In order to attain maximal results under our care, we need your commitment to:
- A PCP (Primary Care Physician) while working with Nutrifarmacy. Nutrifarmacy requires that you have a PCP on record. Nutrifarmacy does not handle medical or mental health emergencies. Your PCP will only be contacted by Nutrifarmacy per medical necessity.
- We recommend strong commitment to Nutrifarmacy in order for maximal therapeutic benefit. Working with multiple health care providers, other than your primary care physician, may delay or undermine the healing process.
- Understand chronic illness is an ongoing process, that in some cases can take years to support properly. Patients should not expect overnight results.
- Compliance with dietary recommendations, supplement support, as well as other therapeutic modalities. Non-compliance will result in a reduction in therapeutic benefits.
- Ongoing support for your healing process will facilitate a healing environment. Nutrifarmacy is obligated to identify behaviors that interfere with your healing process, and may recommend additional outside services. These services include a range of behavioral and mental health therapies. Refusal to make appropriate use of recommended treatment will result in termination of UWC services.
- Understand that Nutrifarmacy implies no guarantee of services concerning the results intended from any treatment and/or recommendations provided to me, that I have the right to choose my treatment plan and that I may refuse any or all treatment suggestions at any time.
- Understand that I have the right to choose which recommendations to incorporate into my treatment plan and that I should always communicate any new treatments, including vitamins/herbs/supplements to my entire healthcare team.
- Acknowledge that I have not been asked to stop/discontinue care provided by my specialty or primary care medical teams.
- Understand that integrative medicine information, data and drug/herb/supplement interactions databases are constantly updated as new information becomes available and that Nutrifarmacy may not be able to anticipate and explain all potential risks and complications due to the ever-changing nature of the field. I agree to allow Nutrifarmacy to exercise their best clinical judgment in my case based on the information available at my time of visit.
- Understand all the facts given to me in this form. I give my consent to Nutrifarmacy to provide initial consultation and follow up consultation services for me. I acknowledge that no guarantee of services have been made to me concerning the results intended from any treatment and/or recommendations provided to me. I attest with my signature below that Nutrifarmacy has discussed all the information on this form, that I have had the chance to ask questions and that all of my questions have been answered.
- I am not an agent of any private, local, county, state or federal agency attempting to gather information without so stating my intentions.
Risks of remaining untreated:
Delay of treatment allows formation of adhesions, scar tissue and other degenerative changes. These changes can further reduce skeletal mobility and include chronic pain cycles. It is quite probable that delay of treatment will complicate the condition, and make future rehabilitation more difficult.
If you have any questions concerning the above, please ask your Doctor of Chiropractic. When you have full understanding and consent to have chiropractic care provided, please print your name and sign and date below.
To insure fluid operation of Nutrifarmacy, the patient agrees to the following:
Appointments
- There is a 7 day cancellation policy for your first Initial appointment.
- There is a 48-hour cancellation policy for all follow-up appointments.
- As a courtesy, we call to confirm the appointment prior to your scheduled time; it is your responsibility to keep the scheduled appointment or reschedule.
- Violation of the cancellation policy will result in billing for the scheduled appointment. If there is refusal to pay for violating the cancellation policy, you will be terminated from the practice.
Additional Testing
- All patients are required to have a Comprehensive Bio-Screen from Principal Labs (or equivalent tests) upon acceptance into the Nutrifarmacy care model. These tests can be no older than 3 months prior to the date of the initial consult. These tests require fasting, which requires a 13-hour period prior of nothing besides water.
- After your initial and follow-up appointments, lab tests and/or diagnostic tests may be ordered. Testing recommendations and cost(s) per test will be reviewed.
- Some lab tests take up to 6 weeks to be finalized. The results will be mailed or emailed to you when they are completed. A follow-up appointment is recommended to discuss the results of these tests.
Billing
- Payment for the office visit, phone consultation or lab tests is expected at time of service. We accept cash, check or credit cards. All credit card payments will be processed the same day of the visit or phone call. All payments are non-refundable.
- If test kits are sent to you, you will be charged the day the kit is mailed.
- Nutrifarmacy does not participate with any insurance carrier. We do not submit medical claims on your behalf and we cannot assist you with claim resolution. All services are strictly on a self-pay basis; however we will provide you with a detailed billing summary that you may submit to your insurance carrier for possible reimbursement. Please note that there may be procedures and laboratory tests that are non-covered due to your individual policy/plan type. Should you have any questions regarding your medical coverage, please call the telephone number on the back of your insurance card.
