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INFORMED CONSENT FOR MEDICAL/COMPLEMENTARY AND ALTERNATIVE MEDICINE TREATMENTS

Medical care is a patient care service provided in response to wide range of medical care needs of patients of all ages regardless of gender, color, race, creed, national origin, or disability, on an as needed basis.

The purpose of medical care is:

●  To treat disease, injury and disability by examination, testing and use of procedures in the aid of diagnosis and treatment.
●  To obtain information needed in diagnosing and examining patients.
●  To prevent or minimize physical and mental disability.
●  To aid patients in achieving their maximum potential within their capabilities.
●  To accelerate convalescence and reduce the length of the functional recovery.

As a patient I have the right to be informed about my condition and recommended care. This disclosure is to help me become better informed so I may make the decision to give or withhold my consent as whether or not to undergo care having had the opportunity to discuss potential benefits, risks, and hazards involved.

I hereby request and voluntarily consent to examination and treatment with complementary and alternative medicine, possibly including homeopathic medicines, vitamins, minerals, supplements, IV therapies, injections, detoxification treatment, lab testing, nutrition recommendations, etc. for me (or for the patient named below, for whom I am legally responsible) by DS Family Medical Group and Dr. Devan Szczepanski, Dr. Catherine Fussell, Dr. Meghan Gaddis, Mauri Freitas, APRN or any other licensed medical providers. I can request further explanation of the procedure or treatment, other alternative procedures or methods of treatment, and information about the material risks of the procedure or treatment.

I understand that the U.S. Food and Drug Administration has not fully evaluated or approved nutritional, herbal and homeopathic supplements, compounded IV’s/injections, bio-identical hormone replacement therapies; however, they have been widely used in Europe and the U.S. for years. I understand that, as with any drugs, hormones, nutritional supplements, and injections may exhibit some side effects in certain sensitive individuals, may interact with certain allopathic medications or labs test, or show symptoms, due to certain pre-existing disease conditions. I do not expect the medical provider to be able to anticipate and explain all risks and complications, and I wish to rely on the medical provider to exercise judgment in recommending the dietary supplements, medications, and treatment, that the medical provider feels at the time, based on the fact then known, is in my best interest. I understand that if I do not take the supplements or treatments as recommended, I may not get the desired results or may increase chances for an adverse effect.

It is my responsibility to keep my medical provider up to date with all of the current medications and supplements that I am taking, so that he/she can make the best informed recommendations for my care.

I have the opportunity to ask questions and discuss with my provider to my satisfaction:
●  My suspected diagnosis or condition
●  The nature, purpose, and potential benefit of the proposed care
●  The inherent risks, complications, potential hazards, or side effects of the treatment or procedure
●  The probability or likelihood, of success
●  Reasonable available alternatives to the proposed treatment or procedure
●  The possible consequences if treatment or advice is not followed and/or nothing is done.

I further acknowledge that no guarantees or assurances have been made to me concerning the results intended from the treatment.

I understand that a complementary and alternative medicine evaluation and treatment may include, but is not limited to: collecting specimens for laboratory evaluation, ordering diagnostic imaging, prescription of certain medications and nutritional supplements, IV therapy, bio-identical hormone replacement therapy, injections, counseling, dietary therapies or other alternative remedies.

I understand that the medical providers at DS Family Medical Group have been trained in a diverse range of diagnostic and treatment options. I understand that DS Family Medical Group is highly specialized and based upon evidence-based medicine, including functional medicine and holistic principles. As such, they may recommend different tests; may interpret standard tests differently; may propose different treatment, or may administer standard treatments differently than most conventional physicians as many perspectives exist in the medicine and in some cases there may be a disagreement among qualified medical experts. Care rendered may therefore be seen by some as outside standard of care or medically unnecessary. Diagnosis and treatment may include some services that are considered non-traditional, non-conventional or alternative medicine.

These services may not be recognized as standard medical practices and may be considered by insurance companies to be experimental or investigational. Along with training, the rationale for these differences is based on clinical experience and ongoing continuing education in evidence based functional and lifestyle medicine.

By signing this form, I acknowledge I have carefully read, or have had read to me, and understand the above consent. I give my permission and consent to care and authorize medical treatment by DS Family Medical Group and their staff, and I am fully aware of what I am signing. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment and I may ask my medical provider for a more detailed explanation.

