Medical Practice Questionnaire

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Note:

If you would like to save your progress on this form, after you have gone through at least 1 question, you will have an icon at the bottom of the form to "Save and Continue Later". You need to click this, and if it asks you to Sign up using Google, Facebook, or Email - you can simply click a link at the bottom that says "Skip Create an Account". The next screen will let you enter your email address and you will receive a link through email to continue filling in your form.

Thank you.

2

Name of Professional Medical Corporation or PLLC (if any)* This field is required.

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Name of Licensee in Charge, and License (e.g., MD, DO, PT)* This field is required.

4

Title (e.g., President)* This field is required.

5

State of incorporation* This field is required.

6

Address* This field is required.

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Phone Number* This field is required.

Area Code

Phone Number

8

Email for Entity* This field is required.

example@example.com

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In what state(s) will the Practice be operating:* This field is required.

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Description of the Practice:

Functional Medicine

Integrative Medicine

Other

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If you selected other, describe below:

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Diagnostic & Therapeutic Modalities:* This field is required.

Food and dietary supplements/herbal products

Movement/exercise

Mind-body/Spirit-Lifestyle modification

Evaluation of lab tests

Other

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If you selected other, please describe below

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Primary Care

I am providing Primary Care services.

I want to try to disclaim providing Primary Care. I want to function in a specialist role.

I want the patient to document their Primary Care Physician of record.

I want the patient to check that they have had an annual physical exam with their Primary Care Physician of record.

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NOTE: Client should let us know whether they really want us to insert risks, benefits and alternatives; normally this is a matter of clinical knowledge, so we leave it up to the clinician. To the extent client wishes us to do some research, we will do our best yet need to disclaim professional knowledge of the latest scientific and medical research and note that consent law is fraught with ambiguity around liability, the rule of law being that reasonable, feasible, and material risks should be disclosed, and the clinician can best evaluate what meets those criteria.

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Expected Benefits of Diagnostic & Therapeutic Approaches* This field is required.Please fill in with respect to each modality (for example: bioidentical hormones; thyroid therapy; appetite suppressants). Please be specific and inclusive. We may include some suggestive language; however, we look to our clinician client for specific language with respect to clinical benefits, risks, and alternatives of each procedure. Use the Enter (carriage return) function to create more space inside the box if necessary.

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Risks & Potential Complications of Diagnostic & Therapeutic Approaches* This field is required.Please fill in with respect to each modality (for example: bioidentical hormones; thyroid therapy; appetite suppressants). Please be specific and inclusive. Use the Enter (carriage return) function to create more space inside the box if necessary. For example: “I understand my authorization is given with the knowledge that the use of one or more appetite suppressants involves some risks and hazards. The more common risks include: nervousness, sleeplessness, headaches, dry mouth, weakness, tiredness, psychological problems, medication allergies, high blood pressure, rapid heartbeat and heart irregularities. Less common, but more serious, risks are: primary pulmonary hypertension and valvular heart disease. These and other risks could, on occasion, be serious or fatal. For any surgery involving general anesthesia, it is extremely important that the anesthetist and surgeon be made aware of your use of any appetite suppressant medication, since potentially dangerous side effects may develop during surgery

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Do your therapeutic modalities encompass detoxification therapies such as fasting?* This field is required.

YESNO

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Alternatives to Diagnostic & Therapeutic Approaches* This field is required.Please fill in with respect to each modality (for example: bioidentical hormones; thyroid therapy; appetite suppressants). Please be specific and inclusive. We may include some suggestive language; however, we look to our clinician client for specific language with respect to clinical benefits, risks, and alternatives of each procedure. Use the Enter (carriage return) function to create more space inside the box if necessary.

20

Are you practicing telemedicine? * This field is required.We include, for purposes of language in the consent form, establishing and/or following up with patients other than through an in-person visit (for example, by phone or audio-visual means in different states, and/or diagnosing and treating new patients while they reside in states other than the one in which you are located).

YESNO

21

Do you profit from sales of dietary supplement to patients (whether in-office or via a Web portal)?* This field is required.

YESNO

22

Will you have a financial/equity interest in the management services organization (MSO) or management company that manages your practice?* This field is required.

YESNO

23

Do you prescribe medication for off-label use? * This field is required.

YESNO

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If you selected yes, please give some examples.

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Would you like to include a clause in the consent by which the patient agrees to assume all risk of treatment, and to indemnify you against injury? * This field is required.Please note that any such language is present for deterrent value. It may or may not be enforceable or raise issues if ever litigated. Many courts disfavor “exculpatory clauses” and may weigh against the physician for including such language. As such, we have tailored the language, but we can provide no guarantee with respect to how courts or enforcement authorities will view the language. We can discuss with you.

