Terms and Conditions of Treatment
Consent of treatment
I understand that my care as a patient at Tree of Life Medicine is directed by a Naturopathic Physician, and/or other licensed professionals. I consent to services rendered and provided to me under the instructions of these professionals assisting in my care.
I may be contacted by Tree of Life Medicine's physician for voluntary participation in clinical research projects. I do however, have the right to refuse these programs without jeopardizing my future care at Tree of Life Medicine in any way.
I have full read and understand the above agreements and authorizations.
HIPAA Notice of Privacy Practices and Consent: I hereby consent to the use and disclosure of my protected health information by Tree of Life Medicine for the purposes of treatment, payment, and healthcare operations, or as otherwise required by law.
Statement of Financial Responsibility
I understand and agree to the following:
-Payment for services rendered are my responsibility as the patient or patient's responsible party.
-I am responsible for paying for all services, including lab tests, rendered at the time of service.
-If I am receiving a discount of any sort, I am responsible for providing accurate and thorough documentation supporting it and I am responsible for paying in full at the time of service.
Insurance Billing:
If I am billing insurance for services rendered, I understand and agree to the following:
-I authorize Tree of Life Medicine to release pertinent medical records related to billing directly to my insurance carrier. This release applies to support of the insurance billing process only.
-I am responsible for any and all charges tht my insurance company will not cover.