There are certain inherent risks with medical care. The attending physician/provider will take every precaution to ensure that you are protected from any potentially hazardous situation.

You will never be forced to undergo any medical treatment that you do not wish to undergo.

PATIENT CONSENT FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

I hereby give my consent for DS Family Medical Group to use and disclose protected health information (PHI) about me to carry out treatment, payment and health care operations (TPO). (The Notice of Privacy Practices provided DS Family Medical Group describes such uses and disclosures more completely.)

I have the right to review the Notice of Privacy Practices prior to signing this consent. DS Family Medical Group reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to Practice Manager, 56 Starbrush Circle, Covington, LA 70435.

With this consent, DS Family Medical Group may call my home or other alternative location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any calls pertaining to my clinical care, including laboratory test results, among others.

With this consent, DS Family Medical Group may mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements as long as they are marked “Confidential”.

With this consent, DS Family Medical Group may e-mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements. I have the right to request that DS Family Medical Group restrict how it uses or discloses my PHI to carry out TPO. The practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.

By signing this form, I am consenting to allow DS Family Medical Group to use and disclose my PHI to carry out TPO.

I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, DS Family Medical Group may decline to provide treatment to me.

I acknowledge that DS Family Medical Group has provided a Notice Of Privacy Practices for me to review. (Please refer to posted Privacy Practices).

FOR MEDICAL AND DIAGNOSTIC TREATMENT RENDERED TO MYSELF OR MY DEPENDENTS, I HEREBY AUTHORIZE THE FOLLOWING:

Consent to medical and diagnostic treatment by the providers of DS Family Medical Group
Payment of authorized Medicare/Healthcare insurance benefits be made on my behalf to DS Family Medical

Group for any services furnished to me
Release of any information to obtain examination, treatment, and/or payment
My photograph to be taken
Photocopies of this form to be valid as the original.

PATIENT FINANCIAL POLICY

If your visit is covered by your insurance plan, we will require a copy of your insurance card along with photo identification in order to allow us to verify the benefits you are eligible for and provide you with an estimate of the amount you might owe for your visit. We will accept assignment of your benefits and file the insurance claim on your behalf. You will be responsible for your deductible, co-payments, or coinsurance at the time of the visit, and are expected to pay any charges that your plan does not cover as a part of their benefits. Deductible amounts are calculated to the best of our ability with information obtained from your insurance benefits; you may ultimately be balance-billed once your insurance has processed your claim. Our providers are participating members of most of the larger insurance plans with members in the area.

In order to reduce confusion and misunderstanding between our patients and the practice, we have adopted the following financial policy. If you have any questions about the policy, please discuss them with our office manager. We are dedicated to providing the best possible care and services to you and regard your complete understanding of your financial responsibilities as an essential element of your care and treatment.

●  For your convenience we will accept Cash, Check, Visa, MasterCard, American Express, Discover and Care Credit. If for any reason your check is returned as Non-sufficient, you WILL BE responsible for any charges we incur on your check.
●  I understand and give my full consent to the physicians/providers at DS Family Medical Group to send any laboratory work necessary to our partnering/contracted lab. I realize these labs are in-network with most insurance companies. I understand that I may be responsible for out of pocket payments to these companies.
●  Any balance is your responsibility and due upon receipt of a statement from our office.
●  An unpaid balance is considered past due after 30 days. If three consecutive statements have been sent you but no payments have been received on your account to reduce your responsibility, you may receive a collection letter and be considered for further collection activity. If your account must be turned over to a collection agency, you risk possible damage to your credit.

I have read and understand the financial policy of the practice and I agree to be bound by its terms. I also understand and agree that such terms may be amended from time-to-time by the practice.

APPOINTMENT CANCELLATION POLICY

Failure to keep your scheduled appointments at DS Family Medical Group hinders our ability to provide the best care to our patients. We ask that you show us consideration by calling at least 24 hours prior to your appointment, if you are unable to attend. Please call DS Family Medical Group at: (985) 246-5670 with your notification. This will allow us the opportunity to offer that appointment to another patient.

