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If you are inquiring about labs please note: When labs or imaging are in need of immediate attention, the physician is notified immediately. The physician will make certain you are notified right away. Non urgent labs are reviewed in order that they are returned. They may take longer to review. The Doctors at Mulberry may take longer to review your labs as they are often more complex in nature and are being very careful about interpretation. Thank you for your understanding.

Join Us

Enrolling in Mulberry Clinics is quick and easy using this secure form.

If you prefer, call (615) 614-2500 to speak with an enrollment specialist and enroll over the phone or in person.
A one-time $99 registration fee per adult will be included in your total initial charges.
Additional family members may be added upon approval for a $99 enrollment fee plus monthly membership fee.
You may cancel your membership at any time with a 30 day notice.

We do not deny membership for pre-existing conditions or lack of insurance coverage. Clinic space is limited. Once you submit this application and complete your medical history form(s) we will contact you if we have any questions or concerns about our physician’s ability to properly care for you given your particular healthcare needs and our current patient capacity. If for any reason your membership is not accepted, we will refund your $99 enrollment fee(s).

Basic Contact Information

First Name * Middle Name (or initial) Last Name * Date of Birth * Sex * Nickname/Preferred Name

Home Address

Address 1 * Address 2 City * State * ZIP Code *

Contact Information

Home Phone Number * Work Phone Number Mobile Phone Number Preferred Contact Number Email Address Confirm Email Address I don't have an email address

Emergency Contact

Emergency Contact First Name * Emergency Contact Middle Name Emergency Contact Last Name * Relationship to Patient Emergency Contact Phone Number *

Set Username and Password for Patient Portal

To gain online access to your medical records and secure communications, 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.
Each participating member on your account must have a unique username and password.

Username *

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

Password * Confirm Password *

Billing

Credit/Debit card monthly auto-payment required for membership fees. SECURELY provide card info online here Provide card info later in-person or by phone

Card Details

Card Number * Expiration Date (mm/yy) * / CVC Code*

Card Billing Address

First name on card * Last name on card * Billing Address * Zip/Postal Code * State/Province *

When would you like your membership to start?

What is the primary reason you are joining Mulberry Clinics?

Primary Care Specific medical issue(s)

Females only: Are you pregnant?

Yes No

"I have read, understand and accept the terms of the Mulberry Clinics Privacy Policy below:" *

PRIVACY POLICY

We at Mulberry Clinics, LLC are committed to safeguarding your privacy. This privacy policy and agreement (this "Privacy Policy") covers how we collect and use information in our electronic medical records and practice management software system (our "EMR") that can be used to identify you and that was created, used, or disclosed in the course of providing a health care service (your "Protected Information"), which includes information that you provide or access via the patient portal at www.MulberryClinics.com (the "Patient Portal").

In this policy, "you" and "your" refer to a user of the Patient Portal, patient, or other person with Protected Information on file with Mulberry Clinics, LLC. “Mulberry Clinics, LLC," "we," "our," and "us" refer to Mulberry Clinics, LLC. and its subsidiaries and affiliates.
Please read this policy carefully. By checking the box, clicking on "I Agree", or otherwise signifying acceptance of this privacy policy, you are acknowledging that you have read it, understand it, and are agreeing to be legally bound by the terms provided here.

The Information We Collect

We collect Protected Information in the form of (1) registration information that you provide in order to enroll as a patient or use the Patient Portal (your "Personal Information"); (2) information that is created, used, or disclosed in the course of providing health care services to you, which we file in your medical record electronically and/or on paper (your "Protected Health Information"); and (3) financial records, such as billing or insurance information, records of payments, and balance statements, related to our provision of health care services to you (your "Billing Information"). We do not collect any more Protected Information than reasonably necessary to provide our services, operate our EMR and the Patient Portal, and respond to your requests.

