Non-Licensed Providers 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.

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

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Provider(s) Name(s)* This field is required.

4

Type of Service/Business* This field is required.

5

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

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State of incorporation* This field is required.

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Address* This field is required.

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Phone Number* This field is required.

Area Code

Phone Number

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Email for Entity* This field is required.

example@example.com

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

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If you selected other, describe below:

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Modalities:* This field is required.

Food and dietary supplements/herbal products

Movement/exercise

Mind-body/Spirit-Lifestyle modification

Other

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If you selected other, please describe below

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Health Care Provider(s)* This field is required.

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

I want the client 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 knowledge of the types of modalities, so we leave it up to the provider. To the extent client wishes us to do some research, we will do our best yet need to disclaim medical and licensed work 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 provider can best evaluate what meets those criteria.

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Expected Benefits of Therapeutic Approaches* This field is required.Please fill in with respect to each modality (for example: Reiki, Executive Health Coaching, herbs, supplements, Biofeedback, Meditation, Bikram Yoga, or different tools you will use). Please be specific and inclusive. We may include some suggestive language; however, we look to our provider client for specific language with respect to benefits, risks, and alternatives of each modality. 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: Reiki, Executive Health Coaching, herbs, supplements, Biofeedback, Meditation, Bikram Yoga, or different tools you will use). 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 of the recommended herbs involves some risks and hazards. The more common risks include: headaches, dry mouth, allergies, and nausea. 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. Think in terms such as: discomfort, side effects, undiscovered drug toxicity, long-term effects that cannot be known, and special risks in case of pregnancy or possible pregnancy.

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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 Modalities* This field is required.Please fill in with respect to each modality (for example: Reiki, Executive Health Coaching, herbs, supplements, Biofeedback, Meditation, Bikram Yoga, or different tools you will use). Please be specific and inclusive. We may include some suggestive language; however, we look to our provider client for specific language with respect to benefits, risks, and alternatives of each modality. Use the Enter (carriage return) function to create more space inside the box if necessary.

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Are you using video-conferencing?* This field is required.We include, for purposes of language in the consent form, establishing and/or following up with clients other than through an in-person visit.

YESNO

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

YESNO

23

Do you work with any management company (includes MSOs)?* This field is required.

YESNO

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Will you have a financial/equity interest in the management company? * This field is required.

YESNO

25

Would you like to include a clause in the consent by which the client agrees to assume all risk of services and modalities, 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 provider 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

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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

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Background and Bio of ProviderSome states require a description of the provider’s background/bio, credentials or certifications (if any), and training (if any). Please provide a short paragraph for use in the consent form.

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

YESNO

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Explanation:

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

Up front

Time of Service

Bill Client later

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

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

YESNO

33

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 client 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

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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

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

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

YESNO

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What services will your business 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

Informational handouts and educational literature

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

Annual physical exam

Cost of recommended herbs

Cost of recommended dietary supplements

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

Cost of recommended follow-up therapies

Other

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

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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 business’ 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:

49

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

YESNO

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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)

52

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

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

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

YESNO

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How many people will have access to client’s private information such as staff, employees, and contractors?

Staff (list):

Contractors (list):

Others (list):

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Do you store client’s information and/or records electronically? * This field is required.

YESNO

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

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

YESNO

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

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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.

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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.

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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.

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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.