Repeated late cancellations, no-shows and late arrivals are disruptive to the optimal delivery of care to you and our other patients. Missed appointments prevent other patients from coming in at the same time and affect the consistency of your own treatment program. As a result, 3 late cancellations or no shows will result in dismissal from DS Family Medical Group In the event that you are discharged from our care, you will be notified of the reason for discharge. Late cancellations due to family emergencies or other extenuating circumstances are excluded from this policy.

At DS Family Medical Group failure to give the 24 hours notice necessary prior to cancellation, will result in a “No- Show Appointment Fee.” This fee will be your direct responsibility. The No-Show Appointment Fee is $50 for any missed office visit that was not cancelled within 24 hours. You will only be charged if you do not provide appropriate notice for your cancellation. Also any same day cancellations will be charged a $50 fee as well. These fees will be collected at your next scheduled office visit. All phone messages received are recorded in a timely fashion in our computer system with a time and date stamp. You may dispute charges in writing to DS Family Medical Group ATTN: Billing Manager, 56 Starbrush Circle, Covington, LA 70435. DS Family Medical Group reserves the right to waive fee or honor charges at its discretion.

I understand DS Family Medical Group’s appointment cancellation policy and understand my responsibility to plan appointments accordingly and notify DS Family Medical Group appropriately, if I have difficulty fulfilling my scheduled appointments.

INFORMED CONSENT REGARDING NUTRITIONAL AND HERBAL SUPPLEMENTS

According to the Federal Food, Drug, and Cosmetic Act, as amended, Section 201(g)(1), the term drug is defined as an “article intended for use in the diagnosis, cure, mitigation, treatment, or prevention of disease.” Technically, vitamins, minerals, trace elements, amino acids, herbs, or homeopathic remedies are not classified as drugs. However, these substances can have significant effects on physiology and must be used rationally.

In this office, we provide nutritional counseling and make individualized recommendations regarding use of these substances in order to upgrade the quality of foods in a patient’s diet and to supply nutrition to support the physiological and biomechanical processes of the human body. Although these products may also be suggested with a specific therapeutic purpose in mind, their use is chiefly designed to support given aspects of metabolic function. Use of nutritional supplements may be safely recommended for patients already using pharmaceutical medications (drugs), but some potentially harmful interactions may occur. For this reason, it is important to keep all of your healthcare providers fully informed about all medications and nutritional supplements, herbs, or hormones you may be taking.

SALE OF NUTRITIONAL SUPPLEMENTS AT DS FAMILY MEDICAL GROUP

You are under no obligation to purchase nutritional supplements at our clinic.

As a service to you, we make nutritional supplements available in our office. We purchase these products only from manufacturers who have gained our confidence through considerable research and experience. We determine quality by considering: (1) the quality of science behind the product; (2) the quality of the ingredients themselves; (3) the quality of the manufacturing process; and (4) the synergism among product components. The brands of supplements that we carry in our facility are those that meet our high standards and tend to produce predictable results.

While these supplements may come at a higher financial cost than those found on the shelves of pharmacies or health food stores, the value must also include assurance of their purity, quality, bioavailability (ability to be properly absorbed and utilized by the body), and effectiveness. The chief reason we make these products available is to ensure quality. You are not guaranteed the same level of quality when you purchase your supplements from the general marketplace. We are not suggesting that such products have no value; however, given the lack of stringent testing requirements for dietary supplements, product quality varies widely.

If you have concerns about this issue, please discuss them with our staff.

I have read and understand the above statement regarding nutritional supplements.

DS Family Medical Group has structured the practice to Utilize true comprehensive care uniquely tailored to what is right for you!

● A Team of Physicians now who ALL practice the Complementary Medicine approach in both preventative wellness and acute care issues (nutrition/diet /supplements in place of OR in addition to traditionally used pharmaceuticals)
● Consultations with our Nutritionist to supervise a Medical Weight Loss and Exercise Program with Body Composition Assessments available at every visit

● 24 hour direct text line for TRUE 360 degree care (985-237-8265)
● A formulary of in-house supplements and nutraceuticals
● Virtual/telemedicine options for appointments when appropriate
● Access to labs and specialized testing (see membership packet menu) ● Full ultrasound capabilities to include cardiac and vascular workups

DS360 is an all-encompassing approach in which the providers not only treat your acute conditions, but moreover provide preventative strategies to help you live healthy longer! DS360 gives patients access to the comprehensive, progressive care that is foundational to DS Family Medical Group’s mission.