YESNO

26

Would you like to include an agreement to arbitrate? * This field is required.Again, this may be unenforceable in some jurisdictions and/or situations, and disfavored by courts, yet potentially useful for deterrent value.

YESNO

27

Do you need more than one consent form? * This field is required.

YESNO

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Explanation:

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Does the patient need to pay up front (when the patient schedules), at time of service, or will you bill them later? * This field is required.

Up front

Time of Service

Bill patient later

30

What are your fees (describe)?* This field is required.For example: 1 hour session is $100; a package for 3 sessions is $250.

31

Do you participate in any insurance panels? * This field is required.

YESNO

32

If you selected yes to the previous question, please specify:

33

Would you like to include a statement that you have no responsibility to determine patient eligibility for insurance benefits? * This field is required.

YESNO

34

Are you par (participating) or non-par (non-participating) in Medicare, yet not opted out?* This field is required.

YESNO

35

If not opted out, do you wish to state that your practice does not accept Medicare or Medicaid patients?

YESNO

36

If you, or any clinician in your practice, is Medicare par or non-par (yet not opted out), do you offer any Medicare-covered services?

YESNO

37

If providing any Medicare-covered services, do you or such clinicians provide services (under an ABN—Advanced Beneficiary Notice) to Medicare patients?

YESNO

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*** If you are: (1) providing a concierge/subscription/membership model of services, (2) Medicare par- or non-par (yet not opted out), and (3) providing services to Medicare beneficiaries, have you checked to determine that each and every service is not covered by Medicare?

YESNO

39

Would you like to include a statement that patient accepts financial responsibility for all charges, even if you provide a superbill? * This field is required.

YESNO

40

Would you like to include a statement that your practice may charge the patient for specific services such as blood or urine tests, ultrasound, and such?* This field is required.

YESNO

41

What is your cancellation policy (describe)? * This field is required.For example: Scheduling of appointments involves the reservation of time specifically for you. Therefore, a minimum of 24 hours (in-advance) notice is required for rescheduling or canceling an appointment. The full fee or half fee may be charged for missed appointments without such notification.

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Would you like to request debit card information from the patient so that you can charge the card in case needed per your cancellation policy? * This field is required.Please note that there are laws relating to “PCI compliance” i.e., governing privacy and security of sensitive information such as debit card information).

YESNO

43

Would you like ask the patient to authorize a credit report, to ascertain financial responsibilities? * This field is required.

YESNO

44

Would you like to include a statement that any return of products must be within so many days of purchase? * This field is required.

YESNO

45

If you selected yes to the previous question, please specify how many days:

46

Would you like to include a statement that the practice provides no refunds?* This field is required.In practice, it is usually wise to refund the patient, at least partially, in order to mitigate risk of complaints and liability.

YESNO

47

What services will your Practice provide in exchange for the Membership Fee? * This field is required.

Initial appointment

Follow-up appointments

Food and dietary supplement recommendations

Mind-body/Spirit/Lifestyle recommendations

Review of laboratory tests

Informational handouts and educational literature

More leisurely/less crowded office visits

Other

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If you selected Initial appointment, please specify duration:

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If you selected Follow-up appointments, please specify the number of appointments and duration of each:

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If you selected Other, please specify:

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Would you like to include a statement that patient financial responsibility for all charges, even if you provide a superbill? * This field is required.

YESNO

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Which services do you want to exclude?* This field is required.(Patient would have to pay for these separately).

Annual physical exam

Cost of lab tests

Cost of recommended medications or medical devices

Cost of recommended dietary supplements

Emergency or urgent care

Services by other providers (whether inside or outside the office)

Cost of recommended follow-up therapies

Cost of recommended narcotic or controlled substances

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What is the Membership Fee?

Inidividual Monthly fee

Household Monthly fee

Other Monthly fee

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When does the Membership become effective?* This field is required.

On the date the Membership Agreement is signed.

On the first of the upcoming month following the Practice’s receipt of the Fee.

Other

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If you selected other for the previous question, please describe:

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Does the Membership automatically renew, unless cancelled by the Member? * This field is required.

YESNO

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If you selected yes to the previous question:Please note that states have laws governing subscription and automatic renewal, that require clear disclosure of subscription/renewal policies and practices that do not impede Members’ efforts to cancel.

describe how often:

describe how many days’ notice are required to cancel the membership:

provide an 800- number Members can call to cancel the Membership:

58

Beyond in-office sales or sending patients to a designated portal to purchase dietary supplements, are you white-labeling dietary supplements? * This field is required.

