NEW New Patient Form

Patient Packet
Name

First Name Last Name
John "Jack" B. Monaco, MD, FACOG, FAARFM, ABAARM

Nashville Hormone & Integrative Medicine Center, LLC

1909 Mallory Lane, Suite 108

Franklin, TN 37067

Phone: 615 964-5871

Fax: 615 716-1040
Dr. Monaco and his staff are pleased that you have chosen us to care for your medical needs. This patient information packet will provide you with information about the practice which is essential for you to understand in order to insure that you receive efficient and high quality medical care. Please read this entire information packet completely and carefully.

In this packet you will receive information on:
- Office hours/Physician Appointments
- Urgent and emergency appointments
- Personal Health & Wellness Assessment (required at initial visit)
- What to expect at your appointment
- Obtaining lab and test results
- Telephone calls
- Prescriptions and prescription refills
- Financial counseling/insurance
- Concierge (VIP) medicine
- Nutritional Consults
- Agreement for Medical Services
OFFICE HOURS/PHYSICIAN APPOINTMENTS

Appointments to see Dr. Monaco are scheduled as follows:

Monday 6:20AM to 2:20PM

Tuesday 6:20 AM to 2:20 PM

Wednesday Lab Appointments Only

Thursday 6:20 AM to 2:20 PM

Friday 6:20AM to 11:00AM.

When calling for an appointment, please indicate to the receptionist whether you are a new patient, returning for a follow-up visit and who referred you.

We ask that you arrive at least 30 minutes prior to your appointment time to allow for parking and registration. A credit card is required at the time that you make your appointment. A charge of $100 will be charged if you fail to show for your appointment. No appointment will be given without a credit card on file. If you arrive late, we may have to reschedule your appointment. A 48-hour cancellation notice is requested for new patient appointments. Cancellations made less than 24 hours may result in a $150 charge for a missed visit. Please bring your initial patient health survey filled out to your appointment. If you do not receive this at least 48 hours prior to your appointment, please call the office and we will e-mail one to you. If you arrive without your completed paperwork, your appointment may be rescheduled. As a courtesy to our patients, we ask for your cooperation. The arrival time for your appointment is not optional; this time is part of your appointment. We strive to run on time and to provide the best service possible.

A CREDIT CARD IS REQUIRED BY DR. MONACO TO BE HELD ON FILE FOR YOUR DURATION OF CARE.

URGENT & EMERGENCY APPOINTMENTS

If an emergency situation arrives, we will do our best to see you that same day or refer you to the closest emergency room. The E.R. physician will contact Dr. Monaco regarding your medical condition

PERSONAL HEALTH & WELLNESS ASSESSMENT

You will receive, either by email or regular mail, a Personal Health & Wellness Assessment which you will need to complete and bring with you to your initial consultation with Dr. Monaco. This assessment will provide our team with a complete personal medical, family and social history to which we refer to when needed. Accurate and complete information is critical for your health care. This provides a basis for which your personalized wellness program will be designed. We ask that you bring this COMPLETED form with you to your appointment. There will not be enough time to fill this out prior to your appointment and failure to have this information will require that we reschedule your appointment.

WHAT TO EXPECT AT YOUR FIRST APPOINTMENT

During your initial consultation, your Health & Wellness assessment will be reviewed and any additional pertinent medical information noted. Your weight and vital signs will be taken. Your physician will perform a physical examination, review your assessment and the nurses’ recommendations and recommend appropriate testing, medications, supplements, as deemed necessary. Follow-up appointments will be scheduled as appropriate for your particular circumstances. For all new patients and annual follow-up, a comprehensive series of lab tests may be ordered. Salivary testing is ordered as necessary to monitor hormone levels in patients using topical hormones.

During follow-up visits, all testing and laboratory results will be reviewed with you. You will receive a copy of all test results. A customized program which may include hormone restoration, medical, nutritional and nutraceutical (supplements) support will be given to you. You will be instructed on the reason for our recommendations, what to expect from your customized program, and how to take and use these medications, hormones and nutrients. You will be provided with a Medication & Supplement Sheet with our recommendations to which you can refer.

OBTAINING LAB AND TEST RESULTS

You will be given a copy of your test results at each follow-up visit.