By law, you have a right to access and amend your medical records. We own original copies of any records created by us or shared with us, which we maintain in accordance with federal and state law. We may provide you with access to your Protected Information via the Patient Portal at our discretion as a convenience to you. We reserve the right to suspend your Patient Portal account at any time.
We may ask you for Protected Information concerning family members or others for whom you are authorized to act as a personal representative. We use this information to create and gather medical records for these people, and will use and disclose this information in the same manner as we use and disclose your Protected Information.

Our Use of Your Protected Information

We will not share your Protected Information with any third party, other than as expressly disclosed in this policy. In general, we will use your Protected Information as necessary to provide you with medical care, respond to your requests, and maintain our EMR and the Patient Portal. We will use your Billing Information to obtain payment for medical services that we provide to you.

We will use and disclose your Protected Information in accordance with the Health Insurance Portability and Accountability Act of 1996 ("HIPAA") and its regulations, including the Standards for Privacy of Individually Identifiable Health Information (the "Privacy Rule"), the Security Standards for the Protection of Electronic Protected Health Information (the "Security Rule"), as well as the Health Information Technology for Economic and Clinical Health Act (the "HITECH Act"), and other applicable federal and state laws.

Condition-Specific Content

Periodically, we may send you news, bulletins, educational materials, marketing materials, or other information based on your Protected Health Information, e.g. targeted to your specific health condition(s). If we choose to send such communications, you will have the ability to opt-out of receiving them, as further provided below. We may also use your Protected Information to make informational content available to you via the Patient Portal.

Opt-Out

If we choose to send you bulletins, updates, or other unsolicited, marketing-related communications, we will provide you with the ability to opt-out of receiving such communications. However, you may not opt-out of formal notices concerning (i) operation of our EMR or the Patient Portal, or (ii) legal and other related notices concerning your relationship to us. Nor may you opt-out of being provided with content passively via internet or Patient Portal pages that you choose to access.
You may disable Patient Portal access to all or some of your Protected Information by sending us a written request to that effect. Doing so does not affect our records, but only determines whether those records are accessible via the Patient Portal.

Anonymous, Aggregate Information

"Aggregate Information" is information that does not identify you, such as statistical information and analyses concerning the use of our services, the number of customers registered in our EMR, usage data for the Patient Portal, aggregated information about health statistics, treatments, conditions or similar aggregated healthcare information, or other aggregated information that is not personally-identifiable.

We may use or disclose Aggregate Information in order to undertake or commission statistical and other summary analyses of (i) the general behavior and characteristics of users participating in our services or using the Patient Portal, (ii) the effect of our services on the behavior of our patients, and (iii) the general characteristics of visitors to our website or the Patient Portal and participants in our services. We may share these analyses and Aggregate Information with third parties. Aggregate Information provided to third parties will not allow anyone to identify you, or determine anything personal about you. We may collect Aggregate Information through features of the software that supports our services, through cookies, and through other means described below.

IP Addresses

We may automatically receive and record information in our server logs from your browser, including your IP address, your computer's name, the type and version of your web browser, referrer addresses and other generally accepted log information. We may also record page views, and other general statistical and tracking information, which will be aggregated with that of other users and may be disclosed to third party consultants in order to understand how our website and the Patient Portal are being used. None of this data contains personal information.

Cookies

A cookie is a small amount of data, which often includes an anonymous unique identifier, which is sent to your browser from a website's computers and is stored on your computer's hard drive. Cookies can be used to provide you with a tailored user experience and to make it easier for you to use a website upon a future visit. We may include cookies on our website or the Patient Portal and use them to recognize you. You may set your browser so that it does not accept cookies. Cookies must be enabled on your web browser, however, if you wish to access certain personalized features of our services.

In order to determine whether your computer is supported by our system, we may collect certain anonymous information. This information includes, but is not limited to, your operating system and browser, as well as the presence of any software that our website or the Patient Portal may require to operate with your computer, or other third party software on your computer. This information is kept strictly confidential and is not shared with third parties, except as provided in this Privacy Policy.

