Welcome toGrace Integrative Healthcare, High Point’s Premier Integrative Holistic Healthcare Center. Our goal is to help you achieve total wellness. We want you to feel healthy all the time, not just some of the time. More importantly, we want you to feel better than ever.
Our medical staff includes Medical Director, Tosha Briles, FNP-C; Medical Assistant Amanda Coble, RMA; Practice Manager Amy Webb, BS; & Medical Receptionist Chelsea Burchett, EMS.
Please visit our website at for complete bio’s on all staff.
Financial Policies
We at Grace Integrative Healthcare are here to help you take care of your health in the best way that we know how. We realize you came in about health and not finances. The following is to assist you in understanding the Grace Integrative financial policies.
**Payment Requirements: Appointments must be paid for at time of service. We do not offer any type of payment plan. We accept Visa, MasterCard, and Discover, American Express, check or cash.
**Charges are based on actual time and services used. This means that each appointment and labs require a follow-up to review. Each follow up appointment is charged $175 based on a 30-40 minute appointment. Some cases are complicated and require either an additional appointment or added time. Added time will be charged at a rate of $25.00 for each additional 15 mins.
**Phone Consults,FaceTime appointments and Skype appointments are charged the same as in-person appointments, with the exception of the first visit.
**Labs: Labs are an important part of our holistic approach and are done on most patients. Since we do not file any insurance, labs can be optionally billed through LabCorp or Grace Integrative Healthcare. Different variables such as copays or deductibles make each individual a unique case. Talk to your healthcare provider to see which suits you best.
**Appointments:We require 24-hour notice if you need to change or cancel your appointment. You will be charged a fee of $75 for any missed appointment, or if the 24 hour in advance cancellation policy was not met. This fee must be paid before any additional services can be provided.
Patient Registration
REFERRED BY______FAMILY PHYSICIAN______
NAME______FEMALE______MALE______
SOCIAL SECURITY NO. ______DATE OF BIRTH ______
ADDRESS______APT______
CITY______STATE______ZIP CODE______
PHONES: HOME(____) ______WORK (_____)______CELL (____)______
EMAIL ADDRESS ______
EMPLOYER ______
ADDRESS ______
CITY______STATE______ZIP CODE______PHONE______
INSURANCE
INSURANCE TYPE: ______POLICY HOLDER: ______
POLICY HOLDERS DOB: ______POLICY ID: ______
GROUP #______PATIENTS NAME: ______
PATIENTS DOB: ______PATIENTS SOCIAL SECURITY NUMBER: ______-_____-______
Consent to the Use and Disclosure of Health Information for Treatment, Payment, or Healthcare Operations
I understand that as part of my healthcare, this organization originates and maintains health records describing my health history, symptoms, examination and test results, diagnoses, treatment, and any plans for future care or treatment. I understand that this information serves as:
●A basis for planning my care and treatment
●A means of communication among many health professionals who contribute to my care
●A source of information for applying my diagnosis and surgical information to my bill
●A means by which a third-party payer can verify that services billed were actually provided
● A tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals
I understand and have been made aware that a copy of your Notice of Privacy Practices has been made available to me that provides a more complete description of information uses and disclosures. I understand that I have the right to review the notice prior to signing this consent. I understand that the organization reserves the right to change their notice and practices and prior to implementation will mail a copy of any revised notice to the address I’ve provided. I understand that I have the right to object to the use of my health information for directory purposes. I understand that I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or healthcare operations and that the organization is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereon.
The following people may have access to my health information:
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NameRelation
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NameRelation
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NameRelation
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Signature of Patient or Legal RepresentativeDate