TELEPHONE CALLS

Any calls after normal business hours will be addressed on the following business day. If you reach our voicemail, leave a DETAILED message, including your name, date of birth, phone number and a pharmacy number for prescription refills. Emergency calls will be addressed immediately. Non-emergency calls will be returned by the end of the day. If you are calling for a prescription refill, leave a message including the name of the medication needed and a prescription number, if available.

PRESCRIPTIONS

Prescriptions will be phoned into a pharmacy ONLY during office hours. Controlled substances will NEVER be phoned into a pharmacy after hours or on weekends. Please allow at least 72 for hormone prescriptions to be called in and compounded so that you do not experience an interruption in therapy. If you use a mail order pharmacy, please tell our staff at the time of your visit so that a short-term prescription can be written for you to use at a local pharmacy until your mail order arrives. All prescriptions are now generated from our electronic medical record system.

FINANCIAL COUNSELING AND INSURANCE

Co-pays are due at the time of each visit. Patients are responsible for all charges not covered by their insurance plans. We appreciate your timely payment of all medical charges. Salivary test kits are purchased at each visit which allows us to pass on a savings to the patient. Payments may be made via Cash, Check, Visa, MasterCard or American Express at the registration desk upon completion of your visit. Returned checks will incur a $25 charge to cover bank costs. Returned checks may also cause loss of the option to pay by check. Refunds for salivary kits may only be given when the kit is returned to the office.

CONCIERGE MEDICINE

Concierge medicine membership is an alternate way of receiving additional services to your medical care from my office. The benefits of being a concierge member include extended consultation time with Dr. Monaco, preferred appointment scheduling, usually within 24 hours, unlimited access with no additional office fees or costs. I am pleased to offer these additional services and I believe that should you choose this option, you will be most pleased. Membership is on a yearly basis and is based on the initial visit. The membership fee may be deductible from your Health Savings Account or Cafeteria Plan. To request a membership form, quote for current membership fees or if you would like to consult with someone about the benefits of Concierge Medicine, please ask to speak with the Administrator, Lesa McPherson Monaco, BS, RN.

NUTRITIONAL CONSULTS

A large component of achieving hormone balance and wellness involves lifestyle and lifestyle modifications. The cornerstone of wellness and lifestyle is nutrition. Part of your customized wellness program may involve a structured lifestyle and nutrition program. We are pleased to have Danielle Gilbert, Dietician available for our patients. She will be able to help you individualize a nutrition and exercise plan to assist you in reaching your health goals. Appointments can be made for a consult with Danielle by our receptionists.

NEW PATIENT GUIDELINES
Thank you for choosing our practice to provide your hormonal and integrative medicine care. We promise to do our very best to address your needs. We make every attempt to see our patients promptly at their appointment time. If we are running late it is usually because a patient has arrived late for their appointment or has not arrived in advance of their appointment.

In order to avoid delays and long wait times and to be considerate of everyone involved we ask for your cooperation with the following:

NEW PATIENTS: Please arrive 30 minutes before your scheduled appointment. You must have your completed initial patient package with you. Please make sure it is filled out completely and accurately. Please call us in advance if you have not received your new patient package or need help locating the document on our website. Failure to do so may result in your appointment being canceled and rescheduled. You will need to plan for traffic delays and allow time for parking.

RETURNING PATIENTS: Please arrive 15 minutes prior to your appointment to allow time for registration. By doing so, we can usually have you into the exam room promptly.

Many of our patients have other appointments for testing. We strive to conclude their visit to make sure that they can complete these tests in a timely fashion.

We hope to avoid having to cancel and reschedule an appointment but in some cases, this may be unavoidable. Your cooperation in this matter is greatly appreciated by all.

If you need to make changes to your appointment please give the office a 48-hour notice or this may result in a fee. You may be charged a fee for same-day cancellations of appointment or failure to show for an appointment.

Please sign below that you understand everything you have read in this packet and that you agree to abide by the patient terms with this office.
Appointment Date