YESNO

59

If white-labeling supplements, have you had your website reviewed for FDA/FTC issues?

Yes

No (we do recommend legal review)

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If white-labeling supplements, have you had your agreement with the contract manufacturer reviewed for liability exposure?

Yes

No (we do recommend legal review)

61

Are you billing insurance for third-party reimbursement electronically?* This field is required.

Yes (HIPAA applies)

No (HIPAA may not apply but is recommended as best practices)

62

Do you currently employ or contract with an IT consultant who can be point person for privacy and security issues? * This field is required.

YESNO

63

If you selected yes to the previous question, please specify name and contact information:

64

Are you a covered entity (such as a physician, healthcare facility) or a business associate (such as a management company, biller, service provider to a covered entity)? * This field is required.

Covered Entity (the Privacy and Security Rule of HIPAA each apply)

Business Associate (some parts of the PrivacyRule may be less relevant to you)

65

Have you ever had a data breach or been subject to any government investigation or lawsuit based on the same? * This field is required.

YESNO

66

How many licensed professions (e.g., MD, NP, PA, etc.) will have access to Protected Health Information (PHI), staff, and contractors within your practice?

Licensed Professionals (list):

Staff (list):

Contractors (list):

67

Do you use an EMR? * This field is required.

YESNO

68

Do you have any special privacy and security needs or concerns? * This field is required.

YESNO

69

If you selected yes to the previous question, please specify:

70

Are you billing insurance for third-party reimbursement electronically? * This field is required.Note: HIPAA compliance is a large topic in and of itself; the Questionnaire is a very early start to help orient us.

Yes (HIPAA applies)

No (HIPAA may not apply but is recommended as best practices)

71

Days and hours of leased occupancy (specify):

Monday Monday Start * (am/pm) to Monday End * (am/pm)
Tuesday Tuesday Start *    (am/pm) to Tuesday End *    (am/pm)
Wednesday Wednesday Start *    (am/pm) to Wednesday End *    (am/pm)
Thursday Thursday Start *    (am/pm) to Thursday End *    (am/pm)
Friday Friday Start *    (am/pm) to Friday End *    (am/pm)
Saturday Saturday Start *    (am/pm) to Saturday End *    (am/pm)

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The OIG Fraud Alert adds:

Apportionment of interior office common space - When permitted by applicable regulations, rental payments may also cover the interior office common space in physicians' offices that are shared by the physicians and any subtenants, such as waiting rooms. If suppliers use such common areas for their patients, it may be appropriate for the suppliers to pay a prorated portion of the charge for such space. The charge for the common space must be apportioned among all physicians and subtenants that use the interior office common space based on the amount of non-common space they occupy and the duration of such occupation. Payment for the use of office common space should not exceed the supplier's pro rata share of the charge for such space based upon the ratio of the space used exclusively by the supplier to the total amount of space (other than common space) occupied by all persons using such common space.

Apportionment of building common space - Where the physician pays a separate charge for areas of a building that are shared by all tenants, such as building lobbies, it may be appropriate for the supplier to pay a prorated portion of such charge. As with interior office common space, the cost of the building common space must be apportioned among all physicians and subtenants based on the amount of non-common space they occupy and the duration of such occupation. For instance, in the example in number one above, the supplier's share of the additional levy for building common space could not be split 50/50.

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1. Annual rent of primary lease (i.e., of Landlord’s lease to Manager):* This field is required.

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2. Number of work days per year:* This field is required.

75

3. Square feet exclusively occupied by Subleasee (i.e., the party (normally the practitioner) that is subleasing from the Leasee (the Manager):* This field is required.

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4. Total number of square feet in the office space:* This field is required.

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5. Average number of hours each day to be rented by Subleasee:* This field is required.

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6. Total number of hours available for office leasing in a day:* This field is required.

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7. Number of days weekly to be rented by Subleasee:* This field is required.

80

8. Number of weeks in the year:* This field is required.

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9. Physician (or Lessee) Office Rent per day: (#1 above / # 2 above)* This field is required.

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10. Percentage of Office Space rented by Subleasee: (#3 above / # 4 above)* This field is required.

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11. Percentage of each day rented by Subleasee: (# 5 above / # 6 above)* This field is required.

84

12. No. of days rented by Subleasee each year: (#7 above x #8 above)* This field is required.

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Fair Mark Value of Annual rent for exclusive space to be paid by Subleasee (typically, practitioner) to Leasee (typically, Manager): * This field is required.

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See diagram below, which is from the OIG Fraud Alert.