- Nutrifarmacy providers do not participate in the Medicare program. If you are a Medicare Part B beneficiary and wish to become a patient of Nutrifarmacy, you are required to accept the terms and conditions set forth in a Private Contract between you and your Nutrifarmacy provider. This Private Contract provides that absolutely no Medicare payment will be made to you or to Nutrifarmacy for the services provided, even if such services are covered by Medicare. Under the Private Contract, you acknowledge that you accept full responsibility for the payment of charges for all services rendered by Nutrifarmacy; such payments are due in full at the time of service. Nutrifarmacy will not require you to sign the Private Contract if you are experiencing an emergency or urgent issue.
- Nutrifarmacy requires all patients provide a handwritten personal history of your current condition, including any information that may be pertinent to your case. Please understand that all information you provide is both valuable as well as pertinent to your case. If circumstances require typing or dictation, please notify Nutrifarmacy and use a trusted party.
Primary Care Physician
- Please note that Dr. Hoeper is not your primary care physicians. We require that you have a primary care physician at home.
Nutrifarmacy provides patients the opportunity to communicate with their physicians, health care providers, and administrative staff by e-mail. Transmitting confidential health information by e-mail, however, has a number of risks, both general and specific, that should be considered before using e-mail.
Risks:
- General e-mail risks are the following: e-mail can be immediately broadcast worldwide and be received by many intended and unintended recipients; recipients can forward e- mail messages to other recipients without the original sender(s) permission or knowledge; users can easily misaddress an e-mail; e-mail is easier to falsify than handwritten or signed documents; backup copies of e-mail may exist even after the sender or the recipient has deleted his/her copy.
- Specific e-mail risks are the following: e-mail containing information pertaining to diagnosis and/or treatment must be included in the protected personal health information; all individuals who have access to the protected personal health information will have access to the e-mail messages; patients who send or receive e-mail from their place of employment risk having their employer read their e-mail.
It is the policy of Nutrifarmacy that all e-mail messages sent or received which concern the diagnosis or treatment of a patient will be a part of that patient’s protected personal health information and will treat such e-mail messages or internet communications with the same degree of confidentiality as afforded other portions of the protected personal health information. Nutrifarmacy will use reasonable means to protect the security and confidentiality of e-mail or internet communication. Because of the risks outlined above, we cannot, however, guarantee the security and confidentiality of e-mail or internet communication.
Patients must consent to the use of e-mail for confidential medical information after having been informed of the above risks. Consent to the use of e-mail includes agreement with the following conditions:
- All e-mails to or from patients concerning diagnosis and/or treatment will be made a part of the protected personal health information. As a part of the protected personal health information, other individuals, such as Nutrifarmacy physicians, nurses, other health care practitioners, insurance coordinators and upon written authorization other health care providers and insurers will have access to e-mail messages contained in protected personal health information.
- Nutrifarmacy may forward e-mail messages within the practice as necessary for diagnosis and treatment. Nutrifarmacy will not, however, forward the email outside the practice without the consent of the patient as required by law.
- Nutrifarmacy will endeavor to read e-mail promptly but can provide no assurance that the recipient of a particular e-mail will read the e-mail message promptly. Therefore, e- mail must not be used in a medical emergency.
- It is the responsibility of the sender to determine whether the intended recipient received the e-mail and when the recipient will respond.
- Because some medical information is so sensitive that unauthorized disclosure can be very damaging, e-mail should not be used for communications concerning diagnosis or treatment of AIDS/HIV infection; other sexually transmissible or communicable diseases, such as syphilis, gonorrhea, herpes, and the like; Behavioral health, Mental health or developmental disability; or alcohol and drug abuse.
- Nutrifarmacy cannot guarantee that electronic communications will be private. However, we will take reasonable steps to protect the confidentiality of the e-mail or internet communication but Nutrifarmacy is not liable for improper disclosure of confidential information not caused by its employee’s gross negligence or wanton misconduct.
- If consent is given for the use of e-mail, it is the responsibility of the patient’s to inform Nutrifarmacy of any types of information you do not want to be sent by e-mail.
- It is the responsibility of the patient to protect their password or other means of access to e-mail sent or received from Nutrifarmacy to protect confidentiality. Nutrifarmacy is not liable for breaches of confidentiality caused by the patient.
Any further use of e-mail initiated by the patient that discusses diagnosis or treatment constitutes informed consent to the foregoing.
I understand that my consent to the use of e-mail may be withdrawn at any time by e-mail or written communication to Nutrifarmacy.
I have read this form carefully and understand the risks and responsibilities associated with the use of e-mail.
I agree to assume all risks associated with the use of e-mail.
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