Go to...

Register with 13th Moon Functional Medicine for Women

Welcome to the 13th Moon Functional Medicine for Women registration page. To register as a patient, please enter your information in the fields below. Please ONLY use this form if you are a new functional medicine client and have not previously registered in the patient portal.

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 our office. 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:" *

Your Rights

Your Choices

Our Uses and Disclosures

Our Responsibilities

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 13th Moon Functional Medicine for Women'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 02/23/2025.

Sign with mouse or finger:

Clear Signature