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Date
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Achieving wellness and hormone balance requires proper training and skill and the full cooperation of the patient. A personalized wellness program will be designed for you which includes, but is not limited to, laboratory testing, saliva testing, other diagnostic testing and imaging, lifestyle evaluation and recommendations, nutritional counseling, prescription medications, compounded medications including bioidentical hormones, thyroid hormone, and adrenal support and high-quality nutraceuticals supplements. In order to achieve the best possible results, reduce the risk of developing chronic disease and reduce the occurrence of adverse events, it is imperative that you follow this protocol exactly without deviation, modification, or substitution. Changing the dosage or recommended schedule of prescription medications may result in adverse events. Modifying or substituting nutritional products for lesser quality products obtained at discount stores or on the internet may negatively affect your results and have, in my experience, resulted in unsatisfactory results, lack of results, and lost time. I recommend only the highest quality nutrients that are produced in the highest caliber facilities which assure that the nutrient contains and does what it is designed to do. Absorption of nutrients is the key and many cheaper products are either poorly absorbed or not absorbed at all. If you have an issue with any medication or nutrients, you must call to discuss these issues with my staff. Any change or deviation made without our knowledge or consent may result in adverse outcomes for which we cannot be responsible. Your cooperation in this matter is necessary and greatly appreciated.
I Agree *

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Today's Date

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Date

FINANCIAL RESPONSIBILITY ACKNOWLEDGEMENT
Private insurance companies and Medicare often dictate what test can be ordered/covered and this coverage cannot be accurately predicted. Reimbursement to physicians is at an all-time low and deductibles are increasing.
*

I understand that I have the right to refuse medical treatment at any time for any reason and such refusal may impact the ability to diagnose and treat me.
*

I understand that I am responsible for the cost of my medical care and for the claims not paid by my insurance company including my insurance deductibles and copays.
*

I understand that I cannot request Nashville Hormone & Integrative Medicine Center, LLC, its’ physicians, employees or agents to dismiss, waive or reduce any charges not reimbursed by my insurance company regardless of the reason.
Proper hormone evaluation may require several different types of testing, in addition to blood testing. These tests may not be covered by your insurance or they may be partially reimbursable by your insurance company. Some tests may be partially covered and require a co-pay. While you have the right to refuse any testing, such refusal may make it difficult or impossible to accurately diagnose and resolve your hormonal issues. The commonly used tests are listed below. Anyone of these tests may be offered to you to address your specific and individual needs.

You have the right to refuse any and all tests that are recommended for you.

New Patient: Self: $550, Ins: $700
Initial Follow-Up: Self: $325. Ins: $400
20 Min Follow-Up: $225
40 Min Follow-Up: $275
Reestablished: Self: $425, Ins: $700
Nurse Visit: Self: &75, Ins: $100
Phone Consult: 20 min- Self: $150, Ins: $175
40 min- Self: $275
60 min- Self: $375
Saliva Kits:
EPT: $90
Cortisol: $150
HP3: $250
Iodine: $85
Heavy Metal: $150
Signature *

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Date *

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Date

Nashville Hormone & Integrative Medicine Center, LLC
Health & Wellness Assessment
John "Jack" B. Monaco, MD, FACOG. FAARFM
Patient Information
Today's Date *

Month Day Year
Date
Social Security Number *
Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Phone Number *
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Email *
example@example.com
Marital Status *
Who referred you? *

Patient Employer Information
Employer Name
Employer Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Spouse or Parent Information
If not available, check the box below

N/A
Name

First Name Last Name
Date of Birth

Month Day Year
Date
Employer
Employer Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Emergency Information-List nearest living relative
In case of emergency we may contact: *
Name *

First Name Last Name
Relationship to patient *
Primary Care Physician
Referring Physician
If not available, check the box below

N/A

Personal Information
Birthplace *
Education *
Occupation *
Children *
Religious Preference *
Drug Allergies *
Food Allergies *
Other Allergies *
Chief Complaint(s) / Symptoms / Reason(s) for Visit *
Are you seeing other physicians
List names, address, phone number & specific problems for which you are being treated
Persons with whom results may be released

OBSTETRICAL/GYN HISTORY

A full Menstrual Cycle is the first day of your cycle to the first day of your next cycle. Ex. Menstruating starts on January 1st, then starts next on February 1st = 31 Day Cycle
If this is not applicable, please check the box below

N/A
How many days does your cycle last?
When was your last pap smear?
Normal?

Yes No
When was your last mammogram?
Normal?

Yes No
Indicate the number of the following
Menarche (onset of menstrual cycle)
Age at onset of periods
Duration of Menstruation
Days
Flow

Light Normal Heavy
Please list all surgeries and the date you had them
Please list all hospitalizations and dates

Risk Assessment for Hereditary Cancers
Name

First Name Last Name
Date of Birth

Month Day Year
Date
Today's Date

Month Day Year
Date
Instructions: Please circle Y for those that apply to YOU and/or YOUR FAMILY – BOTH MOM AND DADS SIDE OF FAMILY. Include any of the below family members:

Yourself | Mother | Father | Brother | Sister | Children | Paternal Uncle/Aunt | Maternal Uncle/Aunt | Niece/Nephew | Maternal Grandmother/Grandfather | Paternal Grandmother/Grandfather | First Cousin

This is to determine if you are at risk of a gene mutation that may cause cancer in you or family members.

Type a question

Yes or No

You

Family Member

Moms/Dads Side

Age at Diagnoses

Breast Cancer

Breast Cancer in both Breast or twice in same person

Male Breast Cancer

Triple Negative Breast Cancer Under 65 (ER-, PR-, Her2-)

Pancreatic Cancer

Ovarian Cancer

Colon/Colorectal Cancer

Uterine/Endometrial

Stomach/Bladder

Other Cancers (Renal, pelvis, brain, biliary tract, small bowel)

Ashkenazi Jewish Ancestry

Have you or any family member ever been tested for BRAC of Lynch Syndrome? If yes, please explain
Signature *

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Date

Month Day Year
Date

DEBIT/CREDIT CARD PAYMENT AND USE AGREEMENT

The mission of Nashville Hormone and Integrative Medicine Center, LLC (hereafter NHIMC) is to provide quality healthcare to our valued patients. We remain committed to maintaining the most efficient billing process for our patients, including the filing of all insurance claims prior to requests for payment. In return, we require that you provide an approved credit or debit card for payment on the patient balance. Once you receive a statement notifying you that an insurance provider has paid their portion of the services provided, you will have a thirty (30) day notification period to make payment arrangements. Your credit/debit card will only be used to pay the patient balance remaining (including deductibles and co-insurance) if you have not made other payment arrangements. Please contact NHIMC’s billing representative at 615-964-5871, if you have any questions concerning this process. We have taken the appropriate steps to secure the safety of your personal and financial information. Your credit/debit card information will be secured in the same manner as protected health information (PHI) and NHIMC will not disclose any personal or financial information to any other people or companies.

PLEASE REVIEW AND SIGN BELOW:

I understand that I have been requested to supply a credit/debit card at the time of registration for the above patient. Upon notification of receipt of insurance payment, any outstanding balance remaining on the above patient’s account will be automatically applied to my credit/debit card after a thirty (30) day notification period, unless I have made other payment arrangements prior to that date.

NHIMC will not be responsible for any card issues, penalties or fees associated with applying my remaining balance to my credit/debit card.

I agree to pay the remaining patient balance for the above patient according to my cardholder agreement.
Signature

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Date

Month Day Year
Date
NOTICE OF ACKNOWLEDGEMENT

I acknowledge that I have received/reviewed the NHIMC Notice of Privacy Practices
(Patient or Personal Representative Signature)

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Relationship to Patient
FINANCIALS AND BILLING

I understand that I am responsible for charges incurred during the course of my treatment by NHIMC .

I will, also, be responsible for any REFERRAL or PRECERTIFICATION authorization required by my insurance company. In the event I fail to obtain the proper REFERRAL or PRECERTIFICATION authorization for Specialty Services, I agree that I am responsible for the charges incurred during my visit.

I authorize NHIMC to release to the Social Security Administration, its intermediaries, or other insurance carriers any and all information needed to secure payment. I permit a copy of this authorization to be used in place of the original and request payment of medical insurance benefits be issued to the physician.

This authorization is valid for any claim and/or billing services rendered to me by NHIMC. Should assistance be required in the collection of any unpaid balance, I agree to pay all collection costs and /or reasonable attorney fees.

I authorize NHIMC to release medical records by fax or mail to a referring physician when deemed necessary.
Signature

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Name

First Name Last Name
Notice of Agreement for Lab Appointments

By signing below, you are agreeing to complete all labs, saliva testing, etc. within 48 hours of your scheduled lab appointment. If these tests are not fully completed within this time frame, your results may not be available in time for your appointment. This will result in rescheduling your appointment and a rescheduling fee of $50.00. If you call and make arrangements with the office to reschedule your appointment, you will not be charged.
Signature

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Date

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Date
Should be Empty:

Patient Packet

NEW PATIENT GUIDELINES

FINANCIAL RESPONSIBILITY ACKNOWLEDGEMENT

OBSTETRICAL/GYN HISTORY

Risk Assessment for Hereditary Cancers