health information
to a funeral director, as authorized by law, in order to permit the funeral director to carry out his/her duties. We may
disclose such information in reasonable anticipation of death. Protected health information may be used and
disclosed for cadaveric organ, eye or tissue donation purposes.
Public Safety: We may, and are sometimes required by law to, disclose your health information to appropriate persons
in order to prevent or lessen a serious and imminent threat to the health or safety of a particular person or the general public
Proof of Immunization: We will disclose proof of immunization to a school that is required to have it before admitting
a student where you have agreed to the disclosure on behalf of yourself or your dependent.
Specialized Government Functions: We may disclose your health information for military or national security purposes
or to correctional institutions or law enforcement officers that have you in their lawful custody.
Workers' Compensation: We may disclose your health information as necessary to comply with workers'
compensation laws. For example, to the extent your care is covered by workers' compensation, we will make periodic
reports to your employer about your condition. We are also required by law to report cases of occupational injury or
occupational illness to the employer or workers' compensation insurer.

Change of Ownership: In the event that this medical practice is sold or merged with another organization, your health information/record will become the property of the new owner, although you will maintain the right to request that copies of your health information be transferred to another physician or medical group.
Breach Notification: In the case of a breach of unsecured protected health information, we will notify you as required
by law. If you have provided us with a current e-mail address, we may use e-mail to communicate information related
to the breach. In some circumstances business associate may provide the notification. We may also provide
notification by other methods as appropriate.

B. WHEN THIS MEDICAL PRACTICE MAY NOT USE OR DISCLOSE YOUR HEALTH INFORMATION

Except as described in this Notice of Privacy Practices, this medical practice will, consistent with its legal obligations, not

use or disclose health information which identifies you without your written authorization. If you do authorize this medical

practice to use or disclose your health information for another purpose, you may revoke your authorization in writing at any

time.

C. YOUR HEALTH INFORMATION RIGHTS

Right to Request Special Privacy Protections: You have the right to request restrictions on certain uses and disclosures of your health information by a written request specifying what information you want to limit, and what limitations on our use or disclosure of that information you wish to have imposed. If you tell us not to disclose information to your commercial health plan concerning health care items or services for which you paid for in full out-of-pocket, we will abide by your request, unless we must disclose the information for treatment or legal reasons. We reserve the right to accept or reject any other request, and will notify you of our decision.
Right to Request Confidential Communications: You have the right to request that you receive your health information
in a specific way or at a specific location. For example, you may ask that we send information to a particular e-mail
account or to your work address. We will comply with all reasonable requests submitted- in writing which specify how
or where you wish to receive these communications
Right to Inspect and Copy: You have the right to inspect and copy your health information, with limited exceptions. To
access your medical information, you must submit a written request detailing what information you want access to,
whether you want to inspect it or get a copy of it, and if you want a copy, your preferred form and format. We will provide
copies in your requested form and form at if it is readily producible, or we will provide you with an alternative format you
find acceptable, or if we can't agree and we maintain the record in an electronic format, your choice of a readable
electronic or hard copy format. We will also send a copy to any other person you designate in writing. We will charge a
reasonable fee which covers our costs for labor, supplies, postage, and if requested and agreed to in advance, the cost
of preparing an explanation or summary. We may deny your request under limited circumstances. If we deny your
request to access your child's records or the records of an incapacitated adult you are representing because we believe
allowing access would be reasonably likely to cause substantial harm to the patient, you will have a right to appeal our
decision.
Right to Amend or Supplement: You have a right to request that we amend your health information that you believe is
incorrect or incomplete. You must make a request to amend in writing, and include the reasons you believe the
information is inaccurate or incomplete. We are not required to change your health information, and will provide you
with information about this medical practice's denial and how you can disagree with the denial. We may deny your
request if we do not have the information, if we did not create the information (unless the person or entity that created the information is no longer available to make the amendment), if you would not be permitted to inspect or copy the
information at issue, or if the information is accurate and complete as is. If we deny your request, you may submit a
written statement of your disagreement with that decision, and we may, in turn, prepare a written rebuttal. All
information related to any request to amend will be maintained and disclosed in conjunction with any subsequent
disclosure of the disputed information.
Right to an Accounting of Disclosures: You have a right to receive an accounting of disclosures of your health
information made by this medical practice, except that this medical practice does not have to account for the
disclosures provided to you or pursuant to your written authorization, or as described in paragraphs 1 (treatment), 2
(payment), 3 (health care operations), 6 (notification and communication with family) and 15 (specialized government
functions) of Section A of this Notice of Privacy Practices or disclosures for purposes of research or public health
which exclude direct patient identifiers, or which are incident to a use or disclosure otherwise permitted or authorized
by law, or the disclosures to a health oversight agency or law enforcement official to the extent this medical practice
has received notice from that agency or official that providing this accounting would be reasonably likely to impede
their activities.
Right to a Paper or Electronic Copy of this Notice. You have a right to notice of our legal duties and privacy practices with respect to your health information, including a right to a paper copy of this Notice of Privacy Practices, even if you have previously requested its receipt by e-mail.

If you would like to exercise one or more of these rights, contact our Privacy Officer listed at the end of this Notice of Privacy Practices.

D. CHANGES TO THIS NOTICE OF PRIVACY PRACTICES

We reserve the right to amend this Notice of Privacy Practices at any time in the future. Until such amendment is made, we are required by law to comply with the terms of this Notice currently in effect. After an amendment is made, the revised Notice of Privacy Protections will apply to all protected health information that we maintain, regardless of when it was created o received. We will keep a copy of the current notice posted in our reception area, and a copy will be available at each appointment. We will also post the current notice on our website.

E. COMPLAINTS

Complaints about this Notice of Privacy Practices or how this medical practice handles your health information should be directed to our Privacy Officer listed at the top of this Notice of Privacy Practices.

If you are not satisfied with the manner in which this office handles a complaint, you may submit a formal complaint to:

Office for Civil Rights. DHHS

2201 Sixth Avenue - M/S: RX-11

Seattle. WA 98121-01831

[email protected]

(206) 615-2290

(206) 615-2296 (TDD)

(206) 615-2297 FAX

The complaint form may be found at

www.hhs.gov/ocr/privacy/hipaa/complaints/hipcomplaint.pdf. You will not be penalized in any way for filing a complaint.

The Privacy Officer for Rise2Health is Sara Watt.

ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

Notice to Patient:

We are required to make available to you a copy of our Notice of Privacy Practices, which states how we may use and/or

disclose your health information. Please sign this form to acknowledge that a copy of the Notice has been made available

to you. You may refuse to sign this acknowledgement, if you wish.

I acknowledge that a copy of this office's Notice of Privacy Practices has been made available to me.

Patient Signature and Date *

Print Name
Signature
Date

FOR OFFICE USE ONLY

We have made every effort to obtain written acknowledgment of receipt of our Notice of Privacy Practices from this patient but it could not be obtained because

The patient refused to sign.

Other (Please provide specific details)

Employee signature
Date

PATIENT INFORMATION

Full Name *

Preferred Pronouns

Date of birth *

Sex *

Male

Female

State *

Phone *

City *

Height and Weight *

Height
Weight

Zip code *

Email *

How did you hear about us?

If referred, please let us know who to thank!

IF UNDER THE AGE OF 18

Parent/Guardian Name: *

Parent/Guardian Phone Number *

Relationship *

Email Address *

IN CASE OF EMERGENCY, PLEASE CONTACT

Name
Relationship
Phone Number

BY WAY OF SIGNATURE, I AUTHORIZE TREATMENT AND ACCEPT FINANCIAL RESPONSIBILITY. IF MY INSURANCE

DOES NOT PAY, I AM RESPONSIBLE FOR ALL BALANCES ON MY ACCOUNT. I UNDERSTAND THAT PAYMENT IS DUE AT

THE TIME OF SERVICE. MY SIGNATURE ALSO GIVES PERMISSION TO EXCHANGE INFORMATION WITH MY INSURANCE

COMPANY(S) TO OBTAIN PAYMENT

Patient Signature
Date
Parent/Guardian Signature
Date

For Hormone Optimization Patients: Dr. David requires 6-month follow ups to track patient progress and to optimize dosage(s) and treatment plan(s). I understand that prescriptions will not be written or extended 6 months after the date of my last appointment, until that time that I am able to complete a follow-up visit. *

Initials

Reason for seeing Dr. David *

GENERAL HEALTH HISTORY

Allergies - Fill in all that apply

Medication Allergies
Food Allergies/Sensitivities
Environmental Allergies
Product Allergies
Other

Medical Ailments/ Diseases

Surgical History

Current Medication / Supplements / Vitamins

Past Medication

If you could improve your physical health or mobility, what would you do?

If you could improve your overall health or wellbeing, what would you do?

If you could improve your appearance, what would you do?

Is there anything else you would like to share with Dr. Joshua David, regarding your physical, mental, or emotional wellbeing, or healthcare goals?

Patient Printed Name & Date

PATIENT CONSENT FORM

Please read and review this consent form and ask questions for clarification if needed. Then, Initial each statement indicating understanding and agreement, and sign at the bottom of the form.

STATEMENT OF PATIENT

I understand that along with the benefits of any medical treatment or therapies, there are both risks and potential complications to treatment, as well as not being treated. Those risks and potential complications have been explained to me. I have not been promised or guaranteed any specific benefit from the administration of these therapies and no warranty or guarantee has been made regarding the results of treatment. I agree to proceed with treatment and to comply with recommended dosages.

_______I agree to comply with requests for ongoing testing to assure proper monitoring of my treatments that may include laboratory evaluation of all aforementioned hormone levels or other diagnostic testing by a physician, my primary care physician, or other specialist. I agree to see my primary care physician, gynecologist, or other practitioner for regular monitoring and for preventative measures that may include but are not limited to complete physicals, rectal examinations and/or colonoscopy, EKG, mammograms, pelvic/breast exams, pap smears, prostate exams, PSA levels, etc.

_______ I agree to immediately report to my physician any adverse reaction or problem that might be related to my therapy. I understand that along with the benefits of any medical treatment or therapies, there are both risks and potential complications to treatment, as well as to not being treated. Those risks and potential complications have been explained to me and I agree that I have received information regarding those risks, potential complications and benefits, and the nature of bio-identical and other hormone treatments and have had all my questions answered. Furthermore, I have not been promised or guaranteed any specific benefit from the administration of bioidentical hormone therapy.

_______ I have been informed that insurance companies may not pay for physician evaluation, laboratory testing, and medications. I therefore agree to pay for all services including physician evaluation, laboratory tests and pharmacy charges, with the understanding that I may not be reimbursed by my insurance company.

_______ I certify this form has been fully explained to me, that I have read it or have had it read to me. I have been educated on the benefits, risks, and possible adverse reactions associated with bio-identical hormone replacement therapy. I have been given the opportunity to ask any questions about hormone replacement therapy, potential complications, required testing, and costs and have had them answered to my satisfaction. I agree not to undergo any treatments unless I fully understand the treatment and have discussed possible risks and benefits. I fully understand what I am signing and hereby request and consent to treatment using bioidentical hormone replacement therapy.

Patient Signature

Clear

Date:

Name (PRINT)

Preparing for your appointment...

Electronic forms will soon be available to fill out online before your appointment. However, in the meantime, we ask that you please arrive at least 15 minutes prior to your scheduled appointment time to ensure there is ample time to complete intake documents prior to the start of your appointment.

Late arrivals...

New Patients who do not arrive (at minimum) 10-minutes prior to your scheduled appointment time may be required to reschedule.

Lab Work...

For your initial HRT appointment, you do not need to fast prior to coming in. We will be able to run your blood work without having you fast.

Lab Results...

When your first lab results are returned to our office, our staff will contact you to set up a brief (no cost) call with Dr. David to review the results and discuss any additional recommendations he may have based on those. Lab Results may take up to a week to be received and reviewed before you are contacted.

Rise2Health

We provide hormone optimization, motor vehicle and sports injury treatment, weight loss, anti-aging cosmetic procedures, natural medicine, and more.

New Patients

Working Hours

Monday 9:00 am – 5:00 pm

Tuesday Closed

Wednesday 9:00 am – 3:00 pm

Thursday 9:00 am – 5:00 pm

Fri - Sun Closed

contact us

1623 NE Broadway Portland, OR 97232

+1 (503) 286-4400

+1 (503) 287-3667

[email protected]

New Patients

Rise2Health

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New Patients

Monday 9:00 am – 5:00 pm

Tuesday Closed

Wednesday 9:00 am – 3:00 pm

Thursday 9:00 am – 5:00 pm

Fri - Sun Closed

contact us

1623 NE Broadway Portland, OR 97232

+1 (503) 286-4400

+1 (503) 287-3667

© 2025 Rise2health. All rights reserved.

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If yes, please list injuries

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