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Urgent medical concerns should be handled by your primary care provider or go to your nearest urgent care/ER.

We have a less than 2 business day cancelation/reschedule fee policy for our patients. Please be aware that Cynthia Culp NP does not overbook or double book her appointments and her time is reserved exclusively for you. In order to accommodate those on the waiting list, we appreciate ample notification when rescheduling and for cancellations. Return patients are charged a fee of $100.00 for either less than a 24 hour business day cancellation/reschedule or for not appearing for their appointment. We hold the first initial appointment with a $150 deposit by credit card. This deposit is non refundable in the event you cancel or reschedule less than 2 business days before your scheduled appointment or do not appear for your appoinment.

Register with Foothills Functional Medicine, PLLC

Welcome to the Foothills Functional Medicine, PLLC registration page. To register as a new patient, please enter your information in the fields below. Please do not use this form if you are already a patient (you have seen any of our practitioners in the past). To set up patient portal access or amend your information, please contact us.

If you are already a registered patient with online access, you can log in here

Basic Contact Information

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

Date of Birth *

Social Security Number 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

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)

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)

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 Foothills Functional Medicine, PLLC'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 11/20/2024.

I consent to the terms of the General Consent to Treatment below:

General Consent to Treatment

This consent provides us with your permission to perform reasonable and necessary medical examinations, testing and treatment. By signing below, you are indicating that:

You consent to treatment at this office (or any other satellite office under common ownership).
You intend this consent to remain effective after a specific diagnosis has been made and treatment recommended.

You have the right at any time to discontinue services. You have the right to discuss the treatment plan with your physician, including the purpose, potential risks, and benefits of any test, treatment, or recommended course of action. If you have any concerns regarding any test or treatment recommend by your health care provider, we encourage you to ask questions.

Patient statement of consent: "I voluntarily request the health care provider(s) at to perform reasonable and necessary medical examination, testing, and treatment for the condition which has brought me to seek care at this practice. I understand that if additional testing, invasive, or interventional procedures are recommended, I will be asked to read and sign additional consent forms prior to the test(s) or procedure(s). I certify that I have read and understand the above statements and consent fully and voluntarily to them."

I consent to the terms of the Telehealth Consent below:

1. I understand that I am voluntarily engaging in a telemedicine consultation done by a "store and forward" route with Foothills Functional Medicine. I understand that I am submitting a health questionnaire that will contain my basic medical history, current symptoms (if any), and goals for treatment that will be reviewed by a licensed medical provider. The medical provider will then approve the desired medical interventions and/or prescriptions being requested after reviewing your submitted information. Your request will be approved pending any contraindications to therapy and you will be notified by email within 12-24 hours. If the medical provider does not approve the interventions and/or prescriptions being requested, you will be notified by email and will be refunded, in full, the purchase price of the skin care prescriptions.

2. I understand that the health questionnaire I fill out on this website that will be submitted to the medical provider will not be the same as a direct patient/health care provider visit due to the fact that I will not be in the same room as my health care provider. I understand that this is a convenience and a courtesy provided by Foothills Functional Medicine.

3. I understand that a telehealth consultation has potential benefits including easier access to care, decreasing costs, and allowing visits to be performed from the comfort of my home.

4. I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my health care provider or I can discontinue the telehealth consult/visit if it is felt that the video conferencing connections are not adequate for the situation.

5. I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. I understand that if there is another individual present during the telehealth consultation (if done via video or phone) that I will be informed of their presence and I will also disclose if there is another individual with myself. It is agreed that these individuals will maintain confidentiality of the information obtained. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history/physical examination that are personally sensitive to me; (2) ask non-medical personnel to leave the telemedicine examination room: and or (3) terminate the consultation at any time.

6. I understand that the alternative to a telemedicine consultation is to forgo evaluation and treatment with Foothills Functional and to seek out an in-person evaluation elsewhere. Thus, I am freely choosing to participate in a telemedicine consultation via a "store and forward" route.

7. I understand that telemedicine has limitations in regard to the physical examination. I understand that the physical exam portion of the care provided through Foothills Functional Medicine will be limited or not done at all. I understand that I am submitting a health questionnaire that will contain my basic medical history, current symptoms (if any), and goals for treatment.

8. Telemedicine services offered through Foothills Functional Medicine are not an Emergency Service and in the event of an emergency or urgent medical issue, I will use a phone to call 911, go to the emergency department, or go to an urgent care.

By signing this form, I certify:

That I have read or had this form explained/read to me and I understand its contents including the risks and benefits of telemedicine.
That I have had the opportunity to ask questions, if desired by emailing Foothills Functional Medicine through the contact us section, and have had them answered to my satisfaction before submitting the requested information

Sign with mouse or finger:

Clear Signature

Go to...

Register with Foothills Functional Medicine, PLLC

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

General Consent to Treatment