Privacy Protection for Children

The Patient Portal is not directed at minors. We will not provide access to the Protected Information of anyone under the age of 18 (a "Minor Dependent") via the Patient Portal except:

We may share Protected Information in communications between a parent or legal guardian and Appleton Clinics GJ, LLC regarding a Minor Dependent's medical care, to the extent permitted by HIPAA, the Privacy Rule, and other applicable laws protecting the privacy of the Minor Dependent;
Personal Information of a Minor Dependent may be listed on a parent's or guardian's Patient Portal account;
Where a third party is responsible for billing and payment, Billing Information BUT NOT related Protected Health Information of a Minor Dependent may be shared with the third party payor.

In general, the Protected Information of a Minor Dependent will be disclosed to a parent or guardian in accordance with HIPAA, the Privacy Rule, and other applicable federal and state laws.

Vendors

In the course of providing products or services to us, our staff, employees, and technical and maintenance contractors may have limited or full access to your Protected Information. A contractor ("Vendor") may include a technician, service-provider, or supplier that provides us with technology, services, and/or content related to (i) enhancing operation and maintenance of the Patient Portal or our EMR, (ii) collecting information, (iii) responding to and sending electronic mail, or (iv) providing other functions necessary to our business. Access to your Protected Information by a Vendor is limited to the information reasonably necessary for that Vendor to perform his or her limited functions for us. We also contractually require each Vendor to protect the privacy of your information consistent with this Privacy Policy.

Imminent Harm

We may, but are not obligated to, reveal certain Protected Information to attorneys, private investigator organizations, or law enforcement agencies if we believe that (a) you are at risk of harm, or (b) you are harming or interfering with (or will imminently harm or interfere with) others or violating (either intentionally or unintentionally) our Terms and Conditions of Use or otherwise violating legal rights.

Legal Requirement

We will reveal your Protected Information to the extent we reasonably believe we are required to do so by law. If we receive legal process calling for the disclosure of your Protected Information, we will attempt to notify you via the email address you supplied during registration within a reasonable amount of time before we respond to the request, unless such notification is not permitted.

Transfer

We are entitled to transfer to a third party information we collect, including any Protected Information, in connection with a sale or transfer (or potential sale or transfer) of the stock of Appleton Clinics GJ, LLC or all or a majority of the assets of the business entity responsible for the information under this Privacy Policy, provided the acquiring third party agrees to safeguard your Protected Information with protections that in all material respects are the same as, or more protective than, those set out in this Privacy Policy.

Disclosure

Except as specified in this Privacy Policy, we will not disclose your Protected Information without your permission. By agreeing to this Privacy Policy, you allow us to use and disclose Protected Information as provided in this document. Specifically, you allow us to use and disclose (including re-disclosures, as allowed in this Privacy Policy) the following types of information:

Medical records received from hospitals, physicians, nurses, and other records owners or records custodians, or created by us in the course of providing medical services to you;
Information regarding HIV or AIDS status or test results;
Mental health information and psychotherapy notes;
Substance abuse information and information from treatment facilities protected under 42 Code of Federal Regulations, Part 2 Company Personnel and Site Vendors.

By submitting Protected Information to us that you received from hospitals, physicians, or other records owners, you specifically consent to the re-disclosure of that information to the extent provided in this Privacy Policy.

Security

Security measures are in place to protect the loss and misuse of your Protected Information.

Security Measures

We use at least 128-bit Secure Socket Layer ("SSL") encryption technology (an industry-standard technology) to prevent phishing and to safeguard your Protected Information whenever it is transferred between servers. To prevent loss of your Protected Information, all data is backed up at least weekly. All of your Protected Information is hosted offsite in an internet data center, access which is controlled 24 hours a day.

Our security systems are structured to prevent unauthorized third parties from accessing your Protected Information. We also monitor network traffic to identify unauthorized attempts to access or alter your Protected Information. However, we do not warrant as fail-proof the security of your Protected Information. Due to the nature of internet communications and evolving technologies, we cannot provide, and we explicitly disclaim, assurance that your Protected Information will remain free from loss or misuse by third parties who, despite our efforts, obtain unauthorized access.

Your Password and Account Information

Regardless of the security we have in place to safeguard your Protected Information, anyone with your password and account information can access your Patient Portal account. You are solely responsible for maintaining the secrecy of your password and account information.

Notice of Security Incident

If we detect or become aware of any unauthorized access to your Protected Information, we will notify you and/or the Secretary of Health and Human Services in accordance with HIPAA, the Privacy Rule, the Security Rule, the HITECH Act, and other applicable federal and state laws.

Changes to this Privacy Policy

We reserve the right to change this Privacy Policy at any time. If we make any changes to this Privacy Policy, you will be prompted to accept the revised Privacy Policy in order to continue using the Patient Portal. If we make any changes regarding disclosure of your Protected Information to third parties, we will attempt to contact you prior to the date that the modified policy is scheduled to take effect via your current email address on file.

Effective Date

The effective date of this Privacy Policy is August 16th, 2016.

I have read and agree to the Patient Agreement below:

Mulberry Clinics, LLC, through its Physician(s), agrees to provide Patient with the Services described in this Agreement on the terms and conditions set forth in this Agreement.

Patient. A patient is defined as those persons for whom the Physician(s) shall provide Services, and who are signatories to, or listed on the enrollment form that is incorporated by reference in this Agreement.
Services. As used in this Agreement the term Services shall mean a package of services, both medical and non-medical, and certain amenities (collectively "Services"), offered by Mulberry Clinics, subject to change without further notice and further described at MulberryClinicSpringHill.com and the Patient Registration Form (attached as Appendix 1).
Fees. In exchange for the services described herein, Patient agrees to pay Mulberry Clinics the amounts as set forth in the Patient Registration Form. These fees are payable upon execution of this Agreement, and are in payment for the services provided to Patient during the term of this Agreement. If this Agreement is cancelled by Mulberry Clinics before the Agreement termination date, then Mulberry Clinics shall refund the Patient's pro–rated share of the original payment remaining after deducting individual charges for services rendered to Patient up to cancellation. If Patient cancels this Agreement, no refunds will be given. In any event, no refunds will be given for registration fees paid.
Non-Participation in Insurance. Patient acknowledges that neither Mulberry Clinics nor the Physician(s) participate in any health insurance or HMO plans or panels and all have opted out of Medicare. Neither of the above make any representations whatsoever that any fees paid under this Agreement are covered by any health insurance or other third party payment plans applicable to the Patient. The Patient shall retain full and complete responsibility for any such determination. If the Patient is eligible for Medicare, or during the term of this Agreement becomes eligible for Medicare, then Patient will sign a Medicare opt-out agreement, and incorporated by reference. This agreement acknowledges your understanding that the Physician has opted out of Medicare, and as a result, Medicare cannot be billed for any services performed for you by the Physician. You agree not to bill Medicare or attempt Medicare reimbursement for any such services. Patient shall renew and sign the opt-out agreement each year.
Insurance or Other Medical Coverage. Patient acknowledges and understands that this Agreement is not an insurance plan, and not a substitute for health insurance or other health plan coverage (such as membership in an HMO). Mulberry Clinics will not cover hospital services, specialist visits, emergency room visits, surgeries, advanced radiology and imaging, worker’s compensation claims or any other services not personally provided by Mulberry Clinics or its Physicians. Patient acknowledges that Mulberry Clinics has advised that patient obtain or keep in full force such health insurance policy (ies) or plans that will cover Patient for general healthcare costs. Patient acknowledge that this Agreement is not a contract that provides health insurance, and this Agreement is not intended to replace any existing or future health insurance or health plan coverage that Patient may carry.
Medical Services. As used in this Agreement, the term Medical Services shall mean those medical services that the Physician himself is permitted to perform under the laws of the State of Tennessee and that are consistent with his training and experience as a family medicine physician, as the case may be. A list of current services offered is available at MulberryClinicSpringHill.com and is subject to change without further notice.
Availability. The Physician may, from time to time, due to vacations, sick days, and other similar situations, not be available to provide the services referred to above in this paragraph 6. During such times, Patient's calls to the Physician, or to the Physician's office, will be directed to a licensed medical provider who is "covering'' for the Physician during his absence. Mulberry Clinics will make every effort to arrange for coverage but cannot guarantee such coverage.
Pharmacy services. Mulberry Clinics has an on-site limited pharmacy. Patient is free to fill prescriptions at any pharmacy of their choice. If Patient elects to have the prescription filled at Mulberry Clinics, the cost of the medication will be charged to Patient and collected as any other fees are collected. Mulberry Clinics will not bill any insurance or other entity for medication costs.
Third-Party Referrals and Preferred Rates. Physician may elect to coordinate with third party medical specialists to whom Patient is referred and may assist Patient in obtaining specialty care. Patient understands that fees paid under this Agreement do not include and do not cover specialists’ fees or fees due to any third-party medical professional other than the Mulberry Clinics Physician(s). In the event Mulberry Clinics is able to negotiate a preferred rate on behalf of Patient for third party services (including, but not limited to advanced imaging, specialist visits, laboratory work, hospitalizations and other third-party medical services), and such preferred rates require Mulberry Clinics to collect payment for services on behalf of the third party, such payments shall be paid by You to Mulberry Clinics in advance of Patient receiving such services. Any such payments on behalf of a Patient do not create any obligation on behalf of Mulberry Clinics other than to pay the third party provider. Patient is under no obligation to use such referrals.
Term; Termination. This Agreement will commence on the date first written above and will extend monthly thereafter. Notwithstanding the above, both Patient and Mulberry Clinics shall have the absolute and unconditional right to terminate the Agreement, without the showing of any cause for termination, upon giving 30 days’ prior written notice to the other party. Unless previously terminated as set forth above, at the expiration of the initial one-month term (and each succeeding monthly term,) the Agreement will automatically renew for successive monthly terms upon the payment of the monthly fee for the contract month.
Electronic Communications. You acknowledge that communications with the Physician using e-mail, facsimile, video chat, texting instant messaging and cell phone (collectively, “Electronic Communications”) are not guaranteed to be secure or confidential methods of communications. As such, You expressly waive the Physician's obligation to guarantee confidentiality with respect to correspondence using such means of communication. You acknowledge that all such communications may become a part of your medical records. Patient authorizes Mulberry Clinics, and its Physicians to communicate with Patient by Electronic Communications regarding Patient's "protected health information" (PHI) (as that term is defined in the Health Insurance Portability and Accountability Act (HIPAA) of 1996 and its implementing regulations).

Patient further acknowledges that:

Electronic Communications are not necessarily secure mediums for sending or receiving PHI and, there is always a possibility that a third party may gain access;
Although Mulberry Clinics and the Physician will make all reasonable efforts to keep Electronic Communications confidential and secure, neither Mulberry Clinics nor the Physician can assure or guarantee the absolute confidentiality of Electronic Communications;
In the discretion of the Physician(s), Electronic Communications may be made a part of Patient's permanent medical record; and,
Electronic Communications are not an appropriate means of communication regarding emergency or other time-sensitive issues or for inquiries regarding sensitive information. In the event of an emergency, or a situation in which Patient could reasonably expect to develop into an emergency, Patient shall call 911 or the nearest emergency room, and follow the directions of emergency personnel.
If Patient does not receive a response to an Electronic Communication within one day, Patient must use another means of communication to contact the Physician(s). Neither Mulberry Clinics nor the Physician(s) will be liable to Patient for any loss, cost, injury, or expense caused by, or resulting from, a delay in responding to Patient as a result of technical failures, including, but not limited to,
1. technical failures attributable to any internet service provider,
2. power outages, failure of any electronic messaging software, or failure to properly address e-mail or text messages,
3. failure of the Clinic’s computers or computer network, or faulty telephone or cable data transmission,
4. any interception of Electronic Communications by a third party; or
5. your failure to comply with the guidelines regarding use of Electronic Communications as set forth in this paragraph.
Change of Law. If there is a change of any law, regulation or rule, federal, state or local, that affects the Agreement including these Terms & Conditions, that are incorporated by reference in the Agreement, or the activities of either party under the Agreement, or any change in the judicial or administrative interpretation of any such law, regulation or rule, and either party reasonably believes in good faith that the change will have a substantial adverse effect on that party's rights, obligations or operations associated with the Agreement, then that party may, upon written notice, require the other party to enter into good faith negotiations to renegotiate the terms of the Agreement including these Terms & Conditions. If the parties are unable to reach an agreement concerning the modification of the Agreement within forty-five days after of date of the effective date of change, then either party may immediately terminate the Agreement by written notice to the other party.
Severability. If for any reason any provision of this Agreement shall be deemed, by a court of competent jurisdiction, to be legally invalid or unenforceable in any jurisdiction to which it applies, the validity of the remainder of this Agreement shall not be affected, and that provision shall be deemed modified to the minimum extent necessary to make that provision consistent with applicable law and in its modified form, and that provision shall then be enforceable.
Reimbursement for services rendered. If this Agreement is held to be invalid for any reason, and if Mulberry Clinics is therefore required to refund all or any portion of the monthly fees paid by Patient, Patient agrees to pay Mulberry Clinics an amount equal to the reasonable value of the Services actually rendered to Patient during the period of time for which the refunded fees were paid.
Amendment. No amendment of this Agreement shall be binding on a party unless it is made in writing and signed by all the parties. Notwithstanding the foregoing, Mulberry Clinics may unilaterally amend this Agreement to the extent required by federal, state, or local law or regulation ("Applicable Law") by sending You 30 days advance written notice of any such change. Any such changes are incorporated by reference into this Agreement without the need for signature by the parties and are effective as of the date established by Mulberry Clinics, except that Patient shall initial any such change at Mulberry Clinics’ request. Moreover, if Applicable Law requires this Agreement to contain provisions that are not expressly set forth in this Agreement, then, to the extent necessary, such provisions shall be incorporated by reference into this Agreement and shall be deemed a part of this Agreement as though they had been expressly set forth in this Agreement.
Assignment. This Agreement, and any rights Patient may have under it, may not be assigned or transferred by Patient.
Relationship of Parties. Patient and the Physician(s) intend and agree that the Physician(s), in performing his/her duties under this Agreement, is an independent contractor, as defined by the guidelines promulgated by the United States Internal Revenue Service and/or the United States Department of Labor, and the Physician(s) shall have exclusive control of his/her work and the manner in which it is performed.
Legal Significance. Patient acknowledges that this Agreement is a legal document and creates certain rights and responsibilities. Patient also acknowledges having had a reasonable time to seek legal advice regarding the Agreement and has either chosen not to do so or has done so and is satisfied with the terms and conditions of the Agreement.
Miscellaneous. This Agreement shall be construed without regard to any presumptions or rules requiring construction against the party causing the instrument to be drafted. Captions in this Agreement are used for convenience only and shall not limit, broaden, or qualify the text.
Entire Agreement. This Agreement contains the entire agreement between the parties and supersedes all prior oral and written understandings and agreements regarding the subject matter of this Agreement.
Jurisdiction. This Agreement shall be governed and construed under the laws of the State of Tennessee and all disputes arising out of this Agreement shall be settled in the District Court of Williamson County, Tennessee.

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Join Us

Basic Contact Information

Home Address

Contact Information

Emergency Contact

Set Username and Password for Patient Portal

Billing

Card Details

Card Billing Address

How did you hear about Mulberry Clinics?

What is the primary reason you are joining Mulberry Clinics?

Females only: Are you pregnant?

Authorization

PRIVACY POLICY

The Information We Collect

Our Use of Your Protected Information

Condition-Specific Content

Opt-Out

Anonymous, Aggregate Information

IP Addresses

Cookies

Privacy Protection for Children

Vendors

Imminent Harm

Legal Requirement

Transfer

Disclosure

Security

Security Measures

Your Password and Account Information

Notice of Security Incident

Changes to this Privacy Policy

Effective Date

Patient further